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12/31/1969 03:59 PM
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Pedunculated Lipoma of the Colon: Risks of Endoscopic Removal
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Pedunculated Lipoma of the Colon: Risks of Endoscopic Removal.
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12/31/1969 03:59 PM
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Endoscopic Removal of Gastric and Duodenal Polyps
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As endoscopic surgery comes into its own, the applications of this modality are increasing. This is well illustrated by the use of endoscopic polypectomy in the colon, and more recently by endoscopic polypectomy in the stomach and duodenum. We can anticipate increased applicability of these technics as the experience widens and the margins of safety increase. The present series of six polypectomies from the stomach and duodenum confirms the applicability of endoscopic polypectomy for this portion of the gastrointestinal tract, attests to its safety, and indicates that these procedures can contribute materially to the care of patients with gastric or duodenal polyps. The real and potential problems are discussed.
(C) 1976 Southern Medical Association
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12/31/1969 03:59 PM
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Endoscopic Removal of a Knotted Nasogastric Tube Lodged in the Posterior Nasopharynx
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colon; The complication of knotting nasogastric (NG) tubes on removal occurs infrequently with small diameter feeding tubes. Knotting of large caliber NG tubes is even more uncommon. We describe our experience in one such case, which was further complicated by the inability to visualize the NG tube in the posterior pharynx for removal through the mouth. We also review the literature and discuss risk factors.
(C) 1999 Southern Medical Association
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12/31/1969 03:59 PM
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Intraoperative Ultrasonography and Cortical Mapping for Removal of Deep Cerebral Tumors
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colon; Stereotactic biopsies of brain tumors have recently become frequent, but prognosis may be improved by more aggressive surgery for primary and metastatic tumors. This report describes techniques for debulking and removal of deep cerebral tumors that are commonly subjected only to biopsy. With the use of intraoperative ultrasonography and cortical mapping, five gliomas were debulked and three metastatic lesions were grossly totally removed. No complications occurred, and the patients metastatic disease had striking neurologic improvement. Deep cerebral tumors may treated aggressively with appropriate surgical techniques in selected patients.
(C) 1991 Southern Medical Association
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12/31/1969 03:59 PM
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A Previous Cholecystectomy Increases the Risk of Developing Advanced Adenomas of the Colon
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Background: There is limited data assessing the relationship between cholecystectomy and colorectal adenomatous polyps (AP). Our aim was to determine if cholecystectomy was associated with an increased prevalence of advanced AP in male veterans.
Methods: The relationship of whether prior cholecystectomy modified the natural history of AP was investigated in a retrospective study. The patients were divided into two groups: 1) those with AP and a history of cholecystectomy, and 2) those with AP, but without a history of cholecystectomy. Factors in each group associated with advanced AP were examined by univariate analysis (UA) and stepwise logistic regression analysis to determine independent predictors of aggressive clinical characteristics of polyps. Statistical significance was determined at a P <= 0.05.
Results: We identified a total of 1234 patients with AP (cases = 127, controls = 1107). The mean age of patients was 64.1 +/- 1.9 (standard deviation) years. By UA, those with a prior cholecystectomy had a greater mean number of AP (4.2 vs. 3.5; P = 0.04) and more advanced polyps (P = 0.037) than those without a cholecystectomy. By logistic regression, prior cholecystectomy was associated with more advanced AP (OR = 1.5 [1.0-2.2]; P = 0.04). Patients who had a cholecystectomy were 51% more likely to have advanced AP. There appeared to be a trend towards increased time from cholecystectomy being associated with advanced polyps (9.69 years vs. 8.99 years, P = 0.056).
Conclusions: A prior cholecystectomy was independently associated with an increased risk of developing advanced AP. Also, there appeared to be a trend toward a greater prevalence of advanced lesions as postcholecystectomy time increased.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Giant Ulcerated Lipoma of the Colon Causing Iron Deficiency Anemia Successfully Treated with Endoscopic Ultrasound-Assisted Resection
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Colonic lipomas are frequently small and asymptomatic. Giant colonic lipoma (GCL) is an uncommon finding at endoscopy, and ulceration with occult blood loss leading to iron deficiency anemia (IDA) is even rarer. The choice of therapeutic procedure to treat symptomatic GCLs has been controversial. We hereby report a case of an ulcerated GCL that presented with occult bleeding and IDA. IDA resolved after the GCL was removed successfully combining endoloop ligation and snare cautery technique under endoscopic ultrasound (EUS) guidance. With the advent of EUS, endoscopic resection of submucosal tumors can be performed relatively safely by providing a viable and useful alternative to surgery.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Thrombosis of the Digital Arteries as the Cause of a Class IIA Ring Avulsion
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colon; I describe a patient who had a dusky finger after a ring avulsion injury. Although blood flow was initially good after removal of the ring, circulatory compromise later developed. Surgical exploration revealed thrombosis of both digital arteries, which was treated with thrombectomy. In such injuries, the circulatory status of the finger needs to be observed after ring removal in case delayed compromise occurs.
