Race does not impact pancreatic cancer treatment and survival in an equal access federal health care system.

BACKGROUND: Black patients with pancreatic adenocarcinoma (PDAC) have been reported to undergo surgical resection less frequently and to have a shorter overall survival duration than white patients. We sought to determine whether disparities in clinical management and overall survival exist between black and white patients with PDAC treated in an equal access health care system. METHODS: Using the Department of Defense (DoD) tumor registry database from 1993 to 2007, patient, tumor, and treatment factors were analyzed to compare rates of therapy and survival between black and white patients. RESULTS: Of 1,008 patients with PDAC, 157 were black (15 %). Thirty-six percent of black and 37 % of white patients presented with locoregional disease (p = 0.85). Among those with locoregional cancers, the odds of black patients having received surgical resection (odds ratio [OR] 1.06, 95 % confidence interval [CI] 0.60-1.89), chemotherapy (OR 0.92, 95 % CI 0.49-1.73) and radiotherapy (OR 1.14, 95 % CI 0.61-2.10) were not different from those of whites. Among those with distant disease, the odds of having received palliative chemotherapy were also similar (OR 0.91, 95 % CI 0.55-1.51). Black and white patients with PDAC had a similar median overall survival. In a multivariate analysis, as compared to whites, black race was not associated with shorter overall survival. CONCLUSIONS: We observed no disparities in either management or survival between white and black patients with PDAC treated in the DoD's equal access health care system. These data suggest that improving the access of minorities with PDAC to health care may reduce disparities in their oncologic outcomes.

Pediatric bilateral spontaneous pneumothoraces in monozygotic twins.

Primary spontaneous pneumothorax from subpleural bleb disease is an uncommon occurrence in pediatric patients. This is a rare case of monozygotic twins presenting at alternating intervals with a single-sided spontaneous pneumothorax, only to have it surgically corrected, and to present later with a subsequent contralateral pneumothorax. A review of familial spontaneous pneumothoraces occurring in children was queried for congenital or genetic syndromes. We concluded that a vast majority of pneumothoraces in children, like adults, are not spontaneous and not familial linked. While they are rare, some congenital syndromes have been identified. The HLA haplotype A2 B40, the gene encoding folliculin, Alph-1-antitrypsin, Marfan's syndrome, Ehlers-Danlos syndrome and Birt-Hogg-Dube syndrome have all been associated with familial spontaneous pneumothoraces. Physicians need to counsel family members to ensure appropriate observation and expedited treatment is not delayed.

Presentation and management of Morgagni hernias in adults: a review of 298 cases.

BACKGROUND: Morgagni hernias are a very rare form of diaphragmatic hernias. No robust studies have been performed to show the true natural history of this disease process. This study aimed to summarize clinically relevant data with respect to Morgagni hernias in adults. These data should help surgeons workup, diagnose, and treat Morgagni hernias in adult patients. METHODS: A literature search was performed using PubMed, Google scholar, and the following key words: Morgagni, Larrey, retrosternal, retrocostoxiphal, retrochondrosternal, parasternal, substernal, anterior diaphragmatic, and subcostosternal. All case reports and series after 1951 that pertained to adults were included in the review. The following data points were queried: age, sex, presentation, studies used during workup, laterality, surgical approach, hernia sac management, specific laparoscopic techniques, and follow-up evaluation. RESULTS: These criteria were met by 135 articles representing 298 patients. Based on the data provided, several conclusions regarding this disease process can be drawn. Most patients (72%) present with symptoms related to their hernia. Pulmonary complaints are the most common symptoms (36%). Men present earlier in life than women. Thoracotomy is the most widely used surgical approach (49%). However, laparoscopic repair has gained popularity since its first report in 1992. Laparoscopic surgeons usually repair the defect with mesh (64%) and do not remove the hernia sac (69%). Laparoscopic repair can be performed with a low complication rate (5%) and a short hospital stay (3 days). Outcomes of other surgical approaches also are reported. CONCLUSIONS: Using modern surgical techniques including laparoscopy, repair of Morgagni hernia can be performed safely with a short hospital stay and with little morbidity or mortality.

Introduction to military medicine: a brief overview.

