Gastric intestinal metaplasia - age, ethnicity and surveillance for gastric cancer

AIM

Determine the prevalence and distribution of gastric intestinal metaplasia (GIM) in a large cohort of patients subjected to esophagogastroscopy (EGD). Evaluate usefulness of grading the severity of gastritis, GIM and the impact of Helicobacter pylori (HP). Define the population at risk for gastric adenocarcinoma (GC) and assess the value of surveillance.

METHODS

In the course of 19 years, we performed 11,600 sequential EGDs in male veterans at Brooklyn, New York. Of all patients, 47 % had EGD only one time while 53 % had EGD repeated, 11 % of these had four or more EGDs. Patients with GIM were matched with equal number of controls with no GI symptoms. All gastric biopsies were processed in one laboratory, using the standardized protocol for histological staining and for grading the severity of epithelial changes.

RESULTS

Of all patients subjected to EGD, 354 (3.05 %) were diagnosed with GIM. Compared to controls, GIM patients were older, 80 % were over 71. Regarding ethnicity, GIM was 5.4 % more frequent in 177 African Americans than in 159 Caucasians. Distribution of GIM did not differ with respect to age or ethnicity. As many as 6 %of GIM cases were diagnosed with GC. Grading of GIM severity had a predictive value, the average grade of severity in GC was 50 % higher than in non-cancer patients with GIM. Severity of gastritis was also a useful biomarker: patients with GC had more severe gastritis. Surprisingly, HP positivity had no predictive value: HP positive patients had similar distribution of GIM as the HP negative patients. Use of proton pump inhibitors in the past was unknown.

CONCLUSION

Prevalence of GC in patients with GIM was more than 200 times higher than reported in normal population. Age more than 70 years and African Americans appeared to be at higher risk. Routine EGD and histological diagnosis, with simple grading of severity of epithelial changes provides a useful predictive information. Individuals with upper GI symptoms undergoing EGD with gastric biopsy benefited from routine clinical screening for GC. Patients with higher severity of GIM should enter surveillance (Tab. 1, Fig. 10, Ref. 45).

Cytodiagnosis of Sacral Chordoma

We report the cytological findings of a sacro-coccygeal chordoma in a 53 year male diagnosed preoperatively by guided fine needle aspiration cytology. The smears shows characteristic Physalliphorous cells in a metachromatic background of myxoid material entrapping cords of cuboidal cells. Differential diagnosis in cytology include conventional and myxoid chondrosarcoma, myxoid liposarcoma, myxoid malignant fibrous histiocytoma(MFH), metastatic mucinous carcinoma and myxo-papillary ependymoma. The distinguishing features between these neoplasms are discussed. Preoperative diagnosis of chordoma permits optimum planned surgery.

The Process of Team Boundary Spanning in Multi-Organizational Contexts

Work teams must increasingly operate in complex environments characterized by multiple external actors beyond team and organizational boundaries. Although previous research demonstrates the importance of boundary spanning activities to team effectiveness, it reveals relatively little about the process of boundary spanning in these environments. In this article, we investigated the processes of boundary spanning across multiple external actors in 10 cross-organizational teams. We identified three sequences for reaching out to external actors: (a) moving inside-out from vertical actors inside the host organization to horizontal actors outside of the host organization, (b) moving outside-in from horizontal actors to vertical, and (c) staying-inside with vertical actors from the host organization. Our observations suggest that inside-out and outside-in sequences were more successful than simply pleasing the host organization. We build on our empirical findings to develop a process theory of how team boundary spanning activities across multiple external actors influence team effectiveness. Our research underscores the importance of a team’s interactions with actors in its external environment beyond those in an immediate supervisory role and provides insight into the dynamics of boundary spanning in multi-organizational contexts.

A rare case of a solitary intraocular neurofibroma

BACKGROUND

Solitary neurofibroma in the absence of neurofibromatosis is of rare occurrence and very few cases have been reported till date.

OBJECTIVE

To report a case of a solitary intra-ocular neurofibroma.

CASE

A 65-year-old man presented to us with a large swelling appearing to arise from right pthisical eye for the past one and a half years. After knowing the extent and origin of mass lesion, right eyeball was enucleated and subjected to histopathological examination which revealed intraocular neurofibroma in the absence of neurofibromatosis which is of very rare occurrence.

CONCLUSION

The isolated neurofibroma of intraocular origin can present as an isolated orbital mass without systemic features.

Deep sclerectomy with mitomycin C in eyes with failed glaucoma surgery and pseudophakia

PURPOSE

To report outcomes of deep sclerectomy (DS) with intraoperative mitomycin C (MMC) application in eyes with previous failed glaucoma surgery (GS) and/or cataract extraction (CE).

