Supraclavicular total scalenectomy with or without first rib resection: technic and results.

This describes the clinical picture of neurogenic TOS, supraclavicular surgical technique, and results of surgery as well as surgical complications.

[The Dutch Institute for Health Care Improvement (CBO) guideline for the diagnosis and treatment of aspecific acute and chronic low back complaints]. / CBO-richtlijn voor diagnostiek en behandeling van acute en chronische aspecifieke lage rugklachten.

Under the auspices of the Dutch Institute for Healthcare Improvement (CBO), a guideline has been developed for the diagnosis and treatment of aspecific low-back pain, based on the recent scientific literature. So-called 'red flags' are used to identify physical disorders. To obtain insight into psychosocial factors, 'yellow flags' are used. Acute low-back pain (0-12 weeks) is treated in a time-contingent manner. Staying active is better than bed rest. If chronicity threatens, exercise therapy can be advised. As part of an activating management, manipulation can be used. For pain relief, paracetamol is the drug of choice. The treatment of chronic low-back pain is aimed at the optimisation of the patients' functionality. Staying active is preferred here as well. Varied exercise therapy is advised. Back training may be considered. Manipulation can be used as part of an activating management. Paracetamol is preferred for pain relief. There is a limited role for percutaneous lumbar facet denervation. Behaviour therapy can be employed and there is a place for multidisciplinary programmes if other methods of treatment have proved insufficiently effective.

Squalamine improves retinal neovascularization.

PURPOSE: Modalities for inhibiting neovascularization may be one avenue to the development of effective therapies for retinopathy. The effect of squalamine, an antiangiogenic amino sterol, on oxygen-induced retinopathy (OIR) was assessed in a mouse model. METHODS: OIR was induced in C57BL6 mice by a 5-day exposure to 75% oxygen from postnatal day (P)7 through P12. Squalamine (25 mg/kg, subcutaneous)treated animals received either daily doses for five days from P12 to P16 or one dose just after removal from oxygen on P12. Each set of animals was killed at P17 to P21. Retinopathy was assessed with a retinopathy scoring system evaluation of retinal wholemounts and by quantification of neovascular nuclei on retinal sections. RESULTS: Animals receiving 5 days of squalamine after a 5-day exposure to oxygen had total retinopathy scores (expressed as median score with 25th and 75th quartiles in parentheses) of 4(3, 5) versus oxygen-only-reared animals with scores of 8(7, 9; P < 0.001). Animals reared in room air and animals exposed to squalamine only had similar retinopathy scores: 1(1, 2) and 1(0, 2). Oxygen-reared animals receiving single-dose squalamine also showed improvement, with a median retinopathy score of 4(4, 6.75) versus oxygen-only-reared animals with median retinopathy score of 9(7, 10; P < 0.001). There was a decreased number of neovascular nuclei extending beyond the inner limiting membrane on retinal sections in animals treated with 5 days (P < 0.01) and 1 day (P < 0.001) of squalamine. CONCLUSIONS: Squalamine significantly improved retinopathy and may be a novel agent for effective treatment of ocular neovascularization.

[Good results from a multidisciplinary and behavioral program for chronic back pain]. / Goede resultaten van een multidisciplinair en gedragsmatig programma voor chronische rugpijn.

OBJECTIVE: To evaluate the results of a multidisciplinary and behavioral program for chronic back pain. DESIGN: Prospective cohort study. METHOD: In 1996, a total of 143 patients with chronic back pain participated in a 4-week multidisciplinary and behavioral treatment program in an outpatient centre for work reintegration (Rug AdviesCentrum) in Zeist, Eindhoven and Noordwijk, the Netherlands. At the start and six months after termination, data were collected on trunk muscle performance, pain intensity, disability and stress related physical complaints, and after 6 months about return to work, analgesics use, and health care utilization. Score differences between the first and the second measurements were tested on statistical significance using paired t-tests and on clinical relevance using the reliable change-index. RESULTS: The study group comprised 99 males and 44 females with a mean age of 41.6 years (range: 23-58). After 6 months the outcome variables were significantly improved statistically: depending on the outcome variable used, the improvement was clinically relevant in 44-91% of patients. The obtained percentage of full return to work at 6-months follow-up was 87%, while 80% had used no pain killers and 91% had made no use of health care facilities. CONCLUSION: The program resulted in important improvements in patients with chronic back pain.

