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Patients with a clinically concerning dominant thyroid nodule have been managed by lobectomy or total thyroidectomy at our institution. We determined the complications associated with both approaches and the ability of thyroid lobectomy to avoid the need for thyroid hormone replacement therapy. Records of all patients with a dominant thyroid nodule managed with surgery from August 1993 through December 2000 were reviewed for demographics, history of head and neck radiation, indication for surgery, preoperative fine-needle aspirate results, final pathologic evaluation, perioperative complications, determinations of need for subsequent thyroid surgery after lobectomy, and need for thyroid hormone replacement therapy after surgery. Patients with a preoperative diagnosis of malignancy or bilateral or diffuse disease were excluded because these conditions would uniformly be managed by bilateral thyroidectomy. The complications for the lobectomy group (n = 131) compared with the total thyroidectomy group (n = 84) were: recurrent laryngeal nerve paresis (4.6% vs 2.4%), recurrent laryngeal nerve injury (0.8% vs 0), and transient hypoparathyroidism (1.5% vs 9.5%; P = 0.007). No permanent hypoparathyroidism was identified in either group. Postoperative thyroid hormone replacement was required in 64 of 131 lobectomy patients (48.8%). Complications associated with either surgery were low. Total thyroidectomy was not associated with clinically significant additive morbidity. Patients treated by lobectomy should be aware of a nearly 50 per cent chance of requiring thyroid hormone replacement. Total thyroidectomy avoids future thyroid surgery; lobectomy patients remain at risk. When complications can be minimized total thyroidectomy should be considered an option in the management for patients with dominant thyroid nodules that require surgery.
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PMID:A comparison of total thyroidectomy and lobectomy in the treatment of dominant thyroid nodules. 1220 1

Congenital cervical teratomas are associated with a high rate of perinatal mortality due to airway obstruction. We describe a multidisciplinary management of a neonate with prenatal diagnosis of giant cervical teratoma. An 'operation on placenta support' (OOPS) technique was carried out during delivery, and intubation was successfully performed with no perinatal anoxic damage. Postnatal computed tomography and angiography showed a huge teratoma covering both sides of the neck with agenesis of the big blood vessels on the left side. A rapidly developing third space phenomenon and deterioration in the general status of the neonate, required early surgical intervention. During surgical excision, the left carotid artery and internal jugular vein, the left lobe of the thyroid gland and the left recurrent laryngeal nerve were not detected. The left vagus, accessory and hypoglossal nerves were positioned between the skin and the tumor, at a distance from their normal anatomical location. Pathologic examination confirmed the diagnosis indicating immature teratoma with no signs of malignancy. The postoperative period was complicated by neurological deterioration, pharyngo-cutaneous fistula and paresis of the left hypoglossal nerve. However, all the symptoms resolved spontaneously. Tracheotomy was performed when the baby was 6 weeks old due to paralysis of the left vocal cord and to severe laryngo-tracheomalacia. She was decannulated when she was 3 years old. Today, she is suffering only from dysphonia. This report confirms the efficacy of a multidisciplinary team-approach and the usefulness of the OOPS technique in prenatally diagnosed cervical masses. It emphasizes the extraordinary characteristics of this case, mainly the development of a third space phenomenon and the unusual surgical findings.
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PMID:A multidisciplinary team approach for management of a giant congenital cervical teratoma. 1224 40

The objective of the study was to assess both the possible complications of percutaneous endoscopic gastrostomy (PEG) in pediatric cancer patients and its effect on weight development. The medical records of 18 children with a median age of 2.5 years (range, 0.5-14.2 years) were reviewed. The diagnoses were leukemia, central nervous system tumors, solid tumors, and lymphoma. The indications for PEG were anticipated therapy-related nutritional problems and inadequate food intake, weight loss, swallowing problems in relation to paresis of the pharynx, and relapse of the disease. Ten children received a PEG at treatment start, and eight children received it at a median time of 3.4 months (range, 0.9-27.4 months) after treatment start. The median duration of having a PEG in place was 12.3 months (range, 1.2-24.0 months). At admission the median weight for age expressed as standard deviation (SD) was -0.11 (range, -2.78-2.68). There was a significant (p =.005) decrease in the median SD from admission until PEG installation. There was also a significant increase in the median SD from the start of PEG use until 1 (p =.04) and 2 (p =.039) months after start. The most common complications were episodes of inflammation of the PEG site, which were successfully treated with topically or orally administered antibiotics, and episodes of infection, which required intravenously administered antibiotics. Taking into consideration the medical condition of the children in the study group and the considerable length of time with a PEG in place, we believe that nutrition via PEG in children with cancer has several advantages and is rarely associated with other than minor complications.
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PMID:Percutaneous endoscopic gastrostomy in children with malignant disease. 1224 27

