Evaluation the adjunctive use of combined bevacizumab and mitomycinc to trabeculectomy in management of recurrent pediatric glaucoma.

PURPOSETO evaluate the efficacy and safety of combined bevacizumab-mitomycin c (MMC) in recurrent cases of pediatric glaucoma.METHODSA prospective non-masked controlled study that included bilateral cases of 12 patients (24 eyes) with recurrent (had previous glaucoma surgery before) pediatric glaucoma. One eye in each patient (12 eyes) was assigned to trabeculectomy operation with combined application of MMC (0.4 mg/ml for 3 min) under and around the scleral flap before trabeculectomy and bevacizumab (avastin) (2.5 mg in 0.2 ml) injected subconjunctivally around the bleb after completing the surgery (group I). The other eye of each patient (12 eyes) was assigned to trabeculectomy operation with application of MMC (0.4 mg/ml for 3 min) only (group II). The mean follow-up period was 13±1 months.ResultsThe mean age was 2.16±1.5 (range 7 months to 4.1 years). No significant difference in preoperative intraoperative pressure (IOP) was observed between the groups (P>0.05). Recurrent primary congenital glaucoma represents 66.7% of the cases. Other cases included were recurrent aphakic and pseudophakic glaucoma 25% and recurrent post uveitic glaucoma 8.3%. The mean IOP was 12.1±4.2, 12.6±5.4, and 12.8±5.2 mm Hg in group I at 3, 6, and 12 months, respectively, and was 12.8±5.3, 13.7±6.7 and 15.6±5.9 mm Hg in group II at 3, 6, and 12 months, respectively. There was a statistically significant difference in the mean IOP between the studied groups at the 1-year follow-up visit (P<0.05). In addition, group I showed a higher statistically significant difference in absolute and total success (75 and 91.7%, respectively) compared with group II (58.3 and 75%, respectively) (P<0.05). The encountered complications included mild hyphema, which occurred in 8.33% in group 1, wound leakage, which occurred in 8.33% in each group, and shallow anterior chamber (AC), which occurred in 16.7% in each group and was the most common encountered complication in the study. One case of shallow AC in group I led to choroidal effusion (8.33%). One case in group II developed late bleb-related endophthalmitis after 3 months, which resulted in phthisis bulbi (8.33%).ConclusionThe additive effect of subconjunctival bevacizumab to MMC-augmented trabeculectomy in the case of recurrent pediatric glaucoma was beneficial in improving the success rate. Better IOP control and prolonging the bleb survivalvia reducing the long-term need of using anti-glaucoma drugs postoperatively without adding complications had also been achieved with this technique. This offers a promising alternative for the treatment of this type of glaucoma.

A randomized, prospective trial of deep venous thrombosis prophylaxis in aortic surgery.

OBJECTIVES: To study the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing elective aortic reconstruction and to determine if aggressive DVT prophylaxis would reduce the incidence of DVT in these patients. DESIGN: Randomized, prospective trial. SETTING: University hospital and Veterans Affairs hospital. PATIENTS: One hundred patients undergoing aortic reconstruction for aneurysmal or occlusive disease randomized to receive DVT prophylaxis (treatment group) or no prophylaxis (control group). Exclusion criteria included a history of DVT, long-term anticoagulant use, or a malignant neoplasm. During the study period, 12 patients were ineligible for follow-up. Ninety-eight patients completed the trial, including 50 patients in the treatment group and 48 patients in the control group. Two patients in the control group died postoperatively of unrelated causes. INTERVENTION: Patients in the treatment group received DVT prophylaxis using a combination of low-dose heparin sodium therapy (5000 U every 12 hours) and calf-length intermittent mechanical compression devices. Control patients received no DVT prophylaxis. MAIN OUTCOME MEASURES: The occurrence of acute lower extremity DVT diagnosed by interval venous duplex ultrasound scan surveillance performed on postoperative days 1, 3, and 7. RESULTS: The overall incidence of proximal DVT in this study was 2%. One case of DVT occurred in the treatment group, and the other one occurred in the control group. There was no statistically significant difference (P = .99) in the incidence of DVT between the 2 groups. One patients in the control group had a nonfatal pulmonary embolus (1% of the patients overall). CONCLUSIONS: The incidence of proximal DVT in patients undergoing elective aortic reconstruction is low compared with patients undergoing other major intraabdominal general surgical procedures. The use of aggressive DVT prophylaxis did not reduce the risk of postoperative proximal DVT in this study. The selective use of DVT prophylaxis in patients undergoing elective aortic surgery should be based on associated concomitant or evolving risk factors.