PATIENTS AND METHODS

Single-surgeon case series of 82 eyes of 82 patients undergoing DS with MMC. The patients had previous CE with IOL and/or conjunctival GS and treated intraocular pressure (IOP) >18 mm Hg. MMC (0.2 mg/ml) was applied for 2-3 min before scleral flap dissection. Complete success was defined as IOP between 6 and 21 mm Hg or a reduction of 20% from baseline without medications. Reoperation for glaucoma or related complications, or loss of light perception vision was considered as failure.

RESULTS

Mean follow-up was 57.7 ± 22.4 months with 78% of patients completing the 3-year follow-up. Mean IOP decreased from 24.0 mm Hg (22.3-25.6, 95% confidence intervals) to 13.4 mm Hg (12.0-14.2) at 3 years after surgery (P<0.001). There was a significant decrease in the number of glaucoma medications from 2.0 ± 1 preoperatively, to 0.3 ± 0.7, 3 years after surgery. Kaplan-Meier cumulative success rates were 85.6% at 1 year, 80.0% at 2 years, and 76% at 3 years. At 3 years, IOP was maintained <19 and 15 mm Hg in 83 and 70% of eyes, respectively. Fourteen eyes (17.1%) had complications. Delayed hypotony (IOP <6 mm Hg) was the commonest complication in five eyes (6.1%).

CONCLUSION

DS with MMC appears to be a safe and effective surgical procedure for eyes with previous intraocular surgery.

Combined phacoemulsification and deep sclerectomy (PDS) with intraoperative mitomycin C (MMC) augmentation

AIM

To report the safety and efficacy of intraoperative mitomycin (MMC) augmentation of combined phacoemulsification and deep sclerectomy (PDS).

METHODS

Retrospective, non-randomized, comparative, interventional case series of 119 eyes (63 with and 56 without MMC augmentation) of 119 patients who had PDS between September 2001 and April 2004.

RESULTS

The mean follow-up was 23 months (range 12-41 months). There were no differences in the baseline characteristics of the two groups except that patients from the phacoemulsification and deep sclerectomy with mitomycin C (PDS-MMC) group were on average, younger by 3 years (P=0.01). Two years after surgery, the probability of maintaining an IOP below 19 and 15 mmHg without glaucoma medications or needle revision was 76 and 62% in the PDS-MMC group and 62 and 45% in the PDS-no MMC group (P=0.02 and 0.04, respectively). Nd:YAG laser goniopuncture was performed in 71.4% of eyes in the PDS-no MMC and 61.9% of the PD-MMC group (P=0.33). Needle revision was performed in 21.4% of the PDS-no MMC and 17.4% of the PDS-MMC group (P=0.65). Ten patients (8.4%) lost more than two lines of Snellen's visual acuity during follow-up, with no difference between the groups. There were few serious complications related to MMC use (hypotony in one eye after laser goniopuncture). The overall incidence of transconjunctival oozing in the PDS-MMC group was 9.5% compared with 5.4% in the PDS-no MMC group.

CONCLUSION

This study demonstrates that augmentation of PDS with MMC is safe. MMC augmentation appears to increase the probability of achieving lower target intraocular pressures after combined PDS.

Sudden asystole during surgery in the cerebellopontine angle

We report a case of a 40-year-old lady undergoing surgery for a tumor in the cerebellopontine angle. Intraoperatively, patient had a sudden asystole without prior warning sign of bradycardia. It could have been the severe form of trigeminocardiac reflex. The cardiac rhythm returned spontaneously once the surgical manipulation stopped. The remainder of the operation was uneventful and no complication occurred afterwards. The possible mechanism of the event is discussed.

Deep sclerectomy and low dose mitomycin C: a randomised prospective trial in west Africa

AIM

To study the efficacy and safety of deep sclerectomy (DS) augmented with intraoperative low dose mitomycin C (MMC) in a west African population.

METHODS

Prospective, randomised, controlled trial. Trial participants were Nigerian patients with medically uncontrolled primary open angle glaucoma undergoing primary surgery at Maja Hospital, Lagos, Nigeria. 39 eyes of 39 patients undergoing DS were randomised into receiving intraoperative MMC 0.25 mg/ml for 2 minutes at the end of procedure (DS-MMC) and a control group (DS-noMMC).

