Podcasts about preoperatively

In this episode of the Back Table MSK podcast, co-hosts and interventional radiologists Dr. Aaron Fritts and Dr. Chris Beck have an in-depth discussion about bone marrow biopsies, including their preferred techniques and devices, potential complications, and management of patient expectations. To start, they cover the typical referral pathway for biopsies, the majority of which involve hematology/oncology indications. Preoperatively, managing patient expectations is important to communicate, especially regarding sedation and pain control. The IRs also walk through the biopsy steps, anatomy of the ilium, and confirmatory imaging with CT and fluoroscopy. They also share their experiences with different biopsy needles such as the OnControl, Jamshid, and Trek systems. There are advantages to using a system that comes with a powered drill, but these can also increase patient anxiety. Additionally, it is important to consider the bone density of the patient when selecting the tool. A manual system may offer sufficient force for demineralized or osteoporotic bone. The hosts also discuss potential unintended outcomes of the procedure, including dry taps and entry into joints or sacral foramina. Finally, they review post-procedural care and patient emergence from sedation. --- SHOW NOTES 00:00 Introduction 03:36 Indications for Biopsy 05:40 Patient Consent and Sedation 13:58 Procedural Steps and Confirmatory Imaging 27:04 Comparison of Different Biopsy Tools 36:11 Dealing with Complications 41:00 Post-Procedural Care --- RESOURCES BackTable VI Episode 381- Anesthesia vs. Moderate Sedation: A Spectrum of Care with Dr. Vishal Kumar: https://www.backtable.com/shows/vi/podcasts/381/anesthesia-vs-moderate-sedation-a-spectrum-of-care OnControl Powered Bone Biopsy System: https://oncontrolsystem.com/ Jamshidi Evolve Bone Marrow Needle: https://www.bd.com/en-us/products-and-solutions/products/product-families/jamshidi-evolve-bone-marrow-needle Trek Powered Bone Biopsy System: https://www.bd.com/en-us/products-and-solutions/products/product-families/bd-trek-powered-bone-biopsy-system

Hello, and welcome to Beauty and the Biz where we talk about the business and marketing side of plastic surgery and how to keep staff for the long-term. I'm your host, Catherine Maley, author of Your Aesthetic Practice – What your patients, are saying as well as consultant to plastic surgeons, to get them more patients and more profits. Now, today's episode is called “How to Keep Staff for the Long-Term with Mark Beaty, MD”. It's so interesting to learn how each surgeon runs their own practice given their interests, personality, and goals. There is no one way to grow a successful practice, although there are fundamentals. So, I interviewed Dr. Beaty, a cosmetic and facial reconstructive surgeon in private practice with 2 locations in and near Atlanta, GA. Dr. Beaty has been in practice for over 40 years and he shared so many pearls such as: How he manages to keep staff for the long-term, even during this time of staff shortages Working with his wife of 22 years who is also a physician in the practice Bringing on an associate this past year and what to watch out for His biggest mistake that set him back 5 years And, listen to the last 10 minutes where I asked him to tell us something we didn't know about him and I was not expecting the answer he gave! Enjoy this week's podcast on how to keep staff for the long-term with our special guest, Dr. Mark Beaty! I look forward to your feedback –

With oral operations, negative outcomes are bound to arise from time to time. Though, when we take the time to continue to stay informed of possible hazards and complications, we can better avoid these possible outcomes. On this episode of Dentist Brain Candy, I share three interesting articles from the the Journal of Oral & Maxillofacial Surgery, including my experience and judgment regarding each topic. I explain what cognitive and negative bias is and how to avoid it, my experience with frailty and oral surgeries, and my personal insight on penicillin and allergy evaluations. Listen in for insight on cognitive bias hazards after operative complications, how to minimize frailty preoperatively through prehabilitation and whether or not penicillin allergy is a risk factor for surgical site infection. Key Takeaways What cognitive and negative cognitive bias is Positive responses that a surgeon can take regarding a cognitive bias hazard Cognitive bias tendencies that can occur Complications to avoid after a complication or an adverse event Minimizing frailty preoperatively through prehabilitation and improving surgical outcomes Dr. Bryan's oral surgery experience with a frail 90 year old patient Important things to take into account when dealing with a frail patient A study on penicillin allergy and if it is a risk factor for surgical site infection after oral and maxillofacial surgery Dr. Bryan's insight on penicillin allergy and allergy evaluations Sneak peek of upcoming episode with Chris Salazar, all about using real estate to create other sources of income outside of dentistry and oral surgery Connect with Dr. Bryan McLelland Dentist Brain Candy Dentist Brain Candy Podcast Dentist Brain Candy App Dentist Brain Candy Continuing Education Dr. Bryan McLelland Dr. Jaw Breaker on Youtube Email Bryanmclelland@hotmail.com Resources Journal of Oral and Maxillofacial Surgery Cognitive Bias Hazards After an Operative Complication Minimizing Frailty Preoperatively Through Prehabilitation: Improving Surgical Outcomes Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery?

