Cytogenetic profile of 109 lipomas.

Cytogenetic analysis of short-term cultures was carried out on 109 lipomas from 92 patients. Clonal chromosomal abnormalities were present in 50% of the tumors analyzed. Based on the results, three main cytogenetic groups were identified and included: (a) tumors with normal karyotypes, (b) tumors with abnormalities involving region q13-15 on chromosome 12, and (c) tumors with other clonal aberrations. Within each of these groups, cytogenetic subgroups could be identified, each characterized by a specific anomaly. Tumors with abnormalities of 12q included specific subgroups with t/ins(1;12)(p32-33;q13-15), t(2;12)(p21-22;q13-14), t(3;12)(q28;q14), t(12;21)(q13;q21), complex, and nonrecurrent aberrations. The group containing heterogeneous clonal aberrations included subgroups with del(13)(q12q22), der(6)(p21-23), der(11)(q13), and nonspecific aberrations. Chromosome bands 1p36, 1p32-33, 2p21-22, 3q27-28, 6p21-23, 11q13, 12q13-15, 13q12, 13q22, 17p13, 17q21, and 21q21-22 were preferentially involved in structural rearrangements in lipomas. The identification of these sites of nonrandom rearrangements may serve to identify genes (at or near the junctions of chromosomal aberrations) involved in normal cellular growth control. Statistical analysis of the data revealed a correlation among karyotypic abnormalities and clinical data, such as age and sex of the patient, and tumor depth, site, and size.

Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?

BACKGROUND: After emergency department (ED) discharge, Spanish-speaking patients with limited English proficiency are less likely than English-proficient patients to be adherent to medical recommendations and are more likely to be dissatisfied with their visit. OBJECTIVES: To determine if integrating a longitudinal medical Spanish and cultural competency curriculum into emergency medicine residency didactics improves patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency. METHODS: Our ED has two Emergency Medicine Residency Programs, University Campus (UC) and South Campus (SC). SC program incorporates a medical Spanish and cultural competency curriculum into their didactics. Real-time Spanish surveys were collected at SC ED on patients who self-identified as primarily Spanish-speaking during registration and who were treated by resident physicians from both residency programs. Surveys assessed whether the treating resident physician communicated in the patient's native Spanish language. Follow-up phone calls assessed patient satisfaction and adherence to discharge instructions. RESULTS: Sixty-three patients self-identified as primarily Spanish-speaking from August 2014 to July 2015 and were initially included in this pilot study. Complete outcome data were available for 55 patients. Overall, resident physicians spoke Spanish 58% of the time. SC resident physicians spoke Spanish with 66% of the patients versus 45% for UC resident physicians. Patients rated resident physician Spanish ability as very good in 13% of encounters - 17% for SC versus 5% for UC. Patient satisfaction with their ED visit was rated as very good in 35% of encounters - 40% for SC resident physicians versus 25% for UC resident physicians. Of the 13 patients for whom Spanish was the language used during the medical encounter who followed medical recommendations, ten (77%) of these encounters were with SC resident physicians and three (23%) encounters were with UC resident physicians. CONCLUSION: Preliminary data suggest that incorporating Spanish language and cultural competency into residency training has an overall beneficial effect on patient satisfaction and adherence to medical recommendations in Spanish-speaking patients with limited English proficiency.

The use of albumin in clinical practice.

The use of albumin in the clinical setting continues to generate controversy. Periodic shortages and the high cost of albumin have compelled many hospitals to develop guidelines regarding albumin administration. Our purpose is to review the human studies involving albumin. Particular emphasis will be placed on comparative trials involving albumin and the less expensive crystalloid solutions. It is hoped that this review will assist the clinician in making judgements concerning the appropriate use of albumin.

Education about death and dying during the clinical years of medical school.

