Mental skills training effectively minimizes operative performance deterioration under stressful conditions: Results of a randomized controlled study.

BACKGROUND: Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress. METHODS: Twenty-four residents were stratified then randomized to receive mental skills and FLS training (MSC group), or only FLS training (control group). Laparoscopic suturing skill was assessed on a live porcine model with and without external stressors. Outcomes were compared with t-tests. RESULTS: Twenty-three residents completed the study. The groups were similar at baseline. There were no differences in suturing at posttest or transfer test under normal conditions. Both groups experienced significantly decreased performance when stress was applied, but the MSC group significantly outperformed controls under stress. CONCLUSIONS: This MSC enabled residents to perform significantly better than controls in the simulated OR under unexpected stressful conditions. These findings support the use of psychological skills as an integral part of a surgical resident training.

Multiple paternity in an aggregate breeding amphibian: the effect of reproductive skew on estimates of male reproductive success.

Aggregate, or explosive, breeding is widespread among vertebrates and likely increases the probability of multiple paternity. We assessed paternity in seven field-collected clutches of the explosively breeding spotted salamander (Ambystoma maculatum) using 10 microsatellite loci to determine the frequency of multiple paternity and the number of males contributing to a female's clutch. Using the Minimum Method of allele counts, multiple paternity was evident in 70% of these egg masses. Simple allele counts underestimate the number of contributing males because this method cannot distinguish multiple fathers with common or similar alleles. Therefore, we used computer simulations to estimate from the offspring genotypes the most likely number of contributing fathers given the distributions of allele frequencies in this population. We determined that two to eight males may contribute to A. maculatum clutches; therefore, multiple paternity is a common strategy in this aggregate breeding species. In aggregate mating systems competition for mates can be intense, thus differential reproductive success (reproductive skew) among males contributing to a female's clutch could be a probable outcome. We use our data to evaluate the potential effect of reproductive skew on estimates of the number of contributing males. We simulated varying scenarios of differential male reproductive success, ranging from equal contribution to high reproductive skew among contributing sires in multiply sired clutches. Our data suggest that even intermediate levels of reproductive skew decrease confidence substantially in estimates of the number of contributing sires when parental genotypes are unknown.

Oscillation and light induction of timeless mRNA in the mammalian circadian clock.

Circadian rhythms in Drosophila melanogaster depend on a molecular feedback loop generated by oscillating products of the period (per) and timeless (tim) genes. In mammals, three per homologs are cyclically expressed in the suprachiasmatic nucleus (SCN), site of the circadian clock, and two of these, mPer1 and mPer2, are induced in response to light. Although this light response distinguishes the mammalian clock from its Drosophila counterpart, overall regulation, including homologous transcriptional activators, appears to be similar. Thus, the basic mechanisms used to generate circadian timing have been conserved. However, contrary to expectations, the recently isolated mammalian tim homolog was reported not to cycle. In this study, we examined mRNA levels of the same tim homolog using a different probe. We observed a significant (approximately threefold) diurnal variation in mTim expression within mouse SCN using two independent methods. Peak levels were evident at the day-to-night transition in light-entrained animals, and the oscillation persisted on the second day in constant conditions. Furthermore, light pulses known to induce phase delays caused significant elevation in mTim mRNA. In contrast, phase-advancing light pulses did not affect mTim levels. The mTim expression profile and the response to nocturnal light are similar to mPer2 and are delayed compared with mPer1. We conclude that temporal ordering of mTim and mPer2 parallels that of their fly homologs. We predict that mTIM may be the preferred functional partner for mPER2 and that expression of mTim and mPer2 may, in fact, be driven by mPER1.

Tracheotomy in patients with acquired immunodeficiency syndrome. Is it necessary?

OBJECTIVE: Patients with acquired immunodeficiency syndrome (AIDS) who develop respiratory failure and require mechanical ventilation have mortality rates of 85%. Tracheotomies are performed in this patient population for prolonged intubation. However, to date, objective data on tracheotomy in patients with AIDS are lacking. Tracheotomy in ventilator-dependent patients with AIDS presents risks to patients and exposes surgeons, nurses, and operating room personnel to human immunodeficiency virus-infected blood. DESIGN: Given these considerations, we retrospectively reviewed our experience with tracheotomy in 10 intubated and ventilator-dependent patients with AIDS. CONCLUSIONS: Our study shows a mortality rate of 100%. We identify predictive factors and a prognosis that may aid in the treatment of these patients.