Dr. Tony Anderson, an anesthesiologist at the Stanford University School of Medicine, joins us to discuss the evolving literature and evidence around perioperative management of buprenorphine. Special thanks to Dr. Ashwini Joshi for her assistance with researching for the episode.  Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017 Jun;126(6):1180-1186. doi: 10.1097/ALN.0000000000001633. PMID: 28511196; PMCID: PMC7041233. Goel A, Azargive S, Lamba W, Bordman J, Englesakis M, Srikandarajah S, Ladha K, Di Renna T, Shanthanna H, Duggan S, Peng P, Hanlon J, Clarke H. The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes. Can J Anaesth. 2019 Feb;66(2):201-217. English. doi: 10.1007/s12630-018-1255-3. Epub 2018 Nov 27. PMID: 30484167. Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St-Jean M, Rashiq S, Van Camp K, Flamer D, Satok-Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019 Aug;123(2):e333-e342. doi: 10.1016/j.bja.2019.03.044. Epub 2019 May 29. PMID: 31153631; PMCID: PMC6676043. Hansen LE, Stone GE, Matson CA, Tybor DJ, Pevear ME, Smith EL. Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: a prospective matched cohort study. J Arthroplasty 2016; 31: 1698-701. (29) Höflich AS, Langer M, Jagsch R, Bäwert A, Winklbaur B, Fischer G, Unger A. Peripartum pain management in opioid dependent women. Eur J Pain. 2012 Apr;16(4):574-84. doi: 10.1016/j.ejpain.2011.08.008. PMID: 22396085; PMCID: PMC3290684. Li A, Schmiesing C, Aggarwal AK.Evidence for Continuing Buprenorphine in the Perioperative Period. Clin J Pain. 2020 Oct; 36(10): 764-774.doi: 10.1097/AJP.0000000000000858. PMID: 32520814 Macintyre PE, Russel RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care 2013; 41: 222-30 (27) Meyer M, Paranya G, Keefer Norris A, Howard D. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain. 2010 Oct;14(9):939-43. doi: 10.1016/j.ejpain.2010.03.002. Epub 2010 May 4. PMID: 20444630. Quaye A, Potter K, Roth S, Acampora G, Mao J, Zhang Y. Perioperative Continuation of Buprenorphine at Low-Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation. Pain Med. 2020 Sep 1;21(9):1955-1960. doi: 10.1093/pm/pnaa020. PMID: 32167541.