Early duplex scan evaluation of four vena caval interruption devices.

PURPOSE: Transvenous inferior vena cava (IVC) filters are used successfully for prevention of pulmonary embolism (PE), but early thrombotic complications such as insertion site thrombosis (IST) and inferior vena cava thrombosis (IVCT) may occur after placement. The frequency of these complications has been uncertain particularly for the wide variety of newer devices. This study was performed to prospectively evaluate IST and IVCT with color-flow venous duplex ultrasound scanning after four IVC filters were placed: the birds' nest filter, the titanium Greenfield filter, the stainless steel Greenfield filter, and the Simon nitinol filter. METHODS: Percutaneous IVC filters were placed in 174 patients over a 21-month period. A birds' nest filter was used in 39 (22%) cases, a titanium Greenfield filter in 67 (39%) cases, a stainless steel Greenfield filter (25%) in 43 patients, and a Simon nitinol filter in 25 (14%) cases. Filters were placed for major deep venous thrombosis in 113 (63%) patients, after PE in 26 (15%) patients, and with prophylaxis in 35 (20%) patients. All patients had color-flow venous duplex ultrasound scanning of the insertion site and the inferior vena cava 7 to 10 days after placement or before discharge to document IST or VCT. RESULTS: Early IST occurred in 43 (24.7%) cases, and early IVCT was observed in 20 (12%) cases in this series. No significant difference was found in the incidence of IST or IVCT among the four filter types used. The incidence of IVCT was significantly higher in patients having filters placed for PE. Men were more likely to receive a prophylactic filter than women in this study, but thrombotic complications were not related to patient sex. Thrombosis was seen with equal frequency at all insertion sites used. No patient died of PE after filter placement during the study period. CONCLUSIONS: The incidence of thrombotic complications for all devices was higher than has generally been reported. No IVC filter used in this study demonstrated superior performance with regard to these thrombotic complications. As vena cava interruption devices are developed or significantly modified, prospective objective analysis of associated thrombotic complications will allow logical selection for clinical use.

Drug and environmentally induced manipulations of the opiate and serotonergic systems alter nociception in neonatal rat pups.

The influence of drug- and environmentally induced alterations in serotonergic and opiate activity on pain sensitivity was assessed in 6-day-old Sprague-Dawley-derived rat pups using tail flick-testing procedures. The opiate agonist morphine was observed to induce tail flick analgesia that was blocked by concurrent administration of the opiate antagonist naloxone. Similarly, the serotonergic agonist quipazine induced analgesia that was blocked by pretreatment with the serotonergic antagonist metergoline. Naloxone alone did not alter tail flick responsivity in non-isolated, nondeprived neonates, suggesting that the opiate system may not exert a significant tonic inhibition of pain sensitivity in neonates. In contrast, the serotonergic system may exert some tonic analgesic influence at this age, given that metergoline was observed to induce slight hyperalgesia in nondeprived, non-isolated neonates. Twenty four hours of food and maternal deprivation, shown previously to increase brain serotonin and 5-hydroxyindole acetic acid and their ratio in neonates (L. P. Spear & F. M. Scalzo, 1984, Developmental Brain Research, in press) was observed to induce tail flick analgesia, an effect blocked by metergoline. Isolation from siblings and the dam and nest for 30 min also induced tail flick analgesia; this analgesia was blocked by treatment with naloxone prior to testing. Together, these experiments support the suggestion that the serotonergic and opiate systems may regulate pain sensitivity even in neonatal rat pups, with agonist- or environmentally precipitated increases in serotonergic or opiate activity inducing significant analgesia during the early postnatal period.