Diltiazem reduces retinal neovascularization in a mouse model of oxygen induced retinopathy.

PURPOSE: To assess the effect of diltiazem, a calcium channel blocking agent, on oxygen induced retinopathy (OIR) in a mouse model using neovascular nuclei quantitation and a quantitative scoring system based on examining fluorescein perfused retinal whole mount preparations. METHODS: The mouse model of oxygen induced retinopathy consisting of a 5 day exposure to 75% oxygen from postnatal day 7 to 12 was used to produce retinal neovascularization. Fluorescein conjugated dextran angiography of retinal vasculature was performed and retinal whole mounts were prepared to score features of retinopathy. The parameters that were scored in a masked fashion included blood vessel growth, blood vessel tuft formation, extra retinal neovascularization, degree of central vasoconstriction, retinal hemorrhage, and tortuosity of vessels. Diltiazem (0.05-0.5 mg/kg/day subcutaneously for five days) was administered to mice pups during exposure to oxygen to determine if calcium channel blockade altered retinopathy. In addition, quantification of retinal neovascular nuclei was performed in a masked fashion with periodic acid Schiff (PAS) staining of frozen eye sections. RESULTS: Animals that were exposed to hyperoxia for five days had a median (25th, 75th quartile) retinopathy score of 9 (8,11) versus control animals that had a retinopathy score of 1 (0,1) with p<0.001. Subscores for blood vessel growth, blood vessel tufts, extra-retinal neovascularization, central vasoconstriction, hemorrhage, and blood vessel tortuosity were all significantly different between control and treated animals. In addition, quantification of neovascular nuclei showed a significant increase in the number of nuclei extending beyond the inner limiting membrane into the vitreous in hyperoxic treated animals. Diltiazem at doses of 0.2 and 0.5 mg/kg/day improved the retinopathy as measured by the total retinopathy score [5 (4,6) and 4 (3.75,5.25), respectively]. The average number of extraretinal neovascular nuclei per retinal section (mean +/-standard deviation) was significantly decreased by diltiazem at doses of 0.2 and 0.5 mg/kg/day (31.4+/-18.8 and 20.9+/-6.9, respectively) when compared to hyperoxic treated animals (56.1+/-21.5). CONCLUSIONS: Diltiazem reduces oxygen induced retinopathy in the mouse as measured by a scoring system based on a retinal whole mount method of retinal neovascularization and by quantification of extra retinal neovascular nuclei.

Fibronectin expression in bronchopulmonary dysplasia.

Bronchopulmonary dysplasia (BPD) is a chronic fibrotic lung disease of neonates. Fibronectin (FN), a component of the extracellular matrix, is increased in the tracheobronchial effluent of neonates destined to develop BPD. Pulmonary FN is derived from plasma and local cellular synthesis. In order to identify which pulmonary cells synthesize FN and to test the hypothesis that FN is more abundant in lungs with BPD, we examined the distribution of pulmonary FN by in situ hybridization (for mRNA) and immunohistochemistry (for protein) in neonatal autopsy lung specimens, comparing lungs with BPD to those without. We used a staging system in which BPD is characterized by disruption of alveolar architecture, severe vascular changes, airway epithelial necrosis, smooth muscle hypertrophy, and peribronchial fibrosis. FN mRNA and protein were found in vascular endothelium, macrophages, fibroblasts, vascular and airway smooth muscle, and chondrocytes as well as in the pulmonary parenchyma in neonates with and without BPD. Hyaline membranes, when present, immunostained intensely for FN protein. FN mRNA was not seen in airway epithelial cells of either group. FN mRNA and protein were first increased in early acute BPD with their levels appearing greatest during the chronic reparative stage of BPD. In long-standing "healed" BPD, lower levels of FN mRNA and protein were seen. These findings are consistent with the association of increased FN with adult fibrotic lung disease and the previously reported increase in FN tracheal effluent levels in infants with BPD. Our results suggest an important role for pulmonary cell-derived FN in the early inflammatory and later proliferative stages of BPD.

Combined ganciclovir and foscarnet in pediatric cytomegalovirus retinitis.

