Long-term survival of uveal melanoma patients after surgery for liver metastases

AIMS

To evaluate the posthepatectomy survival of uveal melanoma patients with liver metastases.

METHODS

Data were collected from the files in the Departments of Ophthalmology, General Surgery and Oncology, for uveal melanoma patients who were seen in the Ocular Oncology Clinic at the Hadassah Medical Center from 1988 to 2007. The main outcome was posthepatectomy survival. Statistical analysis was performed using JMP statistical software.

RESULTS

Of the 558 patients, 74 (13%) developed metastases after a median of 35.0 months from the initial diagnosis. Thirty-five patients underwent hepatectomy. These patients had similar clinical characteristics as those who did not undergo hepatectomy. The median survival time from the detection of metastasis was 3.7-fold higher in the operated patients in comparison with the non-operated patients. Posthepatectomy survival of patients who were found in surgery to have 1-5 metastatic nodules was 3.1 times longer than those with six or more lesions. The hepatectomies of 13 patients resulted in complete resection of the hepatic metastases with clean histological margins (R0). These patients survived 1.9 times longer than those with residual disease (R1/R2).

CONCLUSION

It is possible to extend significantly the life expectancy of uveal melanoma patients who develop isolated hepatic metastases by complete resection of the lesions.

Fluoroscopy-based navigation system in spine surgery

The variability in width, height, and spatial orientation of a spinal pedicle makes pedicle screw insertion a delicate operation. The aim of the current paper is to describe a computer-assisted surgical navigation system based on fluoroscopic X-ray image calibration and three-dimensional optical localizers in order to reduce radiation exposure while increasing accuracy and reliability of the surgical procedure for pedicle screw insertion. Instrumentation using transpedicular screw fixation was performed: in a first group, a conventional surgical procedure was carried out with 26 patients (138 screws); in a second group, a navigated surgical procedure (virtual fluoroscopy) was performed with 26 patients (140 screws). Evaluation of screw placement in every case was done by using plain X-rays and post-operative computer tomography scan. A 5 per cent cortex penetration (7 of 140 pedicle screws) occurred for the computer-assisted group. A 13 per cent penetration (18 of 138 pedicle screws) occurred for the non computer-assisted group. The radiation running time for each vertebra level (two screws) reached 3.5s on average in the computer-assisted group and 11.5s on average in the non computer-assisted group. The operative time for two screws on the same vertebra level reaches 10 min on average in the non computer-assisted group and 11.9 min on average in the computer-assisted group. The fluoroscopy-based (two-dimensional) navigation system for pedicle screw insertion is a safe and reliable procedure for surgery in the lower thoracic and lumbar spine.

[Neurological damage in pelvic injuries: a continuous prospective series of 50 pelvic injuries treated with an iliosacral lag screw]

PURPOSE OF THE STUDY

The purpose of this study was to analyze lesions to the lumbosacral plexus related to pelvic injury and its treatment.

MATERIAL AND METHODS

Forty-four patients presented 50 posterior osteoligamentary lesions of the pelvic girdle. All patients except eight had other injuries. Mean ISS was 27/75. Posterior lesions were: iliosacral disjunction (n=23), extra-foraminal fracture of the sacrum (n=4), transforaminal fracture (n=22), intra-foraminal fracture (n=1). Vertical posterior displacement was > 1 cm for 24 posterior lesions. Orthopedic reduction was performed at admission for all patients. Fluoroscopy-guided percutaneous lag screw fixation was performed in all cases, on the average eight days after the accident. Neurological involvement was evaluated at admission, after surgery, and at last follow-up. Data were recorded for skeletal muscles, lower limb dermatomes, tendon reflexes, and anal tone. Screw emplacement was checked on the CT-scan. Outcome was assessed subjectively with the Majeed score, a self-administered visual analog scale, and use of antalgesic drugs according to the WHO classification.

RESULTS

The neurological examination could not be performed for ten patients at admission. Postoperatively, there was a neurological deficit associated with 26 osteoligamentary lesions (23 lesions of the lumbosacral trunk, 14 lesions of the S1 spinal nerve, 3 lesions of the pudendal nerve, 12 lesions of the superior gluteal nerve, and 10 lesions of the femoral nerve). Patients with neurological involvement had experienced more severe trauma. The iliosacral screw was partially extra-osseous in thirteen cases, with an associated iatrogenic neurological deficit in seven. At mean follow-up of 20 Months (range 4-50) there persisted ten major sequelae including eight cases of hallux extensor deficit.

DISCUSSION

Neurological involvement is underestimated during the acute phase of trauma. After recovery, only the manifestations of major injuries persist. The prognosis is poor in the event of a stretched lumbosacral trunk or gluteal nerve due to iliosacral disjunction. Prognosis is good for nerve contusion due to sacral fracture because of early reduction. The femoral nerve is generally injured by compression due to a peri-fracture hematoma; recovery is the rule. Iliosacral screwing requires rigorous technique by a skilled and experienced surgeon.