(C) 1994 Southern Medical Association
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12/31/1969 03:59 PM
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Percutaneous Nephrolithotomy in 86 Patients: Analysis of Results and Costs
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colon; We reviewed the hospital records of the first 86 patients having percutaneous nephrolithotomy at University Hospital (Birmingham, Ala) between 1983 and 1985. Variables such as stone location, chemical composition of the stone, history of previous renal surgery, and stone size were examined to determine their effect on complication rate, overall success of stone removal, and hospital cost. The overall success rate for the removal of targeted calculi was 94%. In patients with calculi larger than 1.2 cm, the initial success rate was 63%; such patients often required a second procedure. The mean hospital stay for patients with calcium-containing calculi was 6.8 days (mean hospital cost $5,311). Patients with infection-induced calculi had a mean stay of 11.2 days (mean cost $9,362). Compared with the costs of open surgical procedures for stone removal at our institution, percutaneous nephrolithotomy was 46% less expensive. Complications were minimal in most patients, and no patient required open surgical intervention. Percutaneous nephrolithotomy is an effective procedure for removing renal and ureteral calculi. It is associated with low morbidity and is less expensive than open surgical lithotomy procedures.
(C) 1986 Southern Medical Association
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12/31/1969 03:59 PM
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Infective Complications of Prolonged Central Venous (Hickman) Catheterization
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colon; We reviewed infectious complications during 7,671 days of central venous (Hickman) catheter use in 47 patients receiving intensive cytotoxic and supportive therapy for malignant disease. Colonization of the catheter was identified in eight cases of septicemia, two associated with endocarditis. Septicemia was successfully treated in four of five patients after removal of the catheter and in two of three in whom the catheter remained in situ. Infection of the exit site occurred in five patients but in only one was there associated septicemia. Poor patient compliance with the recommended regimen for catheter care was suspected. Thus, the overall rate of catheter-related infection was 1.6 per 1,000 days. Guidelines are discussed for removal of the catheter for suspected catheter-related infection.
(C) 1985 Southern Medical Association
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12/31/1969 03:59 PM
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Ulnar Neuropathy Associated With Subdermal Contraceptive Implant
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colon; Side effects are a common occurrence in the use of subdermal contraceptive implants (Norplant); approximately 70% to 80% of women using the device report abnormal uterine bleeding, headaches, acne, mastalgia, nervousness, appetite changes, and weight gain. Local implant site reactions range from 0.4% to 4.7%, with pain being the most common. Other insertion site complications include infection and implant expulsion. Only three cases have been described in the literature concerning implant site-related neuropathy, involving the sensory branch of the musculocutaneous nerve (lateral cutaneous nerve) in two cases and the antebrachial cutaneous nerve in the third case. We believe our report is the first case of an axonal loosing motor and sensory ulnar neuropathy associated with the removal of a subdermal contraceptive implant (Norplant). We review insertion site complications and their most likely causes. Also, we discuss alternative removal techniques for difficult-to-remove implants.
(C) 1998 Southern Medical Association
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12/31/1969 03:59 PM
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Ganglions of the Hand and Wrist
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colon; The ganglion is the most common soft tissue tumor of the hand and wrist, originating from the joint capsule or tendon sheath. Accurate diagnosis and proper treatment of these entities require a thorough knowledge of the anatomy of the wrist and hand as well as of the ganglion itself. Definitive therapy is based on total surgical removal of the cyst and its connections to the joint or tendon sheath.
(C) 1988 Southern Medical Association
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12/31/1969 03:59 PM
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Pulmonary Complications of Percutaneous Nephrostomy and Kidney Stone Extraction
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colon; Percutaneous nephrostomy and percutaneous removal of kidney stones are widely used procedures that obviate the need for open urologic surgery in many patients. In six patients who had percutaneous renal manipulation, pulmonary complications of varying severity developed, including urinothorax, pneumothorax, hemorrhage, pleural effusion, pneumonia, and atelectasis. Patients having percutaneous renal manipulation should be monitored during and after the procedure for pulmonary complications.
(C) 1988 Southern Medical Association
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12/31/1969 03:59 PM
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Microbiologic Assessment of the Transabdominal Ultrasound Transducer Head
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colon; The objectives of this study were to determine (1) the rate of bacterial isolation from the abdomen of women having obstetric ultrasonography, (2) the rate of bacterial transmission to the transducer head, and (3) the eradication rate after routine wiping of the transducer head. A total of 191 obstetric patients participated in this study. At the start of each day, the transducer head and the coupling gel were cultured. Aerobic cultures were obtained from each patient's periumbilical and suprapubic areas before the transabdominal scan and from the transducer head before and after wiping off the gel with a dry cloth. Daily transducer head and gel cultures were negative. Of the abdominal skin cultures, 175 (92%) were positive; 35 (18%) were positive for serious organisms, and 140 (74%) were positive for organisms of low virulence. Sixty percent of the transducer head cultures from women with abdominal skin pathogens were positive before the gel was wiped off. None of the cultures from the transducer head were positive after removal of the gel. We conclude that many women carry potentially virulent pathogens on the abdominal skin and that transmission of these organisms to the transducer head commonly occurs. Physical removal of the gel from the transducer head effectively eradicates these microorganisms, minimizing patient-to-patient transmission.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Beware the Inverted Diverticulum!