In this podcast, Steven Schull, a third-year U of MN RPAP medical student at Ridgeview Medical Center, presents an interesting case to staff at Ridgeview Medical Center's Live Friday CME program, on April 26, 2019. During his presentation, Steven presents a case of a 41 year old male with a history of right inguinal herniorrhaphy. Enjoy the podcast! Objectives:    Upon completion of this podcast, participants should be able to: Develop a differential diagnosis for inter-operative hypertension. Recognize signs and symptoms of a pheochromocytoma. Demonstrate proper medical management for a pheochromocytoma prior to an adrenalectomy. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Peri-Operative Management of a Hypertensive Crisis" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”   FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES:  INTRODUCTION: Steven Schull is a third-year medical student at the University of Minnesota. He participated in the RPAP (rural physician associate's program) at Ridgeview Medical Center. He presents a case to the staff (on April 26, 2019) at Ridgeview's Live Friday CME Program, of a 41-year old male with a history of right inguinal herniorrhaphy.  THE CASE: The patient had 1-year of groin swelling, pain and then a bulge appeared after some heavy lifting. No other associated symptoms. PMH was unremarkable and he's had one previous herniorrhaphy, vasectomy and knee arthroscopy. No medications or allergies. Former smoker and occasional alcohol use. Vital signs are normal. He has notable right and left reducible inguinal hernias on exam. He's sent to general surgery for surgical management of this. People who get inguinal hernias tend to be obese, have history of smoking, and male gender, due to weaker tissue in the inguinal ring, as well as age. The surgical options include: an anterior open approach or a laparoscopic approach. In this patient, his right hernia has recurred. When does surgery need to happen emergently? Acute, non-reducible swelling (incarceration and/or strangulation), fever or signs of obstruction. In surgery, he was given the following: propofol, etomidate, versed, and fentanyl for anesthesia. Laparoscopic approach was done this time around. Intraoperative diagnosis was recurrent direct right inguinal hernia and a left indirect inguinal hernia. Preoperatively, his BP is normal at 135/75. Upon insufflating CO2 into the abdominal cavity, his BP increases to 235/125. The CRNA gives fentanyl and hydralazine, but no change in BP. MDA arrives now. Why a sudden spike in BP in the OR? Is the patient about to develop malignant hyperthermia? So far no rigidity or elevated temperature. Is the patient in pain suddenly due to the sudden increase intra-abdominal pressure? Pain or inadequate depth of anesthesia is the primary cause of elevated pressure in surgery. Other increased sympathetic tone causes: hypoxia, bladder distention, elevated ICP (edema, hemorrhage intra-operatively). Amphetamine use, thyroid storm, malignant hyperthermia are other possibilities. The patient received large doses of propofol, etomidate, versed, fentanyl, hydralazine, esmolol, NTG and metoprolol. The HTN was refractory to all of this. Still in the 250/110 range. This was an outpatient surgery at an ambulatory surgery center, not an inpatient facility. Fortunately the hernias, were able to be repaired in full, despite the hypertension issues. Patient was then transferred to the inpatient facility. He arrives in the ED at the receiving facility. Patient reports HA, CP and SOB, as well as lower abd pain from the surgery. Now he is mildly tachycardic and still hypertensive at 223/109. O2 sat 90% on RA. He drained 1.4 liters in the Foley catheter placed in the ED. There is now a 3/6 systolic murmur which wasn't appreciated on pre-op exam. Pulses symmetrical and neuro exam is normal. What is going on here? So, where do we go from here? A more comprehensive ER evaluation is in order:  The differential diagnosis from a cardiothoracic standpoint includes a number of things: Acute MI/ACS, aortic dissection, pulmonary embolism and pneumothorax. A bedside echo may be helpful at this point; and this was done showing no obvious