A 37-year-old male presented a sudden diplopia. Ocular examination showed a partial paresis of the left eye (LE) on the left gaze, progressing in a few days towards a total ophthalmoplegia. Further investigation revealed an intra-orbital mass, immunohistologically diagnosed as a Diffuse Large B-cell Lymphoma (DLBCL), according to the WHO classification. Since the patient was in an advanced, disseminated stage of the disease (IVA-E), treatment was based on systemic and intrathecal chemotherapy with a pancranial radiotherapy. The clinical course was poor with only a 10-month survival. We wish to stress that the possibility of orbital malignancy in young adults with acute onset of ophthalmoplegia should be included in the differential diagnosis.
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PMID:Diplopia as an initial manifestation of disseminated non-hodgkin's lymphoma. 1256 15

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are distinct but related aspects of the same dynamic disease process known as venous thromboembolism (VTE). An estimated 200,000 new cases occur in the United States every year, including 94,000 with PE, resulting in an incidence of 23 per 100,000 patients per year-cases. Without treatment, pulmonary embolism is associated with a mortality rate of approximately 30%, causing nearly 50,000 deaths per year. Moreover, based on post-mortem studies, two-thirds of the patients with pulmonary emboli remain undiagnosed. Clinically, PE may present as (1) isolated dyspnea, (2) pleuritic pain and/or hemoptysis, and (3) circulatory collapse. However, clinical history and examination can be notoriously misleading in reaching a diagnosis. A number of acquired etiologic risk factors (predispositions) are associated with a tendency to develop VTE. These include increasing age, immobilization, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, as well as certain types of oral contraception and hormone replacement therapy. In addition, a variety of genetic risk factors, such as factor V Leiden, protein S or C deficiency have also been identified. However, in at least half of the instances, no predisposing factors can be identified (idiopathic PE). In the majority of cases thromboemboli originate in the deep veins of the calf or pelvis. The pathogenic conditions for VTE comprise a triad of factors and include (1) venous stasis, (2) hypercoagulable states, and (3) vascular endothelium injury. Occlusion of pulmonary arteries has variable and transient clinical and pathophysiologic consequences, involving both mechanical and reflex effects of vascular occlusion with a consecutive perfusion defect as well as the release of vasoactive and other inflammatory mediators. The objectives of this article are to present an overview of the etiologic and pathogenic factors promoting VTE as well as the pathophysiologic and inflammatory processes following PE.
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PMID:Principle mechanisms underlying venous thromboembolism: epidemiology, risk factors, pathophysiology and pathogenesis. 1258 87

Gore-Tex has been used as an effective implant for medialization laryngoplasty in the management of paralytic dysphonia; however, reporting of large patient cohorts has been limited. Furthermore, the use of Gore-Tex in the treatment of glottal incompetence secondary to soft tissue defects has not yet been described. Finally, a number of the procedural nuances of using Gore-Tex have not been elucidated. A prospective investigation was done on 142 patients who underwent 152 Gore-Tex medialization laryngoplasties in 183 vocal folds from December 1997 to March 2002. The primary diagnoses prompting the 152 procedures were paralysis in 94, paresis in 18, cancer reconstruction in 14, sulcus vocalis in 6, atrophy in 3, trauma defect in 5, arytenoid dislocation in 3, bilateral paralysis in 3, bilateral paresis in 1, parkinsonism in 4, and neurologic aerodynamic dissociation in 1. One patient who underwent reconstruction of a complex cancer defect required endoscopic removal of the Gore-Tex because of persistent granulation. Clinical observations reveal that Gore-Tex is a versatile implant that is ideally suited for phonosurgical reconstruction of aerodynamic glottal incompetence secondary to a variety of causes. Gore-Tex was especially useful for medialization of complex anatomic soft tissue defects such as those resulting from cancer resection, trauma, atrophy, and sulcus vocalis. There was superior ease in handling, placement, and in vivo adjustability.
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PMID:Medialization laryngoplasty with Gore-Tex for voice restoration secondary to glottal incompetence: indications and observations. 1259 93

Venous thromboembolism (VTE) is a common and potentially lethal disease that recurs frequently and is associated with long-term impairment and suffering. Despite a great deal of effort, the incidence of VTE has not changed substantially in the last 20 years. Independent risk factors include hospitalization (either for surgery or for acute medical illness), trauma, malignant neoplasm, central venous catheters or transvenous pacemakers, superficial vein thrombosis, and extremity paresis. Of these, hospitalization accounts for almost 60% of all VTE occurring in the community. Thus, universal effective prophylaxis of hospitalized patients would significantly reduce the incidence of VTE. Parenteral direct thrombin inhibitors are safe and effective for both prevention and treatment of acute VTE, and do not require laboratory monitoring or dose adjustment. Oral direct thrombin inhibitors may also be safe and effective, and offer enhanced convenience without diet or drug-drug interactions.
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PMID:The potential role of direct thrombin inhibitors in the prevention and treatment of venous thromboembolism. 1297 Jan 23