Induction chemotherapy for advanced head and neck cancer: modification of response to chemotherapy by antiemetics.

Forty Stage IV head and neck cancer patients were entered on a multimodality trial of induction chemotherapy (cisplatin + infusional 5-fluorouracil), surgery, and radiation. During chemotherapy, the patients of Group A (the first 19 patients) were medicated with metoclopramide. The patients of Group B (the next 21 patients) were medicated with droperidol. The groups were comparable. The response rate (complete + partial) was 32% for Group A and 52% for Group B (p = 0.16). Primary site (p = 0.08) and surgical margin (p = 0.005) clearance of tumor were better in Group B. Nodal disease responded poorly to chemotherapy in both groups. Tumor necrosis (p = 0.006) and granulation tissue (p = 0.07) were reduced in surgical specimens after chemotherapy in Group B. The drugs were well tolerated with reversible toxicity; nausea/vomiting (p = 0.01) and weight loss (p = 0.07) after chemotherapy, were increased in Group B. The 2-year survival was 26% for Group A and 62% for Group B (p = 0.027). The median survival was 15 months for Group A and 33 months for Group B (p = 0.05). Progression-free survival improved in Group B (p greater than 0.17). These improvements in response and survival did not appear to reflect changes in surgical or radiotherapy management, but may have reflected an uninhibited effect of cisplatin in Group B. It is theorized that the metabisulfite formulated with metoclopramide altered the pharmacokinetics or pharmacodynamics of cisplatin. This resulted in the poor response to chemotherapy and poor survival in Group A. An analysis of a randomized trial comparing metoclopramide (formulated with metabisulfite) versus a control antiemetic can confirm the data presented in this pilot study. Overall, our patients survived as well as others in comparable multimodality studies in Europe and the United States.

Paranasal sinus carcinoma--diagnosis, treatment, and prognosis.

Sinonasal malignancies account for only 3% of all cancers of the head and neck and typically affect Caucasian males who are 50 to 70 years of age. This report identifies a number of risk and environmental factors that have been linked with the development of such malignancies, the clinical presentation of these tumors, clues to the diagnosis, and the pathology of the most commonly encountered types. Treatment of sinonasal malignancies is controversial and depends largely on the type of tumor encountered. The authors describe surgical and chemotherapeutic modalities, used alone and in combination. The controversy surrounding the utility of radiotherapy before or after surgery is also discussed.

The head and neck sequelae of cervical intravenous drug abuse.

When peripheral veins sclerose, addicts desperately seek new and more dangerous injection sites. At Howard University Hospital, Washington, DC, a disturbing increase in intravenous head and neck complications has been observed. From 1982 to 1985, 30 patients demonstrating complications resulting from intravenous cervical injections were treated. Computed tomography is emphasized as the most helpful diagnostic modality. Its timely use enables physicians to formulate early diagnosis and precise surgical intervention. A suggested diagnostic and treatment protocol is presented as a guideline in the management of this potentially deadly phenomenon.

The management of acute laryngeal trauma.

A case report is presented illustrating the key points in the diagnosis and management of acute laryngeal injury. All patients with a history of injury to the head, neck, or chest should be assessed for possible laryngeal injury. The diagnosis requires a high index of suspicion. Computed tomography (CT scan) of the larynx is strongly advocated as the most important diagnostic tool. The goals in management are airway assurance and voice preservation. Prompt diagnosis will insure timely management and prevent early demise or complicated secondary corrective procedures.

Sarcoidosis of the parotid gland.

The clinical and radiological features of parotid-gland sarcoidosis in 22 patients are presented. This occurred in association with systemic disease as painless, diffuse and nonnodular parotid swelling. Conventional sialography usually demonstrated normal proximal ducts, a few fragile distal ducts and non-specific parenchymal nodules. Computed tomography, with or without simultaneous sialography, defined and characterised such nodules and demonstrated normal periparotid anatomy. Sialography contributes little additional information to thorough clinical examination in non-nodular or multinodular glands. However, solitary nodules appear to be better investigated by sialography, CT and CT-guided aspiration, thereby allowing diagnosis and direct medical therapy and avoiding surgery. Ultrasonography and nuclear scintigraphy were of little value in this study.

Ameloblastomas of the jaws: radiological diagnosis and follow-up.

