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Pituitary. 1999 Aug;2(2):155-62.
Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit.
Martin CH, Schwartz R, Jolesz F, Black PM.
Section of Neurosurgery, Brigham and Women's Hospital, Harvard University, Boston, MA 02115, USA.
BACKGROUND: Transsphenoidal resection is a well known surgical procedure used in the treatment of sellar and parasellar lesions. In certain cases, operative identification of the lesion and achieving a complete resection can be problematic. We describe a surgical image guidance method using an intraoperative MRI which provides definitive identification of a lesion and verification of a complete resection. MATERIAL AND METHODS: Five patients with pituitary macroadenomas underwent transsphenoidal resection of their tumors in the intraoperative MRI unit at the Brigham and Women's Hospital. This unit was developed as a collaboration between General Electric and BWH and is an open configuration 0.5 Tesla MR imager in which surgery can be performed with real time, intraoperative MR guidance. RESULTS: The transsphenoidal resections were performed in a standard fashion in this unit. Intraoperative imaging allowed accurate localization of the lesions, identification of pertinent surrounding structures, and the evaluation of the extent of each resection. In two patients, the resection would have been considered complete based on the surgical field of view alone but MR imaging allowed remaining tissue to be identified. Developing clot was seen in one patient after a fat graft had been placed. CONCLUSION: The intraoperative MR is a surgical modality by which transsphenoidal resection of pituitary macroadenomas can be performed using real-time image guidance. It allows definitive identification of the tumor and an immediate evaluation of whether resection is complete. It also can monitor the occurrence of intraoperative complications such as hemorrhage. This revolutionary device can be an important tool for the surgical management of pituitary tumors.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11081166&dopt=Abstract hemorrhage
Xenotransplantation. 2000 Nov;7(4):247-57.
Inhibition of platelet aggregation in baboons: therapeutic implications for xenotransplantation.
Alwayn IP, Appel JZ, Goepfert C, Buhler L, Cooper DK, Robson SC.
Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
Activation of endothelial cells and platelet sequestration play major roles in rejection of xenografts. The histopathology of both hyperacute and acute vascular or delayed rejection of vascularized discordant xenografts is characterized by interstitial hemorrhage and intravascular thrombosis. Agents that prevent platelet activation and consequent microthrombus formation have proven beneficial in xenograft rejection but do not fully preclude vascular thrombosis. Recently, several new anti-platelet therapies have undergone extensive clinical testing for atherosclerotic thrombotic vascular disorders; other putative therapies are undergoing pre-clinical evaluation. We have investigated the effect of several of these novel agents on platelet aggregation in baboons in order to screen for future potential in xenograft rejection models. METHODS: Drugs tested in these experiments were aurintricarboxylic acid (ATA, von Willebrand Factor-GPIb inhibitor), fucoidin (a selectin-inhibitor), 1-benzylimidazole (1-BI, thromboxane synthase antagonist), prostacyclin (PGI2, endothelial stabilizer), heparin (thrombin antagonist), nitroprusside sodium or nicotinamide (NPN or NA, both NO-donors), and eptifibatide (EFT, GPIIb/IIIa receptor antagonist). These were infused intravenously to nine baboons. Coagulation parameters and platelet counts were monitored and baboons were observed for adverse side-effects. The efficacy of these agents in inhibiting platelet aggregation was assayed in a platelet aggregometer. RESULTS: Treatment with ATA and fucoidin resulted in complete inhibition of platelet aggregation but also in major perturbation of coagulation parameters. 1-BI and PGI2 had no effect when administered alone, but in combination resulted in moderate inhibition of aggregation without disturbance in PT or PTT. NPN and NA had no substantive effects on platelet aggregation. Heparin resulted in specific inhibition of thrombin-induced platelet aggregation and, as anticipated, was associated with moderate prolongation of PTT. Importantly, EFT caused complete inhibition of platelet aggregation without changes in coagulation. Platelet counts, fibrinogen levels, and fibrinogen degradation products remained within the normal ranges in all experiments. CONCLUSIONS: Although excellent inhibition of platelet activation was obtained with ATA and fucoidin, clinical use may be precluded by concomitant disturbances of coagulation. Combinations of heparin and EFT may prove beneficial in preventing the thrombotic disorders associated with xenograft rejection while maintaining adequate hemostatic responses. These agents are to be evaluated in our pig-to-primate xenotransplantation models.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11081759&dopt=Abstract hemorrhage
Ann Thorac Surg. 2000 Oct;70(4):1202-6; discussion 1206-7.