Cytomegalovirus retinitis is the leading cause of blindness in adults and children with acquired immunodeficiency syndrome (AIDS). Although clinical trials on therapy exist for adults, management of cytomegalovirus retinitis in children is not as well-documented. This report describes the clinical course of a 3-year-old child with cytomegalovirus retinitis. After initial failure with single-agent ganciclovir intravenous treatment, early institution of combined treatment with foscarnet and ganciclovir halted progression of the retinitis. This case report highlights the aggressive nature of cytomegalovirus retinitis in children and the consideration of early combined therapy compared to adult patients.

Results of the surgical treatment for thoracic outlet syndrome.

Excellent and good results following different operations for TOS are close to 80%, using simple statistics, where results included many patients followed up for only a few months. Using life-table methods, the success rate is 6% to 9% less, close to 70%, at 5 years. The results were virtually identical for anterior and middle scalenectomy, transaxillary first rib resection, and combined supraclavicular scalenectomy and first rib resection. Secondary success, the results of reoperation on patients in whom the first operation failed, improved the results of the primary operation 15% and 17%, respectively, for transaxillary rib resection and anterior and middle scalenectomy. When the initial operation was combined rib resection and scalenectomy, fewer patients underwent reoperation, as only neurolysis could be performed, and the results improved only 3%. A significant variable in results was etiology: Work-related injuries versus non-work-related accidents, usually auto accidents. Results of three independent studies showed better success rates by 13% to 15%, in patients who had non-work-related auto accidents, as compared with work-related injuries.

Surgical management of subclavian vein obstruction, including six cases of subclavian vein bypass.

BACKGROUND: The indications are still being developed for the various procedures available to treat thrombotic and nonthrombotic subclavian vein obstruction. This article explores our experience with the surgical options, primarily with chronic venous occlusion, but also with acute thrombosis. METHODS: Twelve patients presented with acute or chronic venous thrombosis or nonthrombotic venous obstruction. Treatment included thrombolysis, vein patch angioplasty, thrombectomy, first rib resection, venolysis, and/or subclavian vein bypass by either jugular vein transposition or prosthetic axillojugular bypass. RESULTS: Six patients experienced relief of all symptoms; the other six have had relief from pain but continue to have occasional swelling. CONCLUSIONS: On the basis of our anecdotal experiences and those of others, the following protocol has been developed. After acute thrombosis, lytic therapy is recommended. If successful, first rib resection and venolysis should be considered; if unsuccessful and the patient has significant symptoms, immediate thrombectomy is indicated. If patency is established, rib resection and venolysis should follow. Persistent stenosis is treated by angioplasty, either with a vein patch or percutaneously. Complete occlusion is managed by jugular vein transposition or axillojugular bypass. Temporary arteriovenous fistulas accompany all open venous repairs.

Uveal melanomas in black patients: a case series and comparative review.

Uveal melanomas are rare in black patients. Of a total of 2586 patients with the diagnosis of posterior uveal melanoma who were managed in the Oncology Service at Wills Eye Hospital from 1974 to 1987, 10 patients (0.39%) were black. Data on patient age (mean: 53.9 years), sex (male-to-female ratio: 7:3), and relative frequency of disease between black (0.39% of total cases) and white patients were similar to that of previous reports. The distinguishing characteristics (incidence, risk factors, complications, and prognostic indicators) of uveal melanoma in black versus white patients also were reviewed.

Two doses of early intravenous dexamethasone for the prevention of bronchopulmonary dysplasia in babies with respiratory distress syndrome.

