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PubMed2003

WBC-containing allogeneic blood transfusion and mortality: a meta-analysis of randomized controlled trials.

BACKGROUND: An association between allogeneic blood transfusion (ABT) and mortality was reported by one team of investigators from randomized controlled trials (RCTs) comparing recipients of non-WBC-reduced versus WBC-reduced RBCs in open-heart surgery. A meta-analysis was undertaken to examine whether this finding can be generalized across clinical settings and/or transfused RBC components. STUDY DESIGN AND METHODS: RCTs reporting on adverse immunomodulatory effects of ABT between January 1992 and August 2002 were retrieved. Fourteen studies had recorded mortality as a primary or secondary outcome and met all other criteria for meta-analysis. Summary ORs of mortality in a treatment arm receiving WBC-containing allogeneic RBCs versus a control arm receiving autologous or WBC-reduced allogeneic RBCs were calculated across studies, for groups of studies in which the hypothesis of homogeneity was not rejected. RESULTS: There was no association between ABT and mortality across 14 RCTs reporting on short-term mortality (summary OR, 1.20; 95% CI, 0.87-1.65) or across 3 RCTs reporting on long-term mortality (summary OR, 0.87; 95% CI, 0.64-1.19). In subgroup analyses, RCTs using autologous blood or conducted in abdominal or vascular surgery showed no difference in mortality, but short-term mortality differed across 3 RCTs conducted in open-heart surgery (summary OR, 2.26; 95% CI, 1.31-3.90; p < 0.05) and 7 RCTs comparing recipients of non-WBC-reduced versus WBC-reduced allogeneic RBCs filtered before storage (summary OR, 1.45; 95% CI, 1.00-2.11; p >/= 0.05). CONCLUSIONS: An association between ABT and either short-term or long-term mortality was not detected across clinical settings and transfused RBC components, but subgroup analyses suggest that an association between WBC-containing ABT and short-term mortality may exist in open-heart surgery and in settings where WBC-reduced allogeneic RBCs filtered before storage are administered.

Blood Component Removal↗
PubMed2005

[Subconjuctival application of 5-fluorouracil (5-FU) following surgical treatment of glaucoma with deep sclerectomy--indications, complications and initial evaluation of effectiveness].

PURPOSE: 5-FU is an antimetabolite which increases efficacy of deep sclerectomy by inhibiting subconjuctival fibrosis and fibroblast proliferation. The objective of the study was to analyze glaucoma patients who had undergone sclerectomy and in a post-surgery period required subconjuctival 5-FU injections. MATERIAL AND METHODS: Out of 120 patients who had undergone deep sclerectomy between January through November 2004, 17 were included in the study since they required subconjuctival 5-FU injections in a post-operative period. The analysis comprised of: (1) indications for antimetabolite administration; (2) time that elapsed from the surgery to the first antimetabolite administration; (3) mean dosage; (4) complications observed; and (5) initial evaluation of the treatment. RESULTS: In 13 patients (76.4%), the indication for 5-FU application was persistent intraocular pressure exceeding 15 mmHg; in one patient (5.8%), the 5-FU treatment was started due to an abrupt increase of the pressure from hypotony; in 6 subjects (35.2%), it was the thickening and vascular dilatation in the filtering bleb; in one subject (5.8%) encapsulated filtering bleb. Mean time of administering 5-FU was between the 2nd and 3rd week following surgery. Mean number of injections applied was 3.7 (18.5 mg 5-FU). The following complications were encountered: corneal superficial punctuate keratopathy (6 subjects), choroidal detachment (1 person), irregular astigmatism (1 person). In most cases IOP was well controlled by the end of the follow-up period (< or = 15 mmHg). CONCLUSIONS: 5-FU is safe and does not increase the perioperative risk, and has turned out to be effective in most cases of increased scarring in the filtering bleb site.

Aged↗
PubMed2002

Temporary vena cava filter placement for pulmonary embolism.