wma, but an ECG to start with reveals NSR with non-specific precordial ST changes with LVH criteria met. These are new findings compared to previous. Labs show a K of 2.8, glucose of 396. Troponin is high at 3.68 and the TSH is normal. CT dissection protocol performed and this revealed a 5.5 cm right adrenal mass...pheochromocytoma! Troponin is likely a "leak" or NSTEMI due to cardiac strain from other physiologic abnormalities. There was a huge sympathetic discharge and response in this case. A nicardipine and labetalol infusion are initiated. These are good for BP without effecting stroke volume. ICU admission ensues. Phenoxybenzemine is also now started in the ICU, and a cardiology consult is obtained.  What is happening in the case of a pheo.? Well, the patient classically develops symptoms due to compression of the tumor from insufflating the abdomen, resulting in marked elevation of catecholamines. The elevated glucose, decreased K+ and elevated wbc are also noted, due to elevated adrenocorticoids release. Elevated troponin is of course due to the myocardial strain involved. This patient received vasodilators and meds that decreased cardiac output, so his heart was having to work very hard due to this. While in the ICU, the nicardipine, and labetalol are continued. Cardiology feels there is not likely to be coronary etiology of this, other than poor perfusion due to increased myocardial demand. A coronary CT may be considered. Formal echo was ordered. Doxasosin was started and serum metanephrines were ordered. The decision to have surgery for the pheo was made and due to the special circumstances of a pheo, this was referred to a tertiary facility. Echo revealed hyperdynamic heart with EF of 65%. No structural changes noted. Urine and serum metanephrines came back elevated. This confirms the diagnosis. SUMMARY: Wow. This is an incredibly interesting case, and what an impression this makes on all of us, not to mention, Steven as a medical student. What wreckage a tiny tumor can cause! Elevated blood pressure refractory to multiple medications, a stress cardiomyopathy picture with elevated troponin, not to mention the profound symptoms that the patient experienced. In the process of working up other etiologies and complications of this hypertensive emergency, a pheochromocytoma is detected. A pheochromocytoma is a tumor that is composed of cells that make catecholamines. According to Mayo Clinic Proceedings 1983, there is a 0.3% incidence in the U.S. population. A classic "triad" for pheo includes, episodic headache, tachycardia and sweating. The five P's: pressure (resistant HTN), pain (HA, CP), palpitations (tachy), perspiration, pallor (vasoconstriction peripherally). 90% are benign. Nut of the approximate 10% that are malignant, testing for Multi Endocrine Neoplasia, or MEN 2A and 2B genetic mutations is performed. Dx confirmed by increased 24-hour fractionated metanephrines and catecholamines in urine as well as metanephrines and normetanephrines in the serum. CT and/or MRI are the imaging tests of choice for detecting pheochromocytoma, 95% of which are intra-abdominal and of those, 85-90% are intra-adrenal according to Whalen et.al. in the Journal of Urology from 1992. Briefly, hypertensive emergency involves HTN with end organ damage (ACS, dissection, intra-cerebral hemorrhage, encephalopathy, pulmonary edema, renal failure and even hemolytic anemia). HTN urgency involves elevated BP but no end organ damage. Rapid correction is indicated during an emergency as opposed to correcting over days with an urgency. Alpha blockers must be given just prior to surgery for adrenalectomy. Phenoxybenzaime which is an irreversible alpha 1 receptor antagonist and doxazosin, which is also an alpha 1 receptor blocker, are options for pheochromocytoma treatment, as well as pre-operative treatment for pheo resection. The study cited from Ann of Surg Oncology compared these two meds. Doxazosin is a selective apha blocker and it required more need for vasopressor infusion post-operatively and need for ICU admission. Doxazosin, however, ends up being a far less expensive option between the two. In our patient's case, this was the drug chosen.

