Mental changes associated with hyperparathyroidism.

To document the point that the hyperparathyroidism should be considered a possible cause of unexplained neurological and psychiatric symptoms, the authors present five case reports of confirmed primary hyperparathyroidism in which the patients initially appeared with problems that seemed mainly psychiatric. The presenting symptoms in these cases consisted of varying degrees of depression, catatonia, confusion, disorientation, fatigue, and lethargy; there was no associated bone or renal pathology in four of the cases. The authors include a review of the pertinent literature and a discussion of the effect of calcium and magnesium bivalent ions on the central nervous system associated with hyperparathyroidism. They conclude that more investigation of the role of magnesium in this disease seems warranted.

Parathyroid cysts: Functional and mediastinal.

A report of a functioning mediastinal parathyroid cyst is presented with a review of the world literature. This represents the tenth functional, eleventh mediastinal, and third functioning mediastinal parathyroid cyst reported. The predilection of functional cysts for aberrant locations would suggest on hypothesis of their occurrence by degeneration of pre-existing adenomas based on an inadequacy of their blood supply. The criteria for ascribing functional activity to a parathyroid cyst are presented and discussed.

Bilateral elastofibroma dorsi.

Elastofibroma, a rare, noncapsulated, benign entity (pseudotumor), is characterized by the proliferation of fibrous tissue with elastin and scattered islands of adipose tissue that occurs most often in the infrascapular area of elderly women. We report on a 44-year-old man with bilateral infrascapular elastofibromas.

Operative experience of U.S. general surgery residents in thyroid and parathyroid disease.

BACKGROUND: We wanted to determine whether the experience of general surgery residents is adequate and effective. METHODS: The Resident Statistic Summaries (Report C) of the Residency Review Committee (Surgery) for 8 academic years from 1986 through 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed. RESULTS: For thyroidectomy the average per resident ranged from 10.3 to 12.6. The maximum ranged from 52 to 102. The standard deviations ranged from 6.96 to 8. The most common number of thyroidectomies performed ranged from 7 to 10 per graduating resident. For parathyroidectomy the average ranged from 4.1 to 5.1, the standard deviations were 3.44 to 4, the maximum ranged from 25 to 60, and the most common number performed was 2. CONCLUSIONS: U.S. graduates have highly variable experience in thyroid and parathyroid surgery. Most residents have inadequate experience in parathyroid surgery and marginal experience in thyroid surgery.

Macroamylasemia.

Macroamylasemia, characterized by hyperamylasemia and a normal urinary amylase, has no known specific clinical symptoms. The disparity in serum and urinary amylase levels is due to a macromolecular amylase complex too large for glomerular filtration. This syndrome is presented in a patient with cholecystitis and a partial small bowel obstruction accompanied by persistent pre- and postoperative hyperamylasemia with proven macroamylasemia. The renal amylase clearance to creatinine clearance (CAM/CCR) ratio confirms this hyperamylasemic entity.

Familial cancer: implications for surgical management of high-risk patients.

Knowledge of familial/genetic information about cancer risk involving at least 100 disorders could be utilized profitably by surgeons in their daily practice. Familial cancer of the breast, ovary, and colon, malignant melanoma, and testicular feminization syndrome, and masculinizing Turner's syndrome are discussed. Biological markers, an area of emerging research interest, have been considered for their cancer control potential. Prophylactic surgical implications for certain familial cancer have been given.

Epiploic disorders. Conditions of the epiploic appendages.

Disorders of the epiploic appendages are rarely diagnosed preoperatively and usually result from torsion with subsequent infarction. No diagnostic test or clinical symptoms are pathognomonic of this process, which is a disease of middle age and rarely life-threatening, and the most common preoperative diagnosis is acute appendicitis. An analysis of case information reported in the surgical literature has been combined with our recent experience involving ten cases. Fifty-eight percent of the patients in this collected series were male, and the average age in both sexes was 42 years. The sigmoid colon was the most frequent site of these disorders (41.5%), and acute appendicitis was the most common preoperative diagnosis (37.7%). The treatment is ligation, excision, and occasionally seromuscular inversion. When encountered at exploration, this entity may represent the sole etiology of the abdominal pain if exploration is otherwise negative.

Ethics in surgery: historical perspective.