Current clinical trials are under way to determine the safety and efficacy of temporary inferior vena cava filters for use in patients who need but have contraindications to anticoagulation medications for a short time (<10 days). To date, no data on these types of filters have been published. The authors describe a 20-year-old male trauma patient in whom a pulmonary embolism developed early in his hospital course and who was appropriately placed on anticoagulation therapy. Surgical intervention, however, was necessary to repair complex facial fractures sustained in a motorcycle collision. A filtering infusion catheter was placed until anticoagulation therapy could be resumed. The patient tolerated the surgery without further embolism and has recovered without difficulty.

Accidents, Traffic↗
PubMed1993

[Expression of proliferating cell nuclear antigen following filtration surgery in rabbits].

We evaluated cell replication in wound healing following experimental filtration surgery. Cell replication was measured via immunohistochemistry for proliferating cell nuclear antigen, which is a marker of cell proliferation. Trabeculectomy was performed on albino rabbit eyes, with the filtering site harvested on postoperative days 1, 4, 7, and 14. Samples were fixed with 10% buffered formalin and prepared for paraffin section, and proliferating cell nuclear antigen was detected in filtering site tissue using the labeled streptavidin-biotin method. The number of immunoreactive cells increased at days 4 to 7 and was markedly decreased at day 14; the filtering site was obstructed at days 7 to 14. These findings may have clinical implications for the administration of antiproliferative agents after filtration surgery. Evaluation of cell replication following filtration surgery by detecting proliferating cell nuclear antigen is a simpler technique than autoradiography.

Animals↗
PubMed2006

Protection of the conjunctival flap from contact with mitomycin C during tunnel-trabeculectomy.

AIM: The mid-term appearance of the filtering bleb and surgical outcome following tunnel-trabeculectomy, in which protective measures were carried out to avoid contact between the mitomycin C (MMC) and the conjunctival flap, are presented. METHODS: In a retrospective study the records of 20 consecutive patients who had undergone tunnel-trabeculectomy >/=24 months earlier, using fornix-based conjunctival flap and MMC (0.4 mg/ml) application were evaluated. Inclusion criteria were patients in whom: (I) the MMC-socked sponge was applied without contact with the conjunctival flap; (II) during MMC washout, a second Weck cell sponge was held anterior to the conjunctival flap, to protect the flap from mitomycin contact during its back-flow. Excluded were five patients who either did not complete 24 months of follow-up (n=4) or underwent an intraocular surgery during that period (n=1). RESULTS: After 24-32 (26.9+/-2.2) months, the filtering bleb was completely vascularized and thick in 13/15 patients (86.7%), mostly vascularized with some para-limbal thick cysts in one and avascular and cystic in another. Mean intraocular pressure (IOP) dropped from a preoperative level of 25.3+/-7.0 mmHg with 3.5+/-0.9 hypotensive medications to 13.9+/-2.9 mmHg with 0.9+/-1.1 medications (P<0.0001, Wilcoxon test). Of the five excluded patients, the IOP ranged between 10 and 16 mmHg with 0-1 medications at the last examination, 1-15 months postoperatively. CONCLUSION: In this pilot study, an intraoperative protection of the conjunctival flap from mitomycin contact was mostly associated with a vascularized and thick filtering bleb after mid-term follow-up. Further controlled prospective studies are required to confirm these observations.

Adult↗
PubMed1987

Anaerobic bacterial endophthalmitis.

Eighteen patients with endophthalmitis involving anaerobic bacteria are presented. Endophthalmitis followed cataract surgery in seven patients, penetrating trauma in six, a corneal graft in two, and an infected filtering bleb in two; there was one case of endogenous endophthalmitis. Propionibacterium acnes was the most frequent anaerobe isolated (78% of cases). Thirty-two percent of the patients had polymicrobial infection with mixed aerobic and anaerobic species. Six cases of acute P. acnes endophthalmitis were clinically indistinguishable from other cases of mild to moderately severe endophthalmitis. Four patients presented, after cataract surgery, with chronic, low-grade endophthalmitis of 1 to 15 months' duration, emphasizing that "sterile" endophthalmitis cannot be satisfactory diagnosed clinically. The visual prognosis of treated P. acnes endophthalmitis was often good. Based on principles of anaerobic microbiology, recommendations are made for vitreous collection, transport, and culture.

Adolescent↗
PubMed2001

Low degree of activation of circulating neutrophils determined by flow cytometry during cardiac surgery with cardiopulmonary bypass.