BACKGROUND: Although there has been a dramatic increase in education about death and dying in medical school curricula, the physician's interaction with terminally ill patients and their families still causes concern. The purpose of our study was to determine the impact of the third-year clerkship on education of medical students about death and dying. METHODS: From August 1, 1988, to August 1, 1990, a questionnaire concerning the care of terminally ill patients was distributed to all students completing the third-year clinical clerkship at our medical school. RESULTS: One hundred and eighty questionnaires were distributed, of which 106 were returned, yielding a response rate of 59%. All students had cared for a terminally ill patient during their third year. Forty-four (41%) students responding had never been present when an attending physician talked with a dying patient, and 37 (35%) had never discussed with an attending physician how to deal with a terminally ill patient. During the surgical clerkship 77 (73%) students had never been present when a surgeon had to tell the family of a patient bad news after surgery, and 90 (85%) had never been present when an attending surgeon had informed a family that their relative had died. Despite the fact that the curriculum addresses the stages of death and dying, almost half of the students could not remember these. When they were discharging a terminally ill patient home, one third of students could not identify problems that would be encountered by the family in caring for the patient. CONCLUSIONS: Fifty-seven (54%) felt that they were poorly equipped to deal with terminally ill patients on graduation from medical school, and 91% welcomed the opportunity to be educated in this area during the clinical years.

The surgical management of atypical mycobacterial soft-tissue infections.

Group IV atypical mycobacterial infections, especially Mycobacterium fortuitum and M. chelonei, are being reported with increased frequency. We report our experience with five cases of soft-tissue infection with these acid-fast bacilli. Often these infections are chronic, with formation of abscesses and multiple fistulas. Optimal surgical treatment often requires wide excision of all diseased tissue followed by delayed closure. Presentation, optimal surgical management, and antibiotic therapy are discussed.

Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery.

Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation.

The retained surgical sponge following intra-abdominal surgery. A continuing problem.

The surgical sponge retained following intra-abdominal surgery is a continuing problem. Despite precautions, the incidence of this problem is grossly underestimated. During the past 10 years, we have treated four patients with this problem. The presentation of a retained surgical sponge is highly variable, as is the time before the onset of symptoms. The clinical presentation, predisposing factors, and management are presented as well as guidelines for prevention.

Ischemic stricture and perforation. An unusual complication after successful barium reduction of an intussusception.

Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception.

Does the retrocecal position of the vermiform appendix alter the clinical course of acute appendicitis? A prospective analysis.

Ninety-four adult patients undergoing appendectomy for acute appendicitis were prospectively studied during a 2-year period. Patients were divided into retrocecal (group 1; n = 27 [29%]) and anterior (group 2; n = 67 [71%]) groups according to the position of the appendix. There was no statistical difference between the two groups in duration of symptoms, presenting signs and symptoms, and initial white blood cell count. Furthermore, retrocecal appendicitis was not associated with a higher rate of perforation or increased morbidity. We conclude that the retrocecal position of the appendix does not alter the presentation of appendicitis.

Risk of nonshunt abdominal operation in the patient with cirrhosis.

BACKGROUND: The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension. STUDY DESIGN: We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome. RESULTS: There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p < 0.05). Extensive complications occurred in 28 percent of patients (24 patients; 14 percent after elective operative treatment and 49 percent after emergent procedures). The mortality rate was greatest after gastric procedures (38 percent). Other factors of statistical significance (p < 0.05) associated with poor postoperative outcome included cachexia, preoperative transfusion of fresh frozen plasma, and intraoperative platelet transfusion. Surprisingly, operative blood loss, presence of ascites, and operative time were not associated with increased complications or death. CONCLUSIONS: We conclude that elective, nonshunt abdominal operations can be performed with acceptable morbidity and mortality rates in selected patients with cirrhosis.

Subcapsular hematoma after laparoscopic cholecystectomy, associated with ketorolac administration.

Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. Its adverse effect profile is different from that of the opioid analgesics; in particular, in its lack of respiratory depressive actions. However, ketorolac has risks associated with its perioperative administration, including episodes of substantial gastrointestinal bleeding. A patient undergoing elective laparoscopic cholecystectomy developed a subcapsular hepatic hematoma shortly after receiving a dose of injectable ketorolac. No evidence of parenchymal injury was found on laparoscopy, which argues against iatrogenic trauma. Clinicians should be aware that ketorolac may cause or aggravate bleeding, and it should be used with caution in perioperative patients.

