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Functional morphology of rabbit iridial ciliary processes.

Using scanning electron microscopy of vascular resin casts, it was found that the capillary network of the iridial ciliary processes is supplied by arterioles of its own and drained posteriorly by long isolated venules. These venules pass the ciliary body without greater connection to the venules of the major ciliary processes (shunt-system). Transmission electron microscopy showed that in contrast to the pigment epithelium (PE) of the major ciliary processes, the PE of the iridial processes develops elongated finger-like cytoplasmic processes which protrude into the stroma, often in the direction of the vessels, forming a 'basolateral labyrinth', like the kidney tubule epithelium. After paracentesis, an enlargement and leakage of the iridial ciliary process capillaries was found, resulting in resin leakage at various sites; no leakage was found in the vasculature of the major ciliary processes. Electron microscopically, the basolateral labyrinth of the PE appeared enormously enlarged, forming wide protein-containing intercellular spaces. These findings suggest that the function of the iridial ciliary processes in rabbits has a dual nature. Under normal circumstances, the main function of the iridial processes may be fluid reabsorption rather than aqueous humor secretion. In cases of paracentesis, for example, the very sensitive blood aqueous barrier of this area breaks down with resulting protein exudation.

Animals↗

Comparative study of different techniques of intraocular gas tamponade in the treatment of retinal detachment due to macular hole.

The injection of sulfur hexafluoride (SF6) or perfluoropropane (C3F8) was used as a method of internal tamponade in 43 eyes affected by retinal detachment due to macular hole. The technique of ocular hypotension prior to gas injection varied according to the characteristics of each case, using vitrectomy and SF6 30% in 8 cases (group 1), fluid-gas (SF6) exchange through the pars plana in 10 cases (group 2), paracentesis of the anterior chamber prior to injection of SF6 in 12 cases (group 3) and injection of C3F8 without drainage in 13 cases (group 4). Retinal reattachment was initially achieved in 87 (group 1), 83.3 (group 2), 100 (group 3) and 92.3% (group 4), but 4 recurrences yielded a 6-month follow-up cure of 75 (group 1), 75 (group 2), 91 (group 3) and 84% (group 4). Postoperative complications included proliferative vitreoretinopathy (7%), endophthalmitis (2.3%) and subretinal hemorrhage (2.3%). The use of intraocular gas tamponade appears to be a procedure with an acceptable complication rate in the treatment of retinal detachment due to macular hole. This study suggests the use of paracentesis and SF6 in phakic eyes, C3F8 in aphakic eyes and vitrectomy plus 30% SF6 in eyes with proliferative vitreoretinopathy or vitreoretinal traction adjacent to the macular hole.

Adolescent↗

Tympanostomy tubes: do they significantly benefit the patient?

To gain more information about the role of tympanostomy tubes in the treatment of chronic middle ear effusion, the authors conducted a randomized trial that clearly indicated the short-term advantages of combining the insertion of an Armstrong ventilator tube with paracentesis and fluid aspiration over paracentesis and aspiration alone. A retrospective study of the success rate with three types of tympanostomy tubes (Shepard, Armstrong, and Paparella) was also carried out. The Armstrong tube had the highest success rate.

Child↗

Palliative treatment of malignant refractory ascites by positioning of Denver peritoneovenous shunt.

Malignant ascites is relatively common in patients with certain types of end-stage cancer. Traditional treatments based on fluid and salt restriction and diuretic therapy often are not able to contain neoplastic ascites. These patients consequently undergo repeated abdominal paracentesis, with further plasma protein loss and risk of injury to abdominal viscera. The aim of this study was to evaluate our experience with Denver peritoneovenous shunt and the outcome of patients with malignant ascites and suggest some modifications to improve device patency. From February 1997 to December 1999, 44 Denver peritoneovenous shunts were placed in 42 patients, 17 women and 25 men, aged between 38 and 77 years (mean, 62.3), affected with malignant ascites due to advanced abdominal cancer. At the time of admission, 72% of patients had pain, 88% dysphagia, 66% nausea and/or vomiting, and 83% dyspnea. Eleven patients underwent local anesthesia with lidocaine and 33 general anesthesia with rapidly metabolized drugs. In 27 cases we used the peritoneal-internal jugular right vein surgical approach and in 3 cases the peritoneal-femoral vein surgical access, joining the saphena vein to the cross. In 10 cases, a radiological positioning of the Denver peritoneovenous shunt was effected by a trans-subclavian access. Relief of ascites symptoms was obtained in 87.5% of cases, with reduction of dyspnea, an increased appetite and improved ambulation. Denver peritoneovenous shunt is a good device to relieve malignant ascites, thereby reducing the risk of complications and the number of hospital admissions due to repeated paracentesis and consequently improving the quality of life. A careful patient selection, an accurate follow-up and some device modifications could improve the shunt performance, allowing a wider application of the Denver peritoneovenous shunt.