BACKGROUND: Enhanced expression of adhesion molecules LFA-1 (CD11a/CD18) and Mac-1 (CD11b/CD18) following cardiac surgery with cardiopulmonary bypass (CPB) is held responsible for postoperative complications. Surface expression of these molecules, intracellular pH (pH(i)), and oxidative burst capacity was analyzed to test for neutrophil activation during pediatric cardiac surgery. METHODS: Blood samples were drawn from 36 patients (age: 3--16 years) 24 h preoperatively, after onset of anesthesia, after connection to CPB (CPB1, before and after passing CPB, n = 15), at reperfusion (CPB2), and up to 7 days postoperatively. Cells adhering to CPB filters were isolated (n = 11). Antigen expression, pH(i), and oxidative burst capacity on neutrophils was analyzed by flow cytometry. RESULTS: During surgery, oxidative burst capacity was at low level with a mild increase only 1 day after surgery. pH(i) was decreased throughout the surgery. Surgery induced more than 36% decrease of LFA-1 and Mac-1 expression (P < 0.03). Up to postoperative day 7, no increase of antigen expression above baseline was found. Neutrophils isolated from filters of the CPB had increased LFA-1 and Mac-1 expression (all P < 0.05). Integrin expression on neutrophils passing the CPB at CPB1 was decreased (P < 0.05). CONCLUSION: Reduced adhesion molecule expression on neutrophils may be due to selective filtration of highly adhesive cells. This, in combination with low-level oxidative burst capacity, induced by immunosuppressive cytokines (e.g., interleukin-10), reduced the neutrophil activity. Our data indicate that increased activity of circulating neutrophils cannot exclusively be held responsible for postoperative complications after surgery with CPB.

Adolescent↗
PubMed2006

Clinical evaluation of the use of indocyanine green for peeling the internal limiting membrane in macular hole surgery.

BACKGROUND: To evaluate the role of indocyanine green (infracyanine) in macular hole surgery. METHODS: A retrospective review of 38 consecutive eyes with macular hole, operated on with internal limiting membrane peeling (ILM), using or not using infracyanine (ICG), diluted in glucose 5% and filtered. Anatomical and functional results were analysed in each group, using visual field testing, fluorescein fundus angiography and particularly blue filter fundus photographs for the detection of retinal pigment epithelial changes and lesions of optic nerve fibres layer. RESULTS: Fifteen eyes underwent surgery without ICG and 23 eyes with ICG. The mean period of follow-up was 10 months. The duration of surgery was significantly lower in the group with ICG than without (P < 0.001). Overall, 84% of the holes closed without difference between both groups. The improvement in vision at 1, 6 and 12 months was similar in both groups. Fewer defects in the optic nerve fibres layer were observed in the group with ICG than without (P = 0.02). Staining with ICG revealed the presence of an associated epiretinal membrane in 61% of eyes, whereas it was clinically visible in only 17.5% before surgery. CONCLUSION: Using ICG for ILM peeling produced similar visual results to those obtained without ICG. It reduced significantly the duration of surgery and the trauma to the optic nerve fibres layer, without increasing the risk of retinal pigment epithelial damage. However, in the light of recent reports about the possible toxicity of ICG, its use should be restricted in clinical practice to difficult cases.

Aged↗
PubMed2007

Utility of millipore filter and cell block in thyroid needle aspirates: which method is superior?