Venous thromboembolic disease (VTED) occurs commonly in geriatric medical patients, causing significant morbidity and mortality. Although VTED is preventable, prophylactic anticoagulation is underused. Awareness of the clinical risk factors that contribute to VTED in the elderly is essential for identifying candidates for prophylaxis. Iatrogenic risk factors include venous catheterization, transvenous pacemaker placement, hormone replacement therapy, and immobilization or prolonged bed rest. Medical conditions associated with increased risk include a previous episode of VTED, myocardial infarction, heart failure, severe lung disease, cancer, and neurological conditions associated with paresis. Obstacles to the widespread usage of VTED prophylaxis in geriatric medical patients include the clinically silent nature of VTED, underestimation of the risk and clinical effect of VTED in this population, and concerns about the cost and safety of anticoagulant therapy in this population. Clinical practice guidelines devised specifically for geriatric medical patients facilitate rational use of thromboprophylaxis in this population. The safety, efficacy, cost-effectiveness, and convenience of low-molecular-weight heparins for thromboprophylaxis are reflected in their increasing prominence in clinical practice guidelines and clinical use.
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PMID:Prophylactic anticoagulation for venous thromboembolic disease in geriatric patients. 1451 Nov 71

Metastatic lesions are the most common spinal extradural tumours. Significant advances in their neurosurgical management have been made in the last two decades. This retrospective study was undertaken to summarise the long-term results of surgery and the outcome of patients with cervical spine metastases. Sixty-two patients with cervical spine metastases who underwent instrumented spinal surgery at a single centre in an 12-year period (1989-2000) were analysed. All patients presented with local pain and with either neurological deficits, spinal instability, or a combination of both. A standard anterior approach to the cervical spine was chosen, and a partial or total vertebrectomy and vertebral body replacement with subsequent anterior instrumented fusion were carried out in all cases. General and neurological status was evaluated at baseline and in regular intervals thereafter. Plain X-rays, CT, and MRI were used for preoperative planning. Postoperative follow-up was done by X-rays. The mean follow-up time for all patients was 1.5 years. A stable bony fusion of the cervical spine was achieved in 60 patients (96.8%), with two additional patients needing a further procedure for maintaining the mechanical stability of the spine. There was mild early surgery-related morbidity, and no mortality. The most frequent temporary surgery-related side effect was reversible vocal cord paresis in 5 cases (8.0%). There were 3 cases (4.8%) of early instrumentation failure. One of these was symptomatic and underwent second-look surgery. No late complications occurred due to instrumentation hardware failure. The 1-year survival rate of all patients after surgery was 58%, and the 2-year survival rate was 21%. Our results demonstrate that surgical removal of extradural metastases with subsequent instrumented fusion is a low-morbidity and low-complications procedure with high rates of permanent stabilisation of the compromised cervical spine. In addition, it improves the neurological deficits and relieves the local pain in a significant proportion of patients. Excellent local control of malignant disease can be achieved by the surgical procedure aided by subsequent local and systemic adjuvant therapy. Overall survival time and prognosis of the patients, however, are mainly depending on the type and the stage of the primary malignancy.
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PMID:Results and outcome of neurosurgical treatment for extradural metastases in the cervical spine. 1457 9

Venous thromboembolism is a common and potentially fatal disease. If properly used, anticoagulation therapy is effective in preventing recurrence of venous thromboembolism and in improving survival. Symptomatic patients with an objective diagnosis of acute deep vein thrombosis (DVT) or pulmonary embolism (PE) should receive immediate systemic heparin anticoagulation at dosages sufficient to rapidly prolong the activated partial thromboplastin time into the laboratory-specific therapeutic range; this range corresponds to a plasma heparin concentration of 0.2 to 0.4 IU/ml (as measured by protamine sulfate titration), or 0.3 to 0.7 anti-Xa IU/ml. An oral vitamin K antagonist (e.g. warfarin) should be started within 24 hours after starting heparin; the starting dose should be the estimated patient-specific daily dose with no loading dose. Heparin and warfarin anticoagulation should be overlapped for at least 4 to 5 days and until the international normalized ratio (INR) is within the therapeutic range (2.0 to 3.0) on 2 measurements made at least 24 hours apart. The duration of warfarin anticoagulation should be individualized based on the respective risks of venous thromboembolism recurrence and anticoagulant-related bleeding. In general, warfarin should be continued for at least 3 months, and longer for patients with recurrent or idiopathic venous thromboembolism, malignant neoplasm, neurologic disease with extremity paresis, obesity, or laboratory evidence of a lupus anticoagulant/anticardiolipin antibody, homozygous carrier or combined heterozygous carrier for the factor V R506Q (Leiden) and prothrombin G20210A mutations, and possibly deficiency of either antithrombin, protein C, or protein S. Low molecular weight heparin (LMWH) is effective and well tolerated as acute therapy for patients with DVT or stable PE, and does not require laboratory monitoring or dose adjustment. Outpatient LMWH therapy is also well tolerated and cost effective for most patients with DVT, and possibly for selected patients with PE.
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PMID:Current management of acute symptomatic deep vein thrombosis. 1472 51


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