Adult↗

Hemorrhagic peritoneal carcinomatosis treated with a weekly schedule of carboplatin and paclitaxel. A case report.

Ovarian carcinomas are chemosensitive tumors. Chemotherapy plays a pivotal role also in advanced disease, and the response to chemotherapy appears to be predictive of prolonged survival. Only performance status seems to limit therapy administration and affect patient survival. Here we report on a 66-year-old patient with a clinical status heavily compromised by peritoneal carcinomatosis associated with bloody effusion, which required increasingly frequent paracentesis and transfusions. The clinical conditions worsened under carboplatin monochemotherapy. A further attempt with carboplatin and paclitaxel in a weekly schedule resulted in a clinical response in terms of reduced need for paracentesis and blood support and improved performance status. This case confirms that treatment is the only chance to improve clinical status even in patients with very advanced ovarian cancer and an extensive tumor load. In our opinion, the modified schedule adopted in the case presented here may be worthwhile for future phase II studies in a selected patient population.

Aged↗

Management of symptomatic ascites in recurrent ovarian cancer patients using an intra-abdominal semi-permanent catheter.

Ascites is commonly present in women with advanced-stage ovarian cancer. No standardized protocol exists for the treatment of the patient with recurrent ovarian cancer and rapidly reaccumulating malignant ascites. Palliation of symptoms is most commonly achieved through repeated paracentesis, a procedure that potentially results in injury to intra-abdominal organs, infection, and patient discomfort. Our goal was to improve patient comfort by alleviating symptoms and reducing the need for paracentesis. The Pleurx' catheter offers a number of potential advantages over traditional treatment modalities. Clearly, larger study numbers are required to quantify the morbidity associated with the Pleurx catheter.

Aged↗

Shunt-related abdominal metastases in a child with choroid plexus carcinoma: case report.

OBJECTIVE AND IMPORTANCE: Metastasis of primary brain neoplasms to the abdomen through a ventriculoperitoneal shunt (VPS) has been described for many types of tumors, including medulloblastoma, germ cell tumors, astrocytoma, oligodendroglioma, lymphoma, ependymoma, and melanoma. Choroid plexus tumors (CPTs) are located within the cerebrospinal fluid-containing spaces of the brain and frequently disseminate throughout the craniospinal subarachnoid space, yet VPS-related metastasis of a CPT to the abdomen has not been reported previously. CLINICAL PRESENTATION: We present the case of a 3-year-old boy with choroid plexus carcinoma of the lateral ventricle and preoperative intraventricular dissemination of the tumor. The patient later developed VPS-related abdominal metastases causing abdominal ascites. INTERVENTION: Surgical resection of the tumor was followed by chemotherapy and craniospinal radiation, but the tumor further disseminated throughout the craniospinal subarachnoid space. When the child presented with abdominal ascites, the distal VPS catheter was externalized and drained cerebrospinal fluid at a rate of more than 750 ml/d. Paracentesis was performed for persistent ascites, and cytological analysis of the fluid revealed metastatic tumor cells. CONCLUSION: The child died from widely metastatic tumor and aspiration pneumonia. CPT metastasis to the abdomen through a VPS should be considered in patients with the appropriate clinical findings. This condition may exacerbate overproduction of cerebrospinal fluid, which can occur with CPTs, and treatment must be individualized. Unusual options may be considered, such as long-term shunt externalization or paracentesis.

Abdominal Neoplasms↗

Pharmacotherapy of ascites associated with cirrhosis.