Ethics codes and guidelines date back to the origins of medicine in virtually all civilizations. Developed by the medical practitioners of each era and culture, oaths, prayers, and codes bound new physicians to the profession through agreement with the principles of conduct toward patients, colleagues, and society. Although less famous than the Hippocratic oath, the medical fraternities of ancient India, seventh-century China, and early Hebrew society each had medical oaths or codes that medical apprentices swore to on professional initiation. The Hippocratic oath, which graduating medical students swear to at more than 60% of US medical schools, is perhaps the most enduring medical oath of Western civilization. Other oaths commonly sworn to by new physicians include the Declaration of Geneva (a secular, updated form of the Hippocratic oath formulated by the World Medical Association, Ferney-Voltaire, France) and the Prayer of Moses Maimondes, developed by the 18th-century Jewish physician Marcus Herz.

Supradiaphragmatic right liver lobe and gallbladder.

Descriptions of supradiaphragmatic liver lobules have been previously described in diaphragmatic hernia reviews. A unique case of an otherwise anatomically normal, congenitally positioned right liver lobe and gallbladder in a supradiaphragmatic position with no previous history of trauma was encountered.

Changing patterns of resident operative experience from 1990 to 1997.

HYPOTHESIS: Resident operative experience has increased or decreased with respect to 12 specific operations. DESIGN: A retrospective analysis of resident operative experience reported to the Accreditation Committee for Graduate Medical Education for academic years 1990-1997. SUBJECTS: Residents completing an Accreditation Committee for Graduate Medical Education surgical program. MAIN OUTCOME MEASURES: The total number of residents, average number of operations performed per resident, and the most common operations performed. RESULTS: The number of house staff completing surgical residency training programs has remained constant, while operative volume has increased from 1991 to 1997. Comparison of the frequencies of 12 selected operative procedures performed in academic years 1990-1991 and 1996-1997 found increases in the following procedures: carotid endarterectomy (137%), pancreaticoduodenectomy (66.7%), laparoscopic cholecystectomy (64.8%), parathyroidectomy (51.2%), thyroidectomy (19.2%), colectomy (14.1% to 44.4% depending on subtype), and elective infrarenal aortic aneurysm repair (10.7%). Conversely, frequencies decreased for open cholecystectomy (63.4%), open parietal cell vagotomy (40%), modified radical mastectomy (15.2%), gastroesophageal antireflux procedure (10.4%), and subtotal gastric resection (8.93%). Resident experience was essentially unchanged for emergent infrarenal aortic aneurysm repair and laparoscopic proximal gastric vagotomy. CONCLUSIONS: The number and variety of operative interventions in surgical therapeutics is changing. Continued analysis of the operative experience during surgical training will indicate the need for changing requirements for surgical resident experience. The causes of these shifts are not specifically addressed by this study. Perhaps technological advances in the diagnosis and management of surgical patients or the increase in subspecialty training programs have affected the experience of general surgery trainees.

Necrotizing soft-tissue infections.

OBJECTIVES: To evaluate the causes of necrotizing soft-tissue infections (NSTls) and to determine the outcomes of patients with NSTls. DESIGN: A restrospective survey of the causes and factors associated with the outcomes. SETTING: An urban community hospital serving an indigent population. PATIENTS: A consecutive series of patients with NTSls who were treated between December 11, 1990, and December 28, 1995. INTERVENTIONS: Patients were treated with operative debridement, intravenous antibiotics, and supportive measures. MAIN OUTCOME MEASURES: Patient outcomes, causes, the extent of infection, the health status of the patients, causative organisms, and treatment delays. RESULTS: Forty-five patients with NSTls were identified. Twenty-eight cases (62%) have occurred since January 13, 1994. Parenteral drug abuse, the causative event in 25 cases (56%), accounted for 21 (75%) of the 28 cases identified since January 13, 1994. Skin flora were the primary isolates in 18 (40%) of the cases; 78% of these flora were polymicrobial. Clostridial species were isolated in 8 (18%) of the cases. The overall mortality was 27%. Survivors had less extensive infections and were more stable hemodynamically than nonsurvivors. Patients with necrosis and cellulitis greater than 250 cm2 were less likely to survive than those with less extensive infections. Logistic regression analysis identified the extents of infection, the initial blood pressure, and the initial temperature as independent predictors of outcome in this patient series. CONCLUSIONS: This is 1 of the largest reported series of patients with NSTls in which parenteral drug abuse is a prevalent causative factor. The proportion of NSTls attributable to the injection of illicit substances has increased notably in the past 2 years and has reached epidemic proportions. Survivors of NSTls had less extensive infections and were more often hemodynamically stable than nonsurvivors. Clostridial species were common in patients with NSTls related to parenteral drug abuse, underscoring the need for awareness of the potential for wound botulism in these patients.