This article provides an overview of the current organization and structure of the United States military medical forces. The five levels of care are presented. The "glue" that binds the five levels of care together -- medical evacuation -- is briefly discussed. The logistics system/structure that sustains military medical systems in remote locations is summarized. Finally, the overall command and control of in-theater combat medical assets, the initiative to establish a Joint Military Trauma Record system, and the ongoing efforts to collect real-time casualty data with the goal of enhancing combat care through improved training and early equipment fielding are described.

Are Army-trained surgeons satisfied with their residencies?

OBJECTIVE: To evaluate the perceptions of training adequacy among surgeons educated in Army general surgical residencies as a tool for surgical program directors and students considering a military surgical career. DESIGN: A questionnaire was sent to all general surgeons practicing in the Army during years 1999-2003 (n = 182). In addition to providing basic demographic information, subjects rated their perceptions of training experience in 13 areas on a 5-point Likert scale (1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = neither satisfied nor dissatisfied, 4 = somewhat satisfied, 5 = very satisfied). Respondents were split into 3 groups based on graduation year (1968-1992, 1993-1998, 1999-2003) and thereby roughly on status of military obligation at the time of survey. Scores were compared with analysis of variance. RESULTS: A total of 96 (52.7%) questionnaires were returned, 84 of which were included in this study. The average score for all graduation groups and satisfaction areas was 4.37 +/- 0.91. No differences occurred among the 3 graduation groups in any of the 13 satisfaction areas evaluated, except for pediatric surgery experience, where the most recent graduates rated their satisfaction lower than the other 2 groups (1968-1992, 4.00 +/- 0.61; 1993-1998, 3.96 +/- 1.14; 1999-2003, 3.21 +/- 1.27, p < 0.05). With respect to comparison among the 13 satisfaction areas, several areas of note are present. Satisfaction with training in care for basic surgical problems and the ability to make correct decisions are both higher than 5 other areas (p < 0.01). By contrast, satisfaction with number of cases performed, research training, and pediatric surgery training are lower than at least 3 of the other 12 areas (p < 0.01). CONCLUSION: Army trained general surgeons, from the most distant to recent graduates, are satisfied with their residencies. Lower satisfaction scores in the areas of number of cases performed, research experience, and pediatric surgery training do, however, highlight aspects for continued research and improvement.

Laparoscopic repair of a large symptomatic epiphrenic esophageal diverticulum.

PURPOSE: The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady. METHODS: We report the case of a 59-year-old male patient with Parkinsonism found to have a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a 6-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing a gastrointestinal endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction of the lumen. RESULTS: The patient resumed intake of liquids on postoperative day 1 after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day 3. He reported residual dysphagia to solids postoperatively, which appeared to resolve after pneumatic dilation. CONCLUSIONS: We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe. The comorbidity of Parkinsonism adds complexity to the diagnosis and treatment of this uncommon disorder.

Postoperative pneumoperitoneum on computed tomography: is the operation to blame?

BACKGROUND: Postoperative radiographs demonstrating pneumoperitoneum are a vexing problem for surgeons. This dilemma stems from uncertainty regarding the length of time for resolution of gas introduced operatively via either an open or a laparoscopic approach. We attempted to quantify the duration of pneumoperitoneum after both laparoscopic and open surgery in an animal model. METHODS: A prospective study using 2 groups of 10 pigs (Sus scrofa) was performed. The animals were assigned to undergo either an exploratory laparoscopy or an open abdominal exploration. Postoperatively, sequential computed tomography (CT) scans were performed to assess for the presence of pneumoperitoneum. RESULTS: Pneumoperitoneum resolution occurred sooner than average on CT scan in the laparoscopic group when compared to open group (1.79 days vs 4.73 days respectively; P value of .02). CONCLUSIONS: Postoperative pneumoperitoneum resolves more quickly after laparoscopy when compared to open surgery in the porcine model. This information may aid in evaluating postoperative CT scans demonstrating pneumoperitoneum.

Ultrasound-guided arterial line catheterization in the critically ill: technique and review.

Arterial line catheterization in the critically ill patient is often an arduous task. Here we identify risk factors in the critical care patient that may predict a more difficult arterial catheter insertion. We also describe our ultrasound technique and review of the literature with regard to location of access, complications, and the use of ultrasound guidance.