Cirrhotic patients frequently develop ascites during the course of their disease. The appearance of ascites is the final consequence of profound disturbances in systemic and splanchnic haemodynamics, and in renal and hormonal function. The alterations in renal function consist of a decreased ability to excrete sodium and water, and in more severe cases, a reduction in renal blood flow and glomerular filtration rate. No effective drug therapy is yet available for water retention and renal failure in these patients. Sodium retention, however, may be treated by the administration of diuretics. The diuretics most commonly used in the treatment of cirrhotic patients with ascites are loop diuretics, particularly furosemide (frusemide), and distal, or 'potassium-sparing' diuretics such as spironolactone. Although furosemide has a much greater natriuretic potency than spironolactone in healthy individuals, studies in cirrhotic patients with ascites have shown that spironolactone is more effective than furosemide in the elimination of ascites. Nowadays, however, therapeutic paracentesis associated with plasma expanders has replaced diuretic therapy as the initial treatment for cirrhotic patients hospitalised with tense ascites since it is more effective and is associated with a lower rate of complications than diuretic therapy. Diuretics should be given after the elimination of ascites by paracentesis to avoid the reaccumulation of the abdominal fluid. Only cirrhotic patients with mild ascites should be treated initially with diuretics. Cirrhotic patients with ascites frequently develop a spontaneous infection of the ascitic fluid which is usually caused by Gram-negative bacilli from enteric origin and has a great tendency to recur after therapy. The antibiotics of choice for this infection are third-generation cephalosporins. Long term administration of norfloxacin, which causes a selective elimination of Gram-negative bacilli from the intestinal flora, is effective in preventing the recurrence of ascites infection in these patients. Finally, cirrhotic patients with ascites are prone to develop renal failure when treated with a variety of pharmacological agents, particularly aminoglycosides and nonsteroidal anti-inflammatory drugs. The administration of the latter drugs may also cause dilutional hyponatraemia and refractory ascites since they induce water retention and impair the renal response to diuretics.

Acute Kidney Injury↗

[Treatment of ascites in cirrhotic patients].

Ascites is the most frequent complication of hepatic cirrhosis and its appearance brings a reduction of survival. The treatment aims to mobilise the intraperitoneal liquid and to prevent its reaccumulation. The first step of treatment includes rest in bed, a hyposodic and spironolactone diet, alone or in combination with furosemide or torasemide. However, 10-20% of patients do not respond to treatment or develop adverse effects that limit its use, which is termed refractory ascites. These patients must be considered as possible candidates for a liver transplant and, when this is not possible, the chosen treatment is total paracentesis with an intravenous infusion of albumin. In patients who do not tolerate paracentesis, or who require its realisation with great frequency, other therapeutic options can be evaluated, such as surgical anastomoses, intrahepatic portosystemic percutaneous derivation and, in the final instance, peritoneo-venous shunt.

English Abstract↗

Evaluation of concentration of voriconazole in aqueous humor after topical and oral administration in horses.

OBJECTIVE: To determine penetration of topically and orally administered voriconazole into ocular tissues and evaluate concentrations of the drug in blood and signs of toxicosis after topical application in horses. ANIMALS: 11 healthy adult horses. PROCEDURE: Each eye in 6 horses was treated with a single concentration (0.5%, 1.0%, or 3.0%) of a topically administered voriconazole solution every 4 hours for 7 doses. Anterior chamber paracentesis was performed and plasma samples were collected after application of the final dose. Voriconazole concentrations in aqueous humor (AH) and plasma were measured via high-performance liquid chromatography. Five horses received a single orally administered dose of voriconazole (4 mg/kg); anterior chamber paracentesis was performed, and voriconazole concentrations in AH were measured. RESULTS: Mean +/- SD voriconazole concentrations in AH after topical administration of 0.5%, 1.0%, and 3.0% solutions (n = 4 eyes for each concentration) were 1.43 +/- 0.37 microg/mL, 2.35 +/- 0.78 microg/mL, and 2.40 +/- 0.29 microg/mL, respectively. The 1.0% and 3.0% solutions resulted in significantly higher AH concentrations than the 0.5% solution, and only the 3.0% solution induced signs of ocular toxicosis. Voriconazole was detected in the plasma for 1 hour after the final topically administered dose of all solutions. Mean +/- SD voriconazole concentration in AH after a single orally administered dose was 0.86 +/- 0.22 microg/mL. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that voriconazole effectively penetrated the cornea in clinically normal eyes and reached detectable concentrations in the AH after topical administration. The drug also penetrated noninflamed equine eyes after oral administration. Low plasma concentrations of voriconazole were detected after topical administration.

Administration, Oral↗

Experimental long-term tubal occlusion in cats. A quantitative histopathological study.

Unilateral tubal occlusion was performed in 10 cats, which were sacrificed 26-44 months later. During the observation period repeated bilateral tympanometry and auditory nerve response were recorded. Paracentesis with evacuation of effusion was performed up to eight times and the effusion was examined by viscometry. After sacrifice, quantitative histopathology of the bulla with determination of goblet cell density was carried out. In three ears having glue at the last paracentesis, the histopathologic changes were more pronounced than in the four ears having thin effusion. Three ears were dry at sacrifice with normal tympanometry, the histopathological changes evidently demonstrate the the normalization of the middle ear mucosa. The experiments demonstrate the great importance of tubal patency or function in prognosis of the disease. In ears with anatomically occluded tubes, no recovery occurred, whereas in ears with normalized tubal function, the middle ear mucosa and goblet cell density also normalized. Pathogenic and etiological aspects of secretory otitis are discussed.