Recidivism in an urban trauma center.

The incidence of recurrent injury requiring evaluation and treatment at an urban trauma center was assessed by examination of data from the registry of an urban trauma unit. A subgroup of 342 recidivists sustained 711 traumatic injuries. This represented 6.4% of trauma service activations or consultations. The rates of recurrence in random groups of 100 patients with trauma and 50 patients with traumatic deaths were 5% and 12%, respectively. These rates of recurrent injury are lower than those of several previous reports. Comparison of patients with recurrent episodes of trauma with patients who experience a single episode of trauma revealed significant differences in age, sex distribution, mechanism of injury, and fatal outcomes. Recidivists averaged only 7.9 months between episodes of injury. In patients with recurrent trauma with fatal outcomes, the mean interval between initial injury and death was 18.8 months. Early identification of patients at high risk for recurrence may provide an opportunity for behavior modification.

Ultrasonographic examination of wound tracts.

OBJECTIVE: To determine if ultrasonography is useful in evaluating penetrating injuries of the trunk to assess whether violation of the peritoneum or pleura has occurred. METHODS: The study group was 29 patients who suffered gunshot (n = 17), stab (n = 10), or shotgun (n = 2) wounds. The abdomen was at risk in 21 injuries, the thorax in eight. The results of physical examination and plain x-rays suggested the pleura and or peritoneum might be intact in all patients. Using a 7-MHz transducer, wound tract(s) were images, looking for the presence of soft-tissue air and/or echolucent areas consistent with soft-tissue blood. Injuries were deemed extraperitoneal or extrapleural if (1) the entire tract was visualized; (2) it appeared superficial to the deepest fascial structure in that area; and (3) in shotgun injuries, all visible pellets on x-ray films were identified by ultrasound in the abdominal wall. RESULTS: Evidence of penetration occurred in four abdominal wounds and one thoracic wound. These were confirmed by operation in the abdominal cases and by subsequent chest x-ray examination in the one thoracic wound. The diagnosis of nonpenetration was confirmed in all the remainder by serial benign abdominal examination (n = 15), chest x-ray examination (n = 8), and laparoscopy (n = 1). Positive and negative predictive accuracy were thus 100% in this pilot series. CONCLUSIONS: Ultrasonographic exploration of penetrating truncal injuries is feasible and accurate. Ultrasonographic wound exploration may serve as a noninvasive and safe replacement for diagnostic laparoscopy, conventional local wound exploration, peritoneal lavage, and 6-hour chest x-rays (repeated chest x-rays taken 6 hours after initial chest x-ray examination). If used as part of the initial physical examination, cost-effectiveness can also be realized.

Management of familial breast cancer. I. Biostatistical-genetic aspects and their limitations as derived from a familial breast cancer resource.

Practical guidelines are given to promote decision-making logic by the physician in managing patients seeking consultation (consultands) because they may be at high familial risk for breast cancer and associated malignant neoplasms. The protocol is designed to aid in the assessment of patients who may become candidates for intensified cancer surveillance and/or prophylactic surgery. A resource comprised of 90 extended breast cancer-prone pedigrees provides the basis for these specific recommendations. The resource shows marked tumor heterogeneity among pedigrees, an approximate 50% incidence of breast cancer and associated malignancies among offspring of affected parents, and threefold higher risk for development of mammary carcinoma in the opposite breast of familial patients with unilateral disease than in sporadic patients. In utilizing this protocol, it is crucial that family history be highly accurate from the standpoint of genealogic relationships and pathologic tumor verification so that management recommendations may reflect sound risk factor assessment. Interpretation of familial risk factors should ideally be made by an informed medical-geneticist. All members of the medical team should then be appraised of familial risk and collectively engage in decision making with the consultand. We believe that this approach can foster more effective control of familial breast cancer.

Management of familial breast cancer. II. Case reports, pedigrees, genetic counseling, and team concept.

The lack of therapeutic progress, coupled with limitations in early breast cancer diagnostic surveillance, suggest the need for innovative control programs for this disease. We have provided certian practical criteria for prophylactic subcutaneous mastectomy based on family history, presence of precancerous diseases of the breast, and other breast cancer risk factors, and the attitudes, feelings, and emotional aspects of the patient, all of which temper decisions for the type of cancer surveillance program and/or prophylactic surgery.

The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma.