Eleven of 57 tumours and cysts (19 per cent) seen at two major centres over a 4-year period were ameloblastomas, primary in eight and recurrent in three. Computed Tomography (CT) was the most sensitive imaging technique for detecting ameloblastomas. The radiological features were distinctive maxillary and mandibular pathology in primary cases and soft-tissue, maxillary sinus and asymmetrical deep tissue involvement in both primary and recurrent ameloblastomas. Following surgery and pathological confirmation, serial scans were combined with periodic clinical re-evaluation. We identified clinically occult recurrences in two cases and confirmed a clinically-suspected recurrence in one on the basis of the CT findings. Our protocol appears efficacious and is suggested for the necessary long-term follow-up in all pathologically verified ameloblastomas.

Autograft frontoplasty. A simple technique for correction of post-osteoplastic flap defects.

A rare but distressing complication of frontal embossment was managed after osteoplastic flap surgery. The technique is relatively simple and predictable, consisting of frontal bone autografts, bone paté, and Silastic sheeting. This technique may have potential application to other posttraumatic defects that require frontal contour restoration.

Complications in surgery for stomal recurrences.

Stomal recurrences are diffuse epidermoid carcinomas of the tracheostoma. There is a 8.3% incidence associated with patients having a total laryngectomy. Most can be prevented by several prophylactic measures; however, surgery may be required. The procedure advocated is mediastinal dissection and its surgical technique is outlined. Recently the use of the pectoralis myocutaneous flap has greatly diminished morbidity and mortality associated with this procedure. The complications that may be encountered with mediastinal dissection have been categorized and analyzed. The dynamic interplay of these complications is stressed. Separately, each complication is formidible, but collectively, they may be overwhelming. This entire web of complications is synergistic and at times fatal. In essence, the motto of the surgeon when operating on a patient with a stomal recurrence should be eternal vigilance.

Stomal recurrences: a clinicopathological analysis and protocol for future management.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St. Louis, Mo. During this period, 33 stomal recurrences were diagnosed. These are clinicopathologically analyzed with regard to tumor size, site, histopathology and original surgical procedure. An association with transglottic tumors, emergency tracheotomy and, surprisingly, hemilaryngectomy is noted. Three theories of etiology are discussed. Since treatment to date is disappointing, several proposed methods of prophylaxis are presented. These include emergency laryngectomy, recurrent laryngeal lymphatic dissection and postoperative radiotherapy. The role of wide local excision and mediastinal dissection is also examined. Based upon the analysis and the proposed methods of prophylaxis, a protocol is suggested for the future management of this dreaded complication.

Completion laryngectomy.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St Louis. Forty-two or 9% were completion laryngectomies. Completion laryngectomy is defined as the removal of the remaining larynx following an antecedent partial laryngectomy. These 42 cases are retrospectively analyzed with regard to original conservation surgery, clinical presentation, histopathology, and salvage rate. The most common indications for completion laryngectomy were (1) local recurrence, (2) local recurrence with associated severe upper respiratory obstruction, and (3) fistula control. The overall salvage rate following completion laryngectomy was 55% (23 patients). The highest rate was in patients with previous hemilaryngectomy (69%), followed by subtotal supraglottic laryngectomy (44% and partial laryngopharyngectomy (14%). There is a high incidence of stomal occurrences (24% or ten patients) associated with completion laryngectomy, particularly in patients with antecedent hemilaryngectomy. Most indications for completion laryngectomy appear early; however, all patients must be carefully followed up after conservation surgery.

Maxillary chondrosarcoma.

Chondrosarcoma is a malignant tumor that arises from cartilage. In the maxillary area, the tumors spread locally but may also invade blood vessels and metastasize systemically. Initial surgical resection is the treatment of choice.

Completion laryngectomy.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St. Louis, Missouri. Forty-two or 9.4% were completion laryngectomies. Completion laryngectomy is defined as the removal of the remaining larynx following an antecedent partial laryngectomy. These 42 cases are retrospectively analyzed in regards to original conservation surgery, clinical presentation, histopathology and salvage rate. The most common indications for completion laryngectomy were : 1) local recurrence, 2) local recurrence with associated severe upper respiratory obstruction, and 3) fistula control. The overall salvage rate following completion laryngectomy was 55% (23 patients). The highest rate was in patients with previous hemilaryngectomy (69%), followed by subtotal supraglottic laryngectomy (44%), and partial laryngopharyngectomy (14%). There is a high incidence of stomal occurrences (24% or 10 patients) associated with completion laryngectomy, particularly in patients with anticedent hemilaryngectomy. Most indications for completion laryngectomy present early, however, all patients must be carefully followed. Both the patient and the otolaryngologist must be ever vigilant following conservation surgery.