Albumin and prealbumin concentrations in patients receiving postoperative parenteral nutrition.

This prospective, nonrandomized study was conducted to compare the increases in albumin and prealbumin concentrations in postoperative patients given adequate nutrition support. All surgery patients at least 18 years of age and who required parenteral nutrition were included. Of 86 patients evaluated, 16 met all criteria for study entry. Blood for albumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then weekly. Blood for prealbumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then twice weekly. Albumin concentrations increased from 2.00 +/- 0.35 to 2.21 +/- 0.42 g/dl (NS). Prealbumin concentrations increased from 11.97 +/- 6.31 to 17.29 +/- 8.93 mg/dl (p = 0.017). All but one prealbumin concentration was in the normal range for our laboratory when parenteral nutrition was discontinued. None of the albumin concentrations were ever in the normal range. The prealbumin concentration is a better indicator than albumin of nutrition status in the postoperative patient. Since prealbumin concentrations typically rise into the normal range within a week after adequate caloric supplementation, clinicians may avoid unnecessary increases in protein-calorie intake and laboratory testing of nutrition status by using this measurement.

A technique for repair of recurrent indirect inguinal hernias.

The repair of a recurrent inguinal hernia can be a technically demanding operation. Due to scar tissue from prior surgery, injury to the spermatic cord or compromise of the testicular blood supply is possible. A technique for repair of recurrent indirect inguinal hernia that allows minimal dissection of the spermatic cord structures is described.

Continuous ambulatory peritoneal dialysis associated with peritonitis in older patients.

Our recent experience with peritonitis in patients over the age of 55 years undergoing continuous ambulatory peritoneal dialysis between 1979 and 1989 is reviewed. Thirty-seven patients in this age group underwent Tenckhoff catheter insertion. Severe catheter-related peritonitis occurred at a rate of 1.41 episodes per patient per year. Overall, there were 61 episodes of peritonitis in 31 patients, with an overall mortality rate of 7%. When systemic signs of sepsis were present, this rate rose to 25%. All deaths were associated with fungal, pseudomonal, or polymicrobial infections. Management of these infections may require aggressive measures including repeated laparotomy for control of sepsis.

Tube enterostomy after small bowel resection.

Ostomy formation can be technically difficult when mesenteric shortening and thickening are present. In addition, the high output that follows a small bowel ostomy can be debilitating in the elderly patient or the patient with underlying medical illness. We describe a technique to avoid these difficulties.

Influence of spousal opinions on residency selection.

Fourth-year medical students face the difficult task of choosing a residency consistent with their career goals. Our study investigates the input of the spouse on the residency selection. From July 1, 1988, to July 1, 1990, questionnaires were sent to all 69 spouses of fourth-year medical students at the University of Arizona Medical Center. Fifty-six were returned for a response rate of 81%. Of the 16 women and 40 men who responded (mean age: 27 years), 55 (98%) spouse stated that there had been family discussions on the choice of a residency program, and 41 (73%) respondents thought that they had significant input. When asked to rank the items that most influenced their support for a particular training program, career goals of the medical student (68%) and lifestyle (21%) were most important, whereas prestige, earning capacity, and program length were ranked lowest. Specific concerns expressed by spouses on the selection of a surgical residency included time commitment as the most commonly cited (79%), followed by fatigue (48%). A statistically significant correlation existed between those spouses actively discouraging the choice of general surgery and those objecting to the time commitment during residency (p less than 0.05). We conclude that spouses have significant preferences regarding the choice of a training program following medical school. Career goals and lifestyle appear to be the most important factors; however, despite concern about the time commitment, the majority of spouses are supportive of the selection of a surgical residency.

Antibiotic irrigation and the formation of intraabdominal adhesions.

