[Endothoracic goitre: anatomoclinical and therapeutic considerations]. / Gozzo endotoracico: considerazioni anatomocliniche e terapeutiche.

Substernal goitre is a clinical condition in which the masin bulk of the enlarged gland is firmly located in the chest. The incidence of this pathology ranges in literature from 1.7% and 30%. This study examines 230 cases of substernal goitre out of a total 5.362 operations performed from 1965 to 2000, for thyroid gland pathologies (4.36%). According to their experience the Authors propose a classification based on the anatomical location of the goitre: right, left, anterior and posterior goitre are therefore identified. The surgical procedures performed include 136 subtotal thyroidectomies (59.1%), 59 emithyroidectomies (25.7%) and 23 total thyroidectomies (10%). In 12 cases the operation was confined to removal of the mediastinal mass (5.2%). The cervical approach was the only surgical access route used in all the patients, regardless of the different anatomical variants. Appreciable venous stasis, due to the mediastinal mechanical obstruction exerted by the goitre, was always evident at the operation. In order to limit the risk of bleeding during operation, careful hemostasis of the major vascular pedicles must be performed. Any attempt to legate the smallest vessel, should be avoided since it is a difficult, useless and time-consuming procedure. Minor bleeds promptly stop as soon as the pathological mass is removed. Ligation of the vascular pedicles can be easily achieved; in this way, the goitre is freed from its anatomical connections and the surgeon can safely manage the substernal portion of the mass. The mortality reported in this study was 0.43% (one patient died 30 days postoperatively due to respiratory complications), whereas the morbidity rate was 2.6%.

Pneumoparotid due to spirometry.

Pneumoparotid has been described in patients who generate increased intraoral pressures when playing wind instruments, while coughing, and when undergoing dental work. Some patients have intentionally created pneumoparotid to avoid duties at school or in the military, or to gain attention. We describe a patient who developed pneumoparotid during pulmonary function testing. The diagnosis of pneumoparotid depends on a suggestive clinical situation and glandular swelling with or without crepitus. Observation of aerated saliva per Stensen's duct or air in the parotid duct and/or gland by any imaging study is diagnostic if infection with a gas-forming organism can be reasonably excluded. No specific treatment is required, other than the avoidance of predisposing activities.

[Insulinoma. Clinical and surgical considerations concerning a case]. / Insulinoma. Considerazioni clinico-chirurgiche su di un caso.

Insulinoma is the most common endocrine tumor of the pancreas. It arises from the beta-islet cells of Langerhans. Insulinomas synthesize and secrete insulin autonomously in the presence of low blood glucose levels, causing spontaneous hypoglycemia and characteristic clinical symptoms. The authors examined data the from the most important international research projects on this topic during the past 20 years. Insulinomas are rare, with an annual incidence of 0.5 per million population. Up to 90% patients have benign solitary pancreatic insulinomas. People of all ages can be affected with this neoplasm. The authors reported a case of a large insulinoma of the body and tail of the pancreas, with atypical psychic symptoms. A distal pancreatectomy with splenectomy was performed. No surgical complications occurred in the postoperative course. The psychic symptoms were emphasized with refusal of food. The patient underwent Parenteral Nutrition and was discharged 24 days after the operation. The surgical removal of the tumor permitted the patient to recover completely, with glucose and insulin blood levels in normal range.

Admission interviews: questions of utility and cost in masters of physical therapy programs in the United States.

PURPOSE: The purpose of this research was twofold. The first purpose was to assess the predictive validity of the interview process in student completion of entry level Masters of Physical Therapy programs on the conventional schedule for the university. The second was to provide a descriptive study of interview formats currently used by these institutions and the cost to the institution, estimated by hours of labor used exclusively for the interview process. METHOD: A questionnaire was mailed to the Director of Admissions of 63 accredited Masters of Physical Therapy programs in the United States. Forty-three responded to the questionnaire for a response rate of 68.3%. Twenty-eight programs (65.1%) performed interviews and fifteen (34.9%) programs did not. RESULTS: A two-tailed t-test revealed that no significant difference existed between programs that interview and those that did not with regards to the attrition rate of students. There was great diversity between the programs in interview content and structure. The cost to the institutions in terms of hours averaged 261 hours per school for faculty and support staff combined. CONCLUSION: The schools of physical therapy that award the Masters of Physical Therapy degree vary markedly in the interview content and format both between schools and with recommendations known to enhance validity and reliability. Since, no difference exists in attrition of students between schools that interview and those that do not, the expense and time invested by both the institution and the students are important considerations. The findings of this study indicate the need for continued investigation of the effectiveness of the interview process and alternative methods of valid and reliable student selection.

From whom the bell tolls: the emerging decision-makers for life-support systems in choices of who shall live and who shall die.

In summary, how do we assess these decision-makers, with their wide variations in composition, emerging today from medical technology and advances unknown and unforeseen by earlier practitioners? At the threshold, we should not dismiss lightly the traditional role of the doctor as the autocrat. There is much to be said in his or her favor: 1. The basic decision, after all, is a medical one--diagnosis and prognosis--with the concurrence perhaps of a consultant or a specialist. That decision was and is a major premise. Miss it and one misses the mark. 2. What is so novel, what is so startling about a fateful life-death issue in the medical profession? It is quotidian. In the Armageddon between human life and human demise, doctors have been making those solemn decisions in other areas of medicine from time immemorial. Often--not always--the patient is silently saying to the doctor, "My life is in your hands." 3. And within what context does he act? Usually--not always--he knows the patient. He knows the family. He knows the surrounding circumstances. But there still lurks that gnawing, underlying flaw. The decision-making is not diffused. The doctor stands alone. Small "groups" or "committees," retaining medical guidance, share responsibilities, make more palatable to themselves those agonizing decisions, and contribute to their acceptability by society. Here, then, is the harvest to be reaped by diffusion. What is so striking is that the decision-making process anent life-support systems still calls for a superior breed of men and women.(ABSTRACT TRUNCATED AT 250 WORDS)