Background: For the treatment of the severe infantile coxa vara it is mandatory for the orthopaedic surgeon to observe the mechanobiology of the growing hip before and after the surgical intervention. We hereby would like to present our experiences with the subtrochanteric end-to-side valgization osteotomy and to compare the procedure with the alternatively used Y-shaped osteotomy as described by Pauwels. Methods: Thirteen patients (20 hips) who had undergone subtrochanteric end-to-side valgization were followed for a mean 6.2 years (range, 0.8 to 12.8 y). At the time of surgery the mean age was 7.1 years (range, 2.0 to 13.3 y), last follow-up examination was performed at a mean of 13.4 years of age (range, 5.1 to 18.3 y). The deformities were etiologically based on 5 entities: congenital coxa vara (n = 1), osteochondrodysplasias (n = 12), postosteomyelitic coxa vara (n = 5), and avascular femoral head necrosis in the course of congenital dysplasia of the hip (n = 2). The follow-up rate was 100%. In addition, we analyzed a total of 93 pelvic radiographies with a total of 139 hip joints. Thirty angles and distances were assessed according to parameters described in the literature. Results: Although preoperatively 12 patients presented with a positive Trendelenburg's sign, it was only present postoperatively in 2 patients. Duchenne's limp reduced from 10 to 1. All of the 15 preoperatively apparent nonunions could be healed by means of surgery. Two hips redeveloped pathologically lowered collodiaphyseal angles postoperatively, one of which had to undergo revision surgery. Preoperatively 15 out of 20 patients (75%) showed nonunions all of which healed after surgery. No recurrence could be seen at the time of the last follow-up. The following angles were assessed on plain radiographies of the pelvis preoperatively and directly postoperatively as well as on the last follow-up at a mean of 85 months: CCD-angle 98 degrees/156 degrees/144 degrees, EY-angle 55 degrees/5 degrees/15.7 degrees, AY-angle 32 degrees/75 degrees/66 degrees, CE-angle 20 degrees/25 degrees/18 degrees, AC-angle 20 degrees/18 degrees/20 degrees. The articulotrochanteric distance was 5 mm/26 mm/14 mm. Conclusions: The subtrochanteric end-to-side valgization osteotomy showed to be highly effective in the management of the infantile coxa vara, improving the clinical impairment of the patients postoperatively. All of the preoperatively present nonunions showed osseous consolidation at follow-up examination. Only minor revarization tendencies could be found. The procedure is technically less demanding, safer and more efficient regarding the lengthening of the affected limb in comparison to the Y-shaped intertrochanteric osteotomy as described by Pauwels. Level of Evidence: Case-control study (EBM-level III).

Purpose: To analyze the correlation between morphological and functionalresults 12 months after epiretinal membrane (ERM) surgery. Methods: 31eyes from 31 consecutive patients with nnetamorphopsia and bestcorrected visual acuity (BCVA) below 20/32 underwent a transconjunctival23-gauge vitrectomy with ERM and internal limiting membrane peeling. Preoperatively and 3, 6 and 12 months postoperatively, we assessed BCVA,microperimetry (MP-1) and spectral domain optical coherence tomography(SD-OCT). Photoreceptor inner and outer segment (IS/OS) was graded onSD-OCT images and correlated with microperimetry measurements in thefovea and parafoveal region. Results: The postoperative BCVA wassignificantly better in eyes with an intact IS/OS junction (p < 0.01).In addition, the mean defect depth was postoperatively decreased in thefoveal and parafoveal area in eyes with an intact IS/OS junction. Acorrelation of SD-OCT IS/OS images and microperinnetry in eyes withimprovement in BCVA of at least 2 lines revealed a statisticallysignificant result for the parafoveal quadrants (p < 0.011 for SD-OCTand p < 0.005 for microperimetry) but not for the foveal area alone.Conclusions: The IS/OS regeneration in the parafoveal quadrantscontributes significantly to the recovery of BCVA following ERM surgery.Consequently, functional and morphological tests of the macular areashould not be limited to the fovea but should be extended to theparafoveal region.

Objective: To evaluate prospectively the value of the ‘repositioningtest’ (RT) in preoperative patient selection for the efficacy of malestress urinary incontinence (SUI) treatment using a retroluminartransobturator male sling (AdVance sling). Patients and Methods: 65consecutive patients with SUI after radical prostatectomy were includedin this single-center prospective study. Preoperatively, patients wereclassified into those with ‘positive’ and ‘negative’ RT. Postoperativeresults were analyzed and the association between the result of the RTand postoperative outcome was evaluated. Results: 53 patients (81.5%)showed preoperatively a positive RT and 12 patients (18.5%) a negativeRT. After a follow-up of 12 months, patients with positive RT showed acure rate (0 pads/day) of 83% and patients with a negative RT showedonly a cure rate of 25%. A positive RT significantly correlated withcure in outcome (p < 0.001). Conclusions: Patients with positive RT havea significantly better chance for successful AdVance sling implantation.The RT is minimally invasive, easy to learn and easy to perform.Therefore, the RT is a very useful tool for preoperative patientselection.