RESULTS

There were 21 patients in the DS-noMMC and 18 in the DS-MMC group with no difference in the preoperative characteristics of the groups. Mean follow up was 16.4 (SD 11.3) months. The probability of maintaining an intraocular pressure less than 18 mm Hg with or without additional medications (95% confidence intervals) at 1 year was 70% (47-92%, 95%) and 79% (57-100%), and at 18 months was 35% (8-62%) and 38% (7-69%) for the DS-noMMC and DS-MMC groups, respectively, with no difference in success rates (p = 0.6). An IOP of less than 18 mm Hg without additional medication was maintained in 65% (41-89%) and 73% (49-96%) at 1 year and 24% (8-48%) and 13% (13-46%) at 18 months for the DS-noMMC and DS-MMC groups, respectively (p = 0.5). There were no serious complications related to the procedure.

CONCLUSIONS

The success rates of DS in black west African glaucoma patients, as performed in this study, were low. The study did not achieve sufficient power to detect whether low dose intraoperative MMC application can increase success rates of DS.

Mitomycin C augmented glaucoma surgery: evolution of filtering bleb avascularity, transconjunctival oozing, and leaks

AIMS

To prospectively study the evolution of possible high risk features of conjunctival filtration blebs like avascularity, transconjunctival oozing (TCO), and leaks after mitomycin C (MMC) enhanced glaucoma surgery.

METHODS

Single observer, 2 year prospective study on bleb characteristics of 125 eyes of 125 consecutive patients who had MMC augmented glaucoma surgery with initially successful filtration. MMC (0.2 mg/ml for 2 minutes in most cases) was applied on the area of the scleral flap before dissection. Glaucoma surgeries included were trabeculectomy, deep sclerectomy, and combined procedures. A dry fluorescein strip was applied on the avascular part of the bleb and observed for aqueous egress with flow (point leak, PL) or without (TCO).

RESULTS

The mean time (95% CI) for observing bleb avascularity, TCO, and bleb leaks were 106 days (69 to 143), 208 days (155 to 261), and 609 days (559 to 659), respectively. Bleb leaks were observed in 17 eyes (13.6%)-15 (24.6%) in the trabeculectomy group and two (3.1%) in the deep sclerectomy group (p = 0.003). Kaplan-Meier survival analyses showed that the probability of observing bleb avascularity at sixth, 12th, and 24th month after surgery was 56%, 71%, and 73%, respectively. In eyes with avascular blebs, the probability of developing TCO and leaks was 77% and 1% at 6 months, 81% and 12% at 12 months, and 95% and 26% at 24 months, respectively. Cox's regression analyses and log rank tests showed that eyes with larger avascular blebs (>4 mm) were more likely to develop TCO (hazard ratio 3.77, p = 0.001) and delayed bleb leaks were more likely to be seen in eyes of the trabeculectomy group rather than the deep sclerectomy group (hazard ratio 0.06, p = 0.0006).

CONCLUSIONS

MMC application over the area of scleral flap dissection during glaucoma surgery is associated with a high incidence of bleb avascularity, TCO, and delayed bleb leaks. Most eyes developed bleb avascularity within the first year after surgery. TCO will eventually be seen in all eyes with avascular blebs and the incidence of leaks gradually increases with time. This study shows that patients with eyes undergoing glaucoma surgery with MMC and avascular blebs should be monitored indefinitely.

Combined cataract and glaucoma surgery with mitomycin C: phacoemulsification-trabeculectomy compared to phacoemulsification-deep sclerectomy

AIMS

To compare outcomes of phacoemulsification combined with trabeculectomy (PT) or deep sclerectomy (PDS) with intraoperative mitomycin C (MMC) application.

METHODS

Non-randomised, consecutive, retrospective comparative study. 97 eyes of 97 patients (59 PDS, 38 PT) undergoing combined surgery with intraoperative MMC (0.1-0.4 mg/ml for 1-3 minutes) were identified for inclusion in the study.

RESULTS

The probability of maintaining intraocular pressure (IOP) below 19 mm Hg and 15 mm Hg, with a 30% drop from preoperative IOP and without additional medication, 1 year after surgery were 77.6% (95% CI: 67 to 90) and 71.5% (60 to 85) for the PDS group and 89.5% (80 to 99) and 89.5 (80 to 99) for the PT group, respectively, and these differences were not statistically significant (p>0.05, log rank test). After excluding ocular co-morbidity no differences were observed in the improvement of visual acuity between the two groups. There were no major differences in the complication rates except that delayed bleb leaks were seen in seven eyes (18.4%) of the PT group (p = 0.004).

CONCLUSION

In this study, no statistically significant difference was found in the IOP and visual outcomes between PDS and PT. A significantly higher frequency of late bleb leaks after PT was observed.