Acoustic Impedance Tests↗

A ten-year study on non-surgical treatment of postoperative bile leakage.

AIM: To summarize systematically our ten-year experience in non-surgical treatment of postoperative bile leakage, and explore its methods and indications. METHODS: The clinical data of 57 patients with postoperative bile leakage treated non-surgically from January 1991 to December 2000 were reviewed retrospectively. RESULTS: The site of the leakage was mainly the disrupted or damaged fistulous tracts of T tube in 25 patients (43.9 %), the fossae of gallbladder in 14 cases (24.6 %), the cut surface of liver in 7 cases(12.3 %), and it was undetectable in the other 2 cases. Besides bile leakage, the wrong ligation of bile ducts was found in 3 patients, residual stones of the distal bile duct in 5 patients, benign papillary strictures in 3, and biloma resulting from bile collections in 2. The diagnoses were made according to the history of surgery, clinical situation, abdominal paracentesis, ultrasonography, ERCP, PTC, MRI/MRCP, gastroscopy and percutaneous fistulography. All 57 patients were treated non-surgically at the beginning of bile leakage. The non-surgical methods included keeping original drainage unobstructed, percutaneous abdominal paracentesis or drainage, percutaneous transhepatic cholangial/biliary drainage (PTCD/PTBD),endoscopic management, traditional Chinese medicine and so on. Of the 57 patients,2 patients died,5 were converted to reoperation later, the other 50 were directly cured by non-surgical methods without any complication. The cure rate of the non-surgery was 82.5 %(50/57). CONCLUSION: Many nonoperative methods are available to treat postoperative bile leakage. Non-surgical treatment may serve as the first choice for the treatment of bile leakage for its advantages in higher cure rate, convenience and safety in practice. It is important to choose the specific non-surgical method according to the volume, site of bile leakage and patient's condition.

Adult↗

Leukemic hypopyon.

A seven-year-old girl was successfully treated for acute lymphoblastic leukemia. Despite clinical remission she developed a monocular hypopyon which was treated successfully with topical and subtenons steroids. When the hypopyon reappeared, a diagnostic paracentesis revealed leukemic cells and a normal aqueous lactate dehydrogenase. Leukemic ocular infiltration may clinically mimic both neoplastic and inflammatory ocular conditions. The combination of paracentesis and lactate dehydrogenase assay greatly aid in the correct diagnosis.

Anterior Chamber↗

[Otitis media with effusion: a study of 346 cases in an outpatient clinic].

We treated 346 patients with otitis media with effusion (OME) and 30 (127 episodes) with recurrent acute suppurative otitis media at our outpatient clinic in the 6 years from October 1994 to September 2000. Of these, children under 15 years old numbered 185, mostly boys at a ratio of 1.4: 1.0, while patients aged 15 years or older numbered 161, mostly females at a ratio of 1.3: 1.0. In children, 24 were excluded due to a lack of diagnostic follow-up, 65 (40%) patients improved in conservative management of medication with and without repeated tubal inflation, 79 (49%) improved by paracentesis, and 18 (11%) recovered with the use of pressure equalization tubes (grommets). Of cases aged 15 years or older, follow-up was not possible in 28. Three (2%) were free of OME by conservative treatment, 116 (87%) improved by paracentesis, and 9 (7%) by using tubes. The mean durations of tube insertion was 11.3 months in children and 7.2 months in adults, but 5 adults (4%) continue being treated of this writing. Bilateral cases were 30% of children and 8% of adults with 73% of children affected bilaterally having persistence or recurrence. Acute purulent otitis media progressed to OME in 22% of children but only in 3% of patients aged 15 or older. In 36% of children and 26% of patients aged 15 or older, acute upper respiratory tract infection coincided with or predisposed to OME. Rhinosinusitis was seen in 19% of children and 14% of adults. Coincident allergic rhinitis was seen in 14% of children and 12% of adults with OME. Nasopharyngeal infection and allergy are likely related to OME development. The peak incidence of OME was similar to that of recurrent suppurative otitis media in children, so a seminal precipitating factor appears to result in these 2 conditions.

Acute Disease↗

Clinical practice guidelines for the management of cirrhotic patients with ascites. Committee on Ascites of the Italian Association for the Study of the Liver.