Purpose: To compare the efficacy and safety of three intravitreal bevacizumab upload injections followed by a dexamethasone implant versus dexamethasone implant monotherapy in eyes with macular edema due to retinal vein occlusion. Methods: Sixty-four eyes of 64 patients were included in this prospective, consecutive, nonrandomized case series: group 1 consisted of 38 patients (22 with central retinal vein occlusion, CRVO, 16 with branch retinal vein occlusion, BRVO) treated using a dexamethasone implant (Ozurdex) alone; group 2 consisted of 26 patients (14 CRVO, 12 BRVO) treated with three consecutive intravitreal bevacizumab injections at monthly intervals followed by a dexamethasone implant. In case of recurrence, both cohorts received further dexamethasone implants. Preoperatively and monthly best corrected visual acuity (BCVA, ETDRS), central retinal thickness (Spectralis-OCT), intraocular pressure, and wide-angle fundus photodocumentation (Optomap) were performed. The primary clinical endpoint was BCVA at 6 months after initiation of therapy. Secondary endpoints were central retinal thickness and safety of the therapy applied. Results: In group 1, an increase in BCVA of 2.5 (+/- 1.6) letters in the CRVO and of 13.0 (+/- 3.2) letters in BRVO patients was seen after 6 months, in group 2 of 5.9 (+/- 0.4) letters (CRVO) and 3.8 (+/- 2.4) letters (BRVO), which was not statistically significant. When comparing the two treatment groups with respect to the type of vein occlusion, there was a significant advantage for BRVO patients for the dexamethasone implant monotherapy (BRVO patients in group 1, p = 0.005). Central retinal thickness showed a significant reduction after 6 months only in patients of group 1, both for CRVO (p = 0.01) and BRVO (p = 0.003). First recurrence after the first dexamethasone implant injection occurred after 3.8 months (mean) in CRVO and 3.5 months in BRVO patients (group 1), versus 3.2 and 3.7 months, respectively, in group 2. In group 1, 63.6% with CRVO and 50% with BRVO showed an increased intraocular pressure after treatment; in group 2, 57.1% with CRVO and 50.0% with BRVO, respectively. Conclusion: In CRVO, there was no difference between the two treatment strategies investigated. However, in BRVO, dexamethasone implant monotherapy was associated with better functional outcome. Copyright (C) 2012 S. Karger AG, Basel

Introduction: Since more than 50 years, various surgical procedures have been described for congenital Brown’s syndrome. However most showed low success rates and some even severe side effects. The aim of this retrospective study was to evaluate the results of superior oblique posterior tenectomy. This technique was introduced in 1996 by Mühlendyck. Since this first description no other results have been published by others. Patients and methods: 21 patients with congenital Brown’s syndrome (aged 2 to 29 years) were operated between 2001 and 2006, in the Department of Ophthalmology, Ludwig-Maximilians-University Munich. In all patients, intraoperative forced ductions showed severe passive restriction of elevation in adduction and superior oblique posterior tenectomy was performed as a primary procedure. The squint angle (vertical and horizontal deviation in primary position, lateral gaze, up/down gaze), active elevation in adduction, abnormal head posture at distance fixation, binocular vision (in primary position and anomalous head posture) were assessed in each case. All the measurements were performed 1 day before, 1 month and 3 months after surgery. Eight patients were examined 6-24 months after primary procedure. Results: Intraoperatively, a tight or very tight posterior part of the superior oblique tendon was found in 87 % of operated eyes. At the end of the operation, passive motility in adduction became free (14 eyes) /almost free (7 eyes) on the majority of operated patients (totally 23 