Morbidity and mortality after 94 extrapleural pneumonectomies for empyema.
Shiraishi Y, Nakajima Y, Koyama A, Takasuna K, Katsuragi N, Yoshida S.
Section of Chest Surgery, Fukujuji Hospital, Kiyose, Tokyo, Japan. yujishvb.biglobe.ne.jp
BACKGROUND: Extrapleural pneumonectomy is still indicated in some patients with empyema. We examined morbidity and mortality after this high-risk operation. METHODS: Between 1979 and 1998, 94 (92 chronic, 2 postsurgical) patients with empyema underwent extrapleural pneumonectomy. There were 79 men and 15 women (mean age, 59 years). Eighty-eight patients had a history of tuberculosis, and 53 had undergone a therapeutic pneumothorax. The right side was operated on in 50 patients and left in 44. RESULTS: Operative mortality was 8.5%. Fifteen major complications (1 esophageal perforation, 9 empyemas, and 5 bronchopleural fistulas) occurred in 13 patients. Eight patients required reexploration for hemorrhage. Reexploration was a risk factor for empyema. Bronchopleural fistulas occurred only on the right side. Eighty-nine percent of the 86 operative survivors were free of empyemas at 5 years. Overall 5-year survival was 83%, and survival was better in patients without than in those with empyema. CONCLUSIONS: Extrapleural pneumonectomy for empyema has acceptable morbidity and mortality. Postoperative empyema affects prognosis. Covering a bronchial stump with muscle is recommended, especially when the operation is performed on the right side.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11081871&dopt=Abstract hemorrhage
Nervenarzt. 2000 Oct;71(10):822-7.
[Diagnostic and prognostic value of additional neurologic diagnosis in alcohol withdrawal delirium]
[Article in German]
Haensch CA, Jorg J, Baltzer F.
Klinik fur Neurologie und klinische Neurophysiologie, Universitat Witten/Herdecke, Wuppertal.
A severe course of alcohol withdrawal has been observed in 28% of patients in a neurological intensive care unit due to complicating central nerve system (CNS) diseases. In any atypical alcoholic delirium, especially with focal neurological signs, partial seizures, or decreased level of consciousness, CNS diseases like meningoencephalitis, intracranial hemorrhage, or central pontine myelinolysis must be diagnosed by computed tomography (CT) scan and cerebral spinal fluid (CSF) tap. The diagnostic and prognostic value of CT scan and CSF analysis was examined in 32 persons with alcohol withdrawal syndrome or delirium tremens. Neurological complications and cerebral convulsions at the beginning of delirium tremens appear to predispose the patient to a protracted clinical course and necessary mechanical ventilation. Blood-CSF barrier permeability is increased in 70% of alcohol withdrawal patients and that also seems to be a marker of a prolonged clinical course. Cerebral atrophy as shown in CT scan does not play a role in predicting clinical course. In our experience, CT examination or lumbar puncture is not necessarily recommended if clinical signs are typical for alcohol delirium.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11082813&dopt=Abstract hemorrhage
Nervenarzt. 2000 Oct;71(10):829-34.
[Stroke management in a stroke unit with rural catchment area]
[Article in German]
Hartmann SA, Lerche T, Wiborg A, Widder B.
Klinik fur Neurologie, Bezirkskrankenhaus Gunzburg. stephan.hartmanedizin.uni-ulm.de
The experiences of a rural stroke unit since 1997 are reported. A special referral concept was developed with the emergency services and hospitals of the region. As a result, 35% of patients arrived in the stroke unit within 3 hours after onset of stroke symptoms. This corresponds with the data from larger cities. The major peculiarity of the Gunzburg Stroke Unit is that, after emergency diagnostic and therapeutic procedures, 41% of the patients with mainly internistic problems were transferred to another regional hospital and only 40% were admitted to the inpatient stroke unit. Moreover, among these were an above-average proportion of patients with intracerebral hemorrhage (24% of the inpatients in 1998), and complete acute treatment and rehabilitation were carried out in the same hospital according to an integrative treatment concept. Since 1997, the average hospitalization duration decreased from 11.4 days to 5.9 days and the number of patients per month increased to an average of 22.3. The total hospitalization duration--including inpatient rehabilitation--was 33.9 days. All in all, a comparably good stroke treatment thus is possible outside urban regions.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11082814&dopt=Abstract hemorrhage
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