An ad hoc Committee appointed by the Italian Association for the Study of the Liver prepared these Clinical Practice Guidelines for the Management of Cirrhotic Patients with Ascites. The initial evaluation of a patient with ascites should include a history, physical evaluation, paracentesis with ascitic fluid analysis, abdominal ultrasonography and biochemistry to assess the severity of liver disease and renal functionality. To improve the efficiency of the choice between the different opportunities available in the treatment of ascites, patients can be classified into two subgroups: patients with uncomplicated ascites and patients with complicated ascites, including refractory ascites, bacterial peritonitis, hyponatraemia and renal failure. Based upon evidence emerging from controlled clinical trials or case-control studies, satisfactory treatment for uncomplicated ascites is represented by paracentesis, sodium-restricted diet and diuretics, whereas the treatment of patients with complicated ascites requires other specific approaches. As the prognosis for most patients with ascites is poor, the last part of the paper offers simple criteria in the selection of patients candidates for liver transplantation. The aim of these guidelines is to reduce inappropriate practice and to improve efficiency in the management of patients with ascites. The Committee holds that a periodic update will be necessary to conform to future scientific developments.

Ascites↗

Effects of hydroxyurea on extrachromosomal DNA in patients with advanced ovarian carcinomas.

PURPOSE: In vitro low concentrations of hydroxyurea eliminate double-minute chromosomes (dmins) containing amplified drug-resistance genes and oncogenes from cancer cells. This clinical trial investigated whether a noncytotoxic dose of oral hydroxyurea could reduce the number of dmins in cancer cells in patients with advanced ovarian carcinomas. EXPERIMENTAL DESIGN: The high frequency of ascites associated with ovarian cancer facilitated the monitoring of cytogenetic variations with minimal discomfort in patients who required frequent abdominal paracentesis. Sixteen patients with advanced ovarian carcinomas resistant to conventional cisplatin-based and/or paclitaxel chemotherapy and with ascites requiring frequent abdominal paracentesis were entered in this study. A course of treatment consisted of a single oral dose of 80 mg/kg hydroxyurea every 3 days for 6 weeks. Blood and i.p. levels of hydroxyurea were determined. We monitored the variations of dmins in tumor cells taken from serial abdominal paracenteses. RESULTS: The median number of courses administered to the patients was 1 (range, 1--9). In ascites, hydroxyurea concentrations were 610.3 +/- 76.3, 219.8 +/- 85.6, and 86.1 micromol/liter at 4, 24, and 30 h after oral administration, respectively. Eleven (78.6%) of 14 patient specimens contained dmins before therapy. The number of spreads with tumor cells containing dmins were reduced by more than 50% in 5 (45%) of 11 and 3 (60%) of 5 patients at the completion of the first and second course of chemotherapy, respectively. Using tumor cells taken directly from the patients and grown in soft agar, we documented that concentrations of hydroxyurea in ascites were too low to have any cytotoxic effects. No grade 3--4 hydroxyurea-related toxicities nor any objective responses were observed. However, despite the utilization of a low noncytotoxic dose of hydroxyurea, two patients had prolonged stabilization of their disease for 6 and 10 months, respectively, with concomitant decreases in the number of dmins that remained until progression. CONCLUSIONS: This study showed that, in some circumstances, a noncytotoxic dose of hydroxyurea given to patients with ovarian cancer can decrease the number of metaphase spreads containing dmins in cancer cells.

Administration, Oral↗

Acute lymphocytic leukemia presenting as masquerade syndrome.

An 11-year-old child presented with plastic iridocyclitis and hypopyon. Subsequent paracentesis revealed leukemic infiltrates. A bone marrow biopsy confirmed the diagnosis of acute lymphocytic leukemia. Because of this unusual case of leukemic hypopyon, we advocate anterior chamber paracentesis and pediatrician referral in all cases of refractory uveitis.

Anterior Chamber↗

Malignant ascites: demographics, therapeutic efficacy and predictors of survival.

Demographics, treatment patterns, treatment efficacy and clinical predictors of survival were studied in 76 consecutive patients with malignant ascites. Sixty-four percent of patients were female, and mean age was 63 years. The most common primary malignancies were ovarian cancer, carcinoma of unknown primary, breast cancer, colorectal carcinoma and lymphoma. Ascites was present at the time of diagnosis of malignancy in 39%. Diuretics were administered in 22% of patients with a 22% response in ascites; all responding patients had hepatic metastases. Systemic anticancer therapy was administered in 38%, with a 38% objective response in ascites. Five peritoneovenous shunts were placed, with one shunt functional at 2 weeks. Paracentesis was performed in 71% of patients with complications potentially due to paracentesis occurring in 24% of these patients. Median survival was 78 days from the clinical diagnosis of ascites. Multivariate analysis revealed significantly shortened survival in patients with liver metastases and elevated serum bilirubin, while ovarian cancer was a significant independent predictor of prolonged survival.

Ascites↗