eyes). Inspite of free passive motility, the active monocular elevation in adduction was only slightly improved by 0.5 mm to 5 mm (mean 2.25 mm), like hypotropia in primary position, which was improved by 1 to 12 deg (mean 4 deg). Better results regarding hypotropia in primary position were noted when the preoperative vertical deviation in primary position was more than 10 deg. However in cases with preoperative hypotropia less than 10 deg, a better fusion was obtained. Preoperatively, 17 patients showed an abnormal head posture. Postoperatively, 12 of them totally gave up their posture and 5 improved partially. Of 8 cases with a long-term follow-up, 5 showed unchanged measurements of vertical deviation in primary position, monocular elevation in adduction and head posture. 3 patients with a long-term follow-up had further surgery and an improvement of vertical deviation in straight gaze and active elevation in adduction. Conclusion: The use of superior oblique posterior tenectomy significantly improves abnormal head posture and also improves alignment and ocular rotations in patients with congenital Brown’s syndrome. We did not see any serious side effect like consecutive superior oblique muscle underaction (as in superior oblique tenotomy or recession) and no foreign body extrusion (as in silicone superior oblique tendon expander). So the superior oblique posterior tenectomy is a safe and effective procedure with regard to the head posture. The fact that the passive motility had dramatic improved postoperatively, but the active elevation in adduction improved only slightly, suggests a paretic/ dysinnervational component to the superior oblique in some patients. From this point of view, a therapeutic algorithm depending on intraoperative/ radiological findings in congenital Brown’s syndrome is proposed.

Background: The aim of this study was to assess the prognostic value of cancer antigen (CA) 125 and CA 72-4 in patients with ovarian borderline tumor (BOT). Methods: All women diagnosed and treated for BOT at our institution between 1981 and 2008 were included into this retrospective study (n=101). Preoperatively collected serum samples were analyzed for CA 125 (Architect, Abbott and Elecsys, Roche) and CA 724 (Elecsys, Roche) with reference to clinical data and compared to healthy women (n=109) and ovarian cancer patients (n=130). Results: With a median of 34.7 U/mL (range 18.1-385.0 U/mL) for CA 125 and 2.3 U/mL (range 0.2-277.0 U/mL) for CA 72-4, serum tumor markers in BOT patients were significantly elevated as compared to healthy women with a median CA 125 of 13.5 U/mL (range 4.0-49.7 U/mL) and median CA 72-4 of 0.8 U/mL (range 0.2-20.6 U/mL). In addition, there was a significant difference compared with ovarian cancer patients who showed a median CA 125 of 401.5 U/mL (range 12.5-35,813 U/mL), but no difference was observed for CA 72-4 (median 3.9 U/mL, range 0.3-10,068 U/mL). Patients with a pT1a tumor stage had significantly lower values of CA 125 but not of CA 72-4 compared with individuals with higher tumor stages (median CA 125 29.9 U/mL for pT1a vs. 50.9 U/mL for) pT1a; p=0.014). There was a trend for increased concentrations of CA 125 but not of CA 72-4 in the presence of ascites, endometriosis or peritoneal implants at primary diagnosis. With respect to the prognostic value of CA 125 or CA 72-4, CA 125 was significantly higher at primary diagnosis in patients who later developed recurrence (251.0 U/mL vs. 34.65 U/mL, p=0.012). Conclusions: Serum CA 125 and CA 72-4 concentrations in BOT patients differ from healthy controls and patients with ovarian cancer. CA 125, but not CA 724, at primary diagnosis correlates with tumor stage and tends to be increased in the presence of ascites, endometriosis or peritoneal implants. Moreover, CA 125 at primary diagnosis appears to have prognostic value for recurrence. Clin Chem Lab Med 2009; 47:537-42.