The main goal of thyroid fine-needle aspiration (FNA) is to distinguish nodules that require surgery from those that do not, thereby decreasing the number of diagnostic thyroidectomies. Several cytologic preparations are used to reach a definitive diagnosis, including smears using conventional stains, such as Diff-Quik (DQ) and Papanicolaou (Pap), millipore filters (MF), and cell blocks (CB). This study is undertaken to study the efficacy and adequacy to reach a definitive diagnosis of two cytologic preparations, MF and CB, in thyroid aspirates. All thyroid needle aspirates performed at Emory University Hospitals from January 2003 to April 2005 that had both MF and CB preparations for microscopic evaluation were studied. Conventional stains (DQ and Pap) were prepared. An initial aliquot of the specimen was divided for MF, and the remaining specimen submitted for CB preparation. All MF and CB slides were reviewed blindly. Adequacy criteria were assessed as 6-8 groups of follicular cells, with each containing 10 or more cells. Patient demographics, cytologic diagnoses, and follow-up information were retrieved. A total of 218 cases met our criteria; 21 of these cases were excluded due to lack of available diagnostic slides. Thus, a total of 197 cases were studied. Approximately two-third of the cases (57.9%) were diagnosed on DQ- and Pap-stained smears only, in which both CB and MF were inadequate. About 4.6% of the cases were diagnostic on both CB and MF; 36.0% on MF only, and 1.5% on CB preparation only. In more than half the cases (57.9%), diagnosis of thyroid FNA was rendered only on conventional stained smears. MF smears appeared to be superior for diagnostic yield (40.6%) than CB (6.1%), which is dependent on specimen cellularity. Therefore, MF rather than CB should be added to conventional stained smears (DQ and Pap) to supplement the diagnostic yield, especially in specimens of low cellularity.

Adolescent↗
PubMed2001

Timing of leukocyte filtration during cardiopulmonary bypass.

The effects of leukocyte filtration on the outcome of cardiac surgery with cardiopulmonary bypass (CPB) have been shown by numerous investigators. In the majority of cases a leukocyte filter is placed in the arterial line instead of a standard arterial line filter and used throughout CPB. However, protocols to optimize onset and duration of leukocyte filtration have not been sufficiently evaluated to date. In this paper, current efforts to improve such protocols are demonstrated and discussed. These efforts are based on studies of leukocyte pathogenicity during cardiac surgery. A first study (double-blind randomized) was performed in routine coronary artery bypass graft (CABG) patients to evaluate whether short-term leukocyte filtration during reperfusion by release of the aortic crossclamp would reduce reperfusion-associated myocardial damage. Further data compare the efficacy of three different filtration concepts to reduce CPB- and/or reperfusion-associated leukocyte pathogenicity. Clinical endpoints, standard laboratory variables and functional in vitro assays are provided and discussed.

Cardiopulmonary Bypass↗
PubMed2005

Successful diagnosis of thromboembolism before surgery in a woman with clear cell adenocarcinoma of the endometrium.

Patients with ovarian cancer with clear cell histology often have venous thromboembolism (VTE) even before surgery. In view of the possible association between clear cell histology and VTE in endometrial cancer, we measured the plasma levels of thrombin-antithrombin III complex (TAT) and D-dimer (DD) in the preoperative examinations of a patient with clear cell adenocarcinoma of the endometrium. Plasma TAT and DD were both highly elevated, though the patient had no symptoms of VTE or risk factors such as obesity or diabetes mellitus. Ultrasound Doppler examination and lung perfusion scintigraphy just before surgery revealed a thrombosis in the left popliteal vein and a pulmonary embolism. After implanting an inferior vena cava filter to prevent a fatal embolism of the lung, we performed abdominal total hysterectomy, bilateral salpingo-oophorectomy, and sampling of the pelvic lymph nodes. The VTE gradually disappeared and the plasma levels of TAT and DD returned to normal after surgery. Possibly, the VTE in this patient may have been associated with the clear cell histology.

Adenocarcinoma, Clear Cell↗
PubMed1986

Experience with the helix cava filter.

A new caval filter of helico-spiral geometry (Helix-Filter) was implanted in 13 patients for the prevention of pulmonary embolism (PE). The indications for implantation were: recurrent PE despite adequate anticoagulation (5 cases) or contraindication to anticoagulation (3 cases), incomplete local therapeutic fibrinolysis after severe paracentral PE (2 cases), and prophylaxis in high risk patients (3 cases). Implantation was effected by the saphenous/femoral vein approach in 12 patients, and via the right atrial appendage during open heart surgery in one instance. There were no intraoperative technical problems and in no case was the filter misplaced. During the follow-up period (mean 14.8 months, maximum 28 months) no filter-related complications were encountered. One patient with an exceptionally enlarged vena cava, due to abnormal renal vein inflow, had a fatal recurrent PE despite high dosage heparinization. One patient with an event-free follow-up died 12 months after filter placement from unrelated diseases. The remaining 11 patients are free of symptoms with no recurrent PE, no deterioration of venous circulation or presence of caval thrombosis. Emboli trapped at the filter were documented in 2 patients; spontaneous resolution occurred in one case. Experimental and early clinical results indicate that the hemodynamically optimal design of the Helix-Filter permits controlled and uniform luminal filtering with high patency. As such, it represents an alternative and highly promising solution to the problem of "mechanical" prevention of pulmonary embolism in selected patients.