OBJECTIVE: To determine if duplex ultrasonographic scanning is diagnostically equivalent to arteriography and/or operative exploration in the diagnosis of extremity vascular proximity trauma. DESIGN: A prospective evaluation comparing duplex scanning with arteriography or operative exploration in 50 patients. Subsequently, duplex scanning was used alone for 175 extremity vascular proximity injuries, with other diagnostic methods used when injury was indicated on the duplex scan. SETTING: A busy urban trauma center. PATIENTS: Consecutive sample of 200 patients with 225 extremity injuries. SELECTION CRITERIA: Vascular proximity injury or diminished strength of the extremity pulse. MAIN OUTCOME MEASURES: The presence or absence of vascular proximity injury confirmed on angiography and/or operative exploration. RESULTS: Duplex scanning had 100% sensitivity and 100% specificity compared with arteriography and/or operative exploration in the first 50 cases. In the remaining 175 cases of extremity trauma, vascular injuries were diagnosed with duplex scanning alone. Duplex scanning detected 18 injuries, 17 of which were confirmed by correlation with arteriograms and/or operative exploration. One false-positive result--spasm of the superficial femoral artery--was found on arteriography. Seven unsuspected venous injuries were also diagnosed. CONCLUSIONS: Duplex scanning is a noninvasive, safe, effective method for the initial evaluation of potential extremity vascular proximity injury. It has replaced arteriography in the initial diagnosis of extremity vascular proximity trauma by our trauma service.

Tracheal agenesis.

Tracheal agenesis is a rare cause of respiratory distress in the neonatal period. Temporary survival depends on ventilation through the esophagus. Thirty-eight case reports of tracheal agenesis (including one from this institution) have appeared in the literature. In this paper, we present the case reports of our 2 patients and review the literature. Tracheal agenesis is associated with a wide variety of congenital anomalies, the most frequent being ventricular septal defect. A new classification encompassing seven types of tracheal agenesis is described.

Gasless laparoscopy using a planar lifting technique.

In clinical use, the mechanical lifting technique has demonstrated the ability to displace the abdominal wall and create a useful cavity for visualization and surgical manipulation. By forming a planar ceiling, as opposed to the domed ceiling of conventional pneumoperitoneum, the abdominal organs are brought into closer proximity of the surgeon. Instrument length may be shortened, imparting greater surgical control. Without the necessity for gas sealing, entry portals are simplified. Conventional instruments (right angle clamps) may be introduced through the fan retractor insertion sites or by way of separate stab incisions. The planar lifting technique has the potential for simplifying laparoscopy and restoring instrument control to the operating surgeon.

The interlocking of American surgery. An analysis of surgical leadership in the United States, 1945 through 1985.

To analyze surgical leadership in the United States from 1945 to 1985, 15 positions of influence have been identified. Appointments to these positions have been reviewed by age at appointment, medical school of graduation, site of residency training, solo appointments, and geographic distribution. A weighting scheme was designed to quantify institutional and personal performance. The 460 surgeons involved in this study graduated from 72 medical schools and 68 residency programs. The top ranking medical schools were Harvard, Johns Hopkins, University of Pennsylvania, Washington University in St. Louis, and Northwestern, which together accumulated 48 percent and 47 percent of all points and appointments, respectively. The top ranking residency training programs were Harvard, Johns Hopkins, the Mayo Clinic, Washington University in St. Louis, and the University of Pennsylvania, with Cornell, University of Michigan, Columbia, University of Minnesota, and the University of California in San Francisco occupying the second tier. Personal performances revealed that 40 percent of the top 20 surgeons were located in Southern-based institutions. Since 1965, geographic and institutional diversity has begun to appear in the surgical leadership.

Long-term results with the combined operation for duodenal ulcer disease.

During the twenty year span from 1951 to 1970, the combined operation was selected as the procedure of choice 663 times in the surgical management of duodenal ulcer disease. A retrospective study of these cases represents a 70 per cent follow-up rate; thirty-two additional patients expired during this period of causes unrelated to peptic ulcer disease or the procedure, bringing the crude follow-up rate to 77 per cent. The known recurrence rate was 0.85 per cent and the mortality 0.6 per cent. None of the deaths were due to the operative procedure itself. Diarrhea (11 per cent) and dumping (24 per cent) were the principle postoperative sequelae, neither of which represented a significant problem after twelve to fourteen months. Their incidence after 1960 in this series was decreased due to improved technic, better overall total surgical care, and reduction of the extent of resection from 75 to 50 per cent. The results, as interpreted by surgeon, patients, and gastroenterologist, have been reviewed.