Bronchopulmonary dysplasia is an important complication of ventilation in babies for which treatment with steroids has been advocated. We report the results of a phase I study of early i.v. dexamethasone to prevent the development of bronchopulmonary dysplasia in a high-risk population of ventilated premature babies, < 30 wk gestation, with surfactant-treated respiratory distress syndrome. This study used a limited dexamethasone dosing regimen to minimize toxicity but used administration early in the course of acute lung disease to interrupt the injury cycle. Forty babies were enrolled; 19 were randomized to receive dexamethasone (0.5 mg/kg birth weight at 12-18 h of age and a second dose 12 h later) and 21 were randomized to receive placebo (i.v. saline). The dexamethasone group required less ventilatory support (mean airway, peak inspiratory and end expiratory pressures, and intermittent mandatory ventilation) and supplemental oxygen after study d 4 (all p < 0.05, repeated measures analysis of variance). Improved tidal volume in the dexamethasone group, as measured by pulmonary function testing of infants who remained intubated, was seen on study d 7 (p = 0.02, t test). The dexamethasone group required shorter hospitalizations (median of 95 d versus 106 d, p = 0.01) (proportional hazards regression). Survival in the dexamethasone group was 89% versus 67% in the placebo group (p = 0.08, chi 2 analysis). Survival without bronchopulmonary dysplasia, diagnosed at 36 wk corrected gestational age, was 68% in the dexamethasone group versus 43% in the placebo group (p = 0.14).(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylactic effects of recombinant human superoxide dismutase in neonatal lung injury.

To determine if recombinant human Cu-Zn superoxide dismutase (rhSOD) would prevent acute lung injury caused by hyperoxia and barotrauma, 26 newborn piglets were studied. Ten piglets were hyperventilated (arterial PCO2 15-20 Torr) with 100% O2 for 48 h. A second group received identical treatment for 4 h (n = 2) or 48 h (n = 8) but was given 5 mg/kg of rhSOD intratracheally at time 0. Six piglets were normally ventilated (arterial PCO2 40-45 Torr) for 48 h with 21% O2. Pulmonary function and tracheal aspirates were examined at time 0 and at 24 and 48 h, and bronchoalveolar lavage was performed at 48 h. In piglets treated with hyperoxia and hyperventilation, lung compliance decreased 42%, and tracheal aspirates showed an increase in neutrophil chemotactic activity (32%), total cell counts (135%), elastase activity (93%), and albumin concentration (339%) over 48 h (P < 0.05). All variables were significantly lower in rhSOD-treated piglets and comparable to normoxic control values. Surfactant remained active in all groups. Immunohistochemistry demonstrated that at 48 h significant rhSOD was distributed homogeneously in terminal airways. Adding rhSOD to tracheal aspirates of hyperoxic hyperventilated piglets did not alter neutrophil chemotaxis, suggesting that rhSOD protected the lung by reducing the production of chemotactic mediators. Results indicate that acute lung injury caused by 48 h of hyperoxia and hyperventilation is significantly ameliorated by prophylactic intratracheal administration of rhSOD.

Diabetes-related eye disorders.

Ocular complications from diabetes represent a significant public health problem. Diabetic retinopathy alone represents a leading cause of new blindness each year in the United States. Neovascular glaucoma from diabetes, although not nearly as common, inflicts devastating consequences on vision. Together with the more frequent occurrence of other ocular disorders that cause visual impairment, the visual toll of diabetes is staggering. Much of this blindness is preventable with early detection and timely treatment.

Ossification in the patellar tendon and patella alta following sports injuries in children. Complications of sleeve fractures after conservative treatment.

Two patients with sleeve fractures of the patella and tibial tuberosity respectively are described. Our two cases demonstrate that the diagnosis can be difficult; patella alta and ossification in the patellar tendon are complications of conservative treatment. Early diagnosis and operative reduction and fixation are mandatory.

Retinal detachment after cataract surgery. Predisposing factors.

The authors studied the characteristics of 376 eyes of 361 patients with primary retinal detachment (RD) and surgical aphakia (103 eyes) or pseudophakia (273 eyes). Of the pseudophakic eyes, 17 had an iris-fixated intraocular lens (IOL), 111 had an anterior chamber (AC) IOL, and 145 had a posterior chamber (PC) IOL. Of the PC IOL cases, 48 (33%) had undergone YAG capsulotomy, and 46% of them developed RD within 6 months after capsulotomy. The frequency of no breaks found in pseudophakic RD (15%) was significantly higher than in RD with simple aphakia (5%). The most frequent reasons were incomplete fundus view due to a small pupil in the iris-fixated (83%) and the AC (44%) groups, and cloudiness of capsular remnants in the PC group (78%). In pseudophakic RD, sizable single tears, located more posteriorly than in RD with simple aphakia, were frequent. The authors speculate that in pseudophakic RD the retinal breaks may resemble those noted in phakic RD.