CONCLUSION

About 52% of posterior osteoligamentary injuries are associated with neurological symptoms. After recovery, permanent deficit persists in 21.7%. The most common sequelae are hallux extensor and gluteus medius palsy due to stretching of the lumbosacral trunk.

[Budd-Chiari syndrome: updated treatment modalities]

Budd-Chiari Syndrome (BCS) refers to hepatic venous outflow obstruction, resulting in simultaneous occurrence of hepatic congestion and portal hypertension, leading to a typical clinical triad consisting of right upper quadrant pain, hepatomegaly and ascites. Contrary to Asia and Africa, where BCS is caused primarily by an obstructing membranous web, BCS in the western world is considered a thrombotic complication of an underlying hypercoagulable state. Recognition of the contribution of hypercoagulability as a causative factor in BCS, has led to acknowledgement of the importance of anti-coagulant therapy in BCS. Indeed, a conservative approach consisting of diuretics and anti-coagulant therapy is considered an appropriate treatment strategy for the BCS patient, in the absence of significant hepatic insult. However, once disease progression is noted, based on clinical symptoms, hepatic laboratory disturbance or histological evidence of irreversible hepatic damage, a definite invasive treatment should be applied. The specific procedure to be used is dependent upon the extent of hepatic insult and the anatomical characteristics of the venous obstruction in any individual patient. In the absence of significant hepatic damage, one may employ surgical shunting or invasive roentgenic measures, such as TransJugular Intrahepatic Porto-Systemic Shunt procedure, for the decompression of the portal system. Alternatively, in cases of a single localized obstruction, one may use balloon angioplasty with stent insertion. In contrast, upon evidence of significant hepatic damage, liver transplantation becomes necessary. To date, numerous studies report excellent results regarding the success of liver transplantation for patients with advanced BCS disease accompanied by significant hepatic damage.

Video reconstructions in dentistry

OBJECTIVES

To present two practical techniques for three-dimensional (3D) modeling of the human jaw from a sequence of intra-oral images.

DESIGN

A data acquisition system consists of: 3D digitizing arm, CCD camera and a laser projector in addition to a software module of two 3D modeling techniques; shape from shading (SFS) and space carving (SC).

SETTING AND SAMPLE POPULATION

Several experiments have been conducted on a sample of students at the Computer Vision and Image Processing (CVIP) Laboratory at the University of Louisville, Louisville, KY. Other experiments were performed on solid models of human jaw.

EXPERIMENTAL VARIABLE

The SFS technique, using perspective projection and camera calibration, extracts the 3D information from a sequence of two-dimensional images of the jaw. Data fusion of range data and 3D registration techniques develop the complete jaw model. The SC approach is implemented on a sequence of calibrated images. On the two reconstructions, we fit a mesh model to the data, in order to create a solid 3D model.

OUTCOME MEASURE

The accuracy of the reconstructed 3D model of human jaw is calculated based on the measurements on real jaws.

RESULTS

The SFS-based technique seems to provide more faithful information about the shape of the tooth tops. However, the SC algorithm successfully reconstructed 3D models of the human jaw with sub-millimeter accuracy, which is as accurate as (or even better than) the first technique without using any range measurements or laser projectors. The average error in distance calculation was found to be 0.74 mm, which is an acceptable resolution for many orthodontics and maxillofacial applications.

CONCLUSION

Accurate 3D reconstruction of the human jaw enables many orthodontics and dental imaging research findings to be applied directly to a digital jaw model--not to a cast--using computer vision and medical imaging tools.

Late onset Ommaya reservoir infection due to Staphylococcus aureus: case report and review of Ommaya Infections

The Ommaya reservoir system has been used for the treatment of chronic central nervous system infections and intracranial tumors for more than three decades. The majority of reported Ommaya reservoir infections occur proximate to the time the device is accessed. A review of the literature reveals that late onset of reservoir infection is quite rare. We report a case of Ommaya reservoir infection due to Staphylococcus aureus that was diagnosed seven years after its insertion and usage for intracerebral non-Hodgkin's lymphoma and review the literature on the microbiology and management of Ommaya reservoir infections.

Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial

CONTEXT

Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients.

OBJECTIVE

To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock.

DESIGN AND SETTING

Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000.

PATIENTS

A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin).

MAIN OUTCOME MEASURE

All-cause mortality 28 days after initiation of study medication.

RESULTS

Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001).

CONCLUSIONS

High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.

Kidney transplantation unraveling Wolfram syndrome: a case report

BACKGROUND

In Wolfram syndrome insulin-dependent diabetes is associated with a multisystem neurodegenerative disorder. There are no prior reports of kidney transplantation in patients with Wolfram syndrome.

METHODS

Kidney transplantation was undertaken in a child with dysplastic kidneys, sensorineural hearing impairment and bilateral optic atrophy-a combination of features insufficient to define Wolfram syndrome.

RESULTS

After the procedure diabetes mellitus, diabetes insipidus and urinary bladder dysfunction emerged, thereby revealing Wolfram syndrome.

CONCLUSIONS

We discuss the etiology of our patient's postoperative events, and conclude that kidney transplantation may expose dormant manifestations-or aggravate existing manifestations-of Wolfram syndrome.