Adult↗
PubMed2000

Effect of phacoemulsification surgery on hypotony following trabeculectomy surgery.

OBJECTIVE: To review the effect of phacoemulsification surgery in eyes with chronic hypotony following trabeculectomy with mitomycin C. DESIGN: Retrospective analysis of all eyes that underwent phacoemulsification surgery for symptomatic cataracts and had a preoperative diagnosis of chronic hypotony (intraocular pressure [IOP] </=6 mm Hg) for at least 6 months following trabeculectomy with mitomycin C. Each case had at least 6 months' follow-up after the phacoemulsification surgery. SETTING: A tertiary care referral center. INTERVENTION: Clear cornea phacoemulsification surgery, with minimal perioperative anti-inflammatory medication and retention of viscoelastic in eyes at case conclusion. MAIN OUTCOME MEASURES: Intraocular pressure, visual acuity, and complications. RESULTS: Nine eyes of 9 patients were identified. Mean preoperative IOP was 4. 2 +/- 1.4 mm Hg; the mean postoperative IOP was 7.3 +/- 2.8 mm Hg (P=.009). Intraocular pressure increased in all but 2 eyes. One of these 2 eyes experienced an acutely elevated IOP (34 mm Hg) on postoperative day 4, which dropped back to preoperative levels after trabeculectomy flap needling. Mean preoperative visual acuity was 20/300; mean postoperative visual acuity was 20/40. CONCLUSION: Phacoemulsification surgery may be associated with a statistically significant elevation in IOP in previously filtered eyes with hypotony, resulting in resolution of hypotony in some of these challenging cases. Arch Ophthalmol. 2000;118:763-765

Aged↗
PubMed1988

[Carotid endarterectomy under cervical epidural anesthesia. Analysis of neurologic manifestations].

Carotid endarterectomy can be complicated by neurological events due to different mechanisms. Monitoring cerebral function is difficult under general anaesthesia. By contrast, the monitoring of awareness and neurological deficit is very easy under regional anaesthesia. The aim of this study was to assess the requirement for arterial shunting during endarterectomy performed under cervical epidural anaesthesia, to analyse the neurological events and to compare the value of clinical and electroencephalographic monitoring. Sixty-four patients were included in this study. Cervical epidural anesthesia was performed with 0.375% bupivacaine and 100-150 micrograms fentanyl. In 19 high risk patients, a one-channel electroencephalographic filter processor (Cerebral function monitor, Critikon) was placed over the affected hemisphere. Before surgery, it was estimated, on angiographic and Doppler data, that 18 patients needed an arterial shunt for carotid clamping. An arterial shunt was in fact inserted during surgery in only four patients, because of cerebral ischaemia after carotid clamping. Transient obnubilation was observed during carotid clamping in three other patients; it disappeared on unclamping in two, and on increasing blood pressure in the third. An additional patient suffered from a very short loss of awareness after declamping, due to cerebral embolism. The cerebral function monitor never documented false positive results, but failed to detect one out of every five neurological events. Controlateral carotid occlusion and preoperative stroke were documented to correlate with peroperative neurological events. Cervical epidural anaesthesia, which maintains consciousness during surgery, reduced in high-risk patients the need for arterial shunting as well as that for the analysis of neurological events.

Aged↗
PubMed2002

Erythrocyte viability in blood salvaged during total joint arthroplasty with cement.