The efficacy of antibiotic peritoneal lavage in the prevention of postoperative infection is controversial. The role of intraperitoneally administered cefazolin and tetracycline in the formation of adhesions was studied in the rodent model. Thirty-two rats were divided into 3 groups. Group 1 underwent midline laparotomy with instillation of 10 ml of normal saline solution. Group 2 and Group 3 underwent the same procedure with instillation of 0.2 percent saline solutions of cefazolin or tetracycline, respectively. Animals were sacrificed after 2 weeks. Intraabdominal adhesions were graded and samples of parietal peritoneum were processed for histologic data. Group 2 and Group 3 had significantly higher adhesion scores compared with Group 1 (p less than 0.001). Histologic appearance of both antibiotic-irrigated groups showed mesothelial thickening with presence of fibroblasts and collagen. Cefazolin and tetracycline irrigation of the abdominal cavity contributes to the formation of peritoneal adhesions in the rat model.

Value of lymph node biopsy in the treatment of patients with the human immunodeficiency virus.

The indications and value of lymph node biopsy in patients infected with the human immunodeficiency virus (HIV) are not clearly defined. We reviewed 29 consecutive lymph node biopsies performed on 24 patients with the HIV over a 4-year period. Indications for biopsy included: (1) new or worsening medical symptoms with no detectable etiology in patients with lymphadenopathy, (2) disproportionately larger or enlarging lymph node in patients with generalized adenopathy, and (3) exclusion of concomitant disease in patients with previously defined infectious or neoplastic processes. The biopsy samples exhibited a diversity of histologic appearances including atypical and reactive hyperplasia, malignancy, and infection. Nineteen biopsies (64%) resulted in the institution or alteration of treatment. The absolute number of T-helper cells prior to biopsy was significantly lower in patients with a diagnosis of malignancy or infection (p < 0.05), as well as in those who eventually died (p < 0.05). Four (14%) minor complications resulted from lymph node biopsy. Based on our results, we conclude that lymph node biopsy is indicated in the above three subsets of HIV-infected patients. Biopsy can be performed with minimal morbidity and significantly alters therapy in the majority of patients.

A model for the assessment of students' physician-patient interaction skills on the surgical clerkship.

Physician-patient interaction skills are predominantly taught by successful role modeling but are rarely evaluated formally and systematically. This study describes a new model for the assessment of student physician-patient interaction skills and reports results of use in 78 third-year medical students on clerkships at two institutions. A single nurse instructor at each institution evaluated these skills using an 18-item checklist during student performance of wound care and dressing changes. Students were focused on the evaluation of their technical skills and were unaware of the evaluation of their interaction skills. Immediate feedback on performance was provided. The mean percentage score for the interaction skills was 35%, and no improvement was noted with greater clinical experience (later rotations). We conclude that there is a striking deficiency in physician-patient interaction skills among third-year students. The model described is effective for both evaluation and feedback.

Effect of surgical manipulation of polytetrafluoroethylene grafts on microstructural properties and healing characteristics.

The effects on graft healing of alterations in the microstructure of polytetrafluoroethylene (PTFE) grafts induced by surgical instruments have not been fully elucidated. This study evaluates changes in the structural and physical properties of PTFE grafts resulting from the intentional application of commonly used surgical instruments and the influence of these changes on cellular ingrowth. The extent of cellular ingrowth into intact (10, 30, and 60 microns unreinforced and 30 microns reinforced [R]) and structurally compromised PTFE grafts (30 reinforced and 60 microns nonreinforced) implanted subcutaneously in Sprague-Dawley (n = 14) rats was evaluated at 7 and 21 days. The thrombogenicity of 10-, 30-, 60-, and 80-microns intact graft segments was determined gravimetrically after suspension in the internal jugular vein of dogs for 90 minutes. Cellular ingrowth consisting of fibroblasts, macrophages, and microvessels was directly related to porosity and was most extensive in 60-microns uncompromised graft segments, being 7-, 17-, and 20-fold greater than was observed in 60- and 30R-microns compromised grafts and undamaged 10-microns grafts, respectively. There was a direct relationship between porosity and thrombogenicity of intact graft segments suspended in the jugular vein. The amount of thrombus adherent to 80-microns graft segments was eightfold greater compared with 10-microns grafts. Manipulation of PTFE with surgical instruments significantly impairs healing and may be a possible etiologic factor in the poor long-term performance of these grafts.