BACKGROUND: Erythrocyte salvage, the collection of a patient's blood shed from the surgical wound, is one aspect of blood management. Previous investigators have examined salvaged blood for content; however, to our knowledge, none have examined the viability of erythrocytes after exposure to the chemical and thermal reactions produced by motorized instruments and polymethylmethacrylate during surgery. The purpose of this study was to determine the viability of salvaged erythrocytes from patients undergoing primary total joint arthroplasty with cement. METHODS: Erythrocyte viability studies were performed on specimens from three subjects with use of a double isotope-labeling technique employing chromium-51 and technetium-99m. With use of a fresh blood specimen obtained prior to surgery and a specimen of salvaged blood that had been recycled, washed, and filtered with use of the Cell Saver, the viability of the Cell-Saver-processed erythrocytes, labeled with chromium-51, was calculated on the basis of the technetium-99m-labeled red blood-cell mass. RESULTS: The mean erythrocyte viability (and standard deviation) in blood salvaged with use of the Cell Saver was 88.0% +/- 3.8%. The standard of the American Association of Blood Banks for minimum erythrocyte viability in adequately cross-matched allogeneic blood or predeposited autologous blood is 70%. CONCLUSIONS: The high rate of viability of the erythrocytes in this study shows that the Cell Saver is a valuable adjunct to other blood management techniques for patients having total joint arthroplasty. We believe that the very high mean rate of erythrocyte viability and the extremely small standard deviation in our three subjects, as compared with the standards of the American Association of Blood Banks, made additional study subjects unnecessary.

Arthroplasty, Replacement↗
PubMed2000

[Appropriate hospital utilization in emergency surgery: application of the Appropiatness Evaluation Protocol].

UNLABELLED: The Authors developed and tested a new version of the Appropriateness Evaluation Protocol (AEP) to review 160 clinical records of the Emergency Surgery Department of Policlinico Umberto I-Rome. The modifications to the AEP also allow to evaluate the appropriate ward of hospitalization of acute patients (Surgery, Orthopedics, Head & Neck, Burns). RESULTS: 26 (16%) out 160 admissions failed the AEP criteria; 85 of the remaining admissions were judged appropriate in the Emergency Surgery Department (53% of the whole sample), 14 (9%) in the Head & Neck Department, 10 (6%) in the Orthopedic Department, 25 (16%) not in an Emergency Surgery Department. Only 63% of the appropriate admissions has been judged adequate in the Emergency Surgery Department. The Authors conclude that it is necessary to improve the primary "filter" of the hospitalization (the ambulatory care component of the National Health System). Finally, this version of the AEP was shown to be reliable, an useful tool in the hands of trained physicians.

Emergency Service, Hospital↗
PubMed1986

[Aorto-iliocaval fistula caused by rupture of an aneurysm. Apropos of 3 cases].

Three cases of aorto-iliocaval fistula are reported. Two cases were diagnosed during operation, an emergency laparotomy being indicated by the picture of hemodynamic shock unimproved by intravenous fluids, and without reduction in number of circulating red cells, associated with a painful abdominal aorta aneurysm. Recovery occurred after surgical closure of fistula and grafting of the aneurysm. In one case a caval stenosis required the insertion of a prophylactic subrenal clip. The third case was original in that a paradoxical pulmonary embolus developed in a patient with a primary left iliac aneurysm complicated by phlebitis. The hemodynamic state was such that a first stage operation. allowed insertion of a Greenfield's filter by the jugular route. Arteriography confirmed the diagnosis of a fistula and surgery was successful. Possible clinical manifestations of aortocaval fistula and surgical therapeutic measures are discussed.

Aged↗
PubMed1993

Sturge-Weber syndrome: management of glaucoma with combined trabeculotomy-trabeculectomy.

We reviewed the records of 16 patients (19 eyes) with Sturge-Weber syndrome (SWS). Scleral pigmentation was present in 12 (63.2%) of these eyes; nevus of Ota in two (10.6%). Combined trabeculotomy-trabeculectomy was performed in 18 eyes. After a mean follow up of 42 months (range, 1 to 8 years), intraocular pressure was controlled (< or = 22 mm Hg) in 11 eyes (61.1%), and visual acuity was better than 6/60 in eight. Intraoperative hyphema occurred in four eyes (22.2%); vitreous loss in three (16.7%). Postoperative choroidal detachment occurred in three eyes (16.7%); vitreous hemorrhage in one (5.6%). In all of the cases of repeat surgery (three eyes), postoperative subconjunctival injections of 5-fluorouracil resulted in a diffuse filtering bleb. We conclude that combined trabeculotomy-trabeculectomy is a promising treatment for patients with SWS with glaucoma.

Child↗