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SP, Pantelidaki C, et al. Endoscopic removal of inverted sigmoid diverticulum-Is it a dangerous that ICD are the only potential mimics of colon polyps would be incorrect. Submucosal lesions are often
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12/31/1969 03:59 PM
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Unexpected Gallbladder Cancer With Cutaneous Seeding After Laparoscopic Cholecystectomy
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colon; We describe a case of gallbladder carcinoma involving full thickness of the gallbladder-wall after laparoscopic cholecystectomy for cholecystitis. Laparotomy for removal of the gallbladder bed and excision of the umbilical cannula site revealed focal residual tumor in the liver bed and microscopic tumor implant in the cannula site. Postoperatively, the patient had radiotherapy of the tumor bed and umbilical scar. Eleven months later, the patient was alive without any evidence of relapse. Excision of the gallbladder bed and laparoscopic scar with or without complementary radiotherapy may be indicated for management of cases in which transmural extension of the unexpected gallbladder carcinoma occurs after laparoscopic cholecystectomy.
(C) 1994 Southern Medical Association
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12/31/1969 03:59 PM
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Massive Asymmetric Virginal Breast Hypertrophy
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colon; Massive unilateral virginal breast hypertrophy in a 13-year-old girl was treated by right breast reduction, with removal of 2,968 g of breast tissue. A year later, the patient had enlargement of the left breast, and contralateral reduction mammoplasty was done. Two-year follow-up has shown no further enlargement. This case lends itself to a discussion with regard to the differential diagnosis of unilateral breast hypertrophy in adolescence. True virginal gigantomastia is relatively rare. Surgical reduction mammoplasty plays a pivotal role in the treatment of massive virginal breast hypertrophy.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Coagulase-Negative Staphylococci
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colon; Coagulase-negative staphylococci, long considered to be harmless commensals or contaminants, have emerged as major pathogens as medical technology has advanced. They are a major cause of intravenous-catheter-associated bacteremia, endocarditis, otitis media, and infection of joint prostheses, vascular grafts, cardiac pacemakers, cerebrospinal fluid shunts, postoperative wounds, the urinary tract, and the eye. Therapy includes removal of infected foreign bodies and administration of appropriate antimicrobial agents.
(C) 1988 Southern Medical Association
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12/31/1969 03:59 PM
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Myocardial Calcifications in Neonates and Infants: A Unique Tissue Reaction
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colon; The deposit of calcium salts into myocardial cells represents the process of dystrophic calcification. Once it causes alterations in cellular calcium hemostasis, it can initiate deleterious events leading to ischemic myocardial injury and cell death. Myocardial calcifications in infants are markedly different from those in adults; calcifications are significantly more frequent in cases of myocardial necrosis in the young, and can be demonstrated microscopically without removal of necrotic fibers and scar formation, which are the adult's usual stages of response to myocardial necrosis. Important functional and clinical implications in myocardial calcification, other than serving as a marker for necrosis, relate to accelerated myocardial calcification after cardiac surgery in infants.
(C) 1991 Southern Medical Association
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12/31/1969 03:59 PM
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Fragmentation Hemolysis: An Unusual Indication for Valve Replacement in Native Valve Infective Endocarditis
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colon; Intravascular mechanical fragmentation of erythrocytes is an uncommon occurrence in native valve infective endocarditis. We report a case of fragmentation hemolysis in a patient with tricuspid valve endocarditis due to Staphylococcus aureus. She received transfusion of multiple units of packed red blood cells and ultimately required surgical removal of the affected valve to control the hemolytic process. We believe this to be only the fifth such reported case and the first in which surgical therapy was necessary to control the hemolytic process.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Familial Polyposis in Children: Early Detection and Preferred Treatment
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colon; Familial polyposis is a disease with high malignant potential. When the diagnosis is established, surgical removal of the premalignant tissue should be complete. Reports of early malignant expression of the disease have led us to recommend early surveillance and treatment of children from affected families. We describe four children who had total colectomy, rectal mucosectomy, and ileoanal anastomosis, and relate our reasons for preferring this modality of therapy for familial polyposis in young patients.
(C) 1984 Southern Medical Association
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12/31/1969 03:59 PM
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Respiratory Depression in a Child Unintentionally Exposed to Transdermal Fentanyl Patch
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colon; A 2-year-old boy was found unresponsive after sleeping in bed with his grandmother. After the patient was intubated and ventilated, paramedics discovered a transdermal fentanyl patch on the victim's back. Removal of the patch and treatment with naloxone resolved symptoms. This is the first reported case of secondary exposure to a fentanyl patch causing clinically significant respiratory depression in the pediatric population, and it emphasizes a new hazard of such drug use.
(C) 1997 Southern Medical Association
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12/31/1969 03:59 PM
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Presentation and Management of a Thyroglossal Duct Cyst With a Papillary Carcinoma
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colon; Thyroglossal duct carcinoma is rare, and its presentation is similar to that of a thyroglossal duct cyst: a nontender, palpable mass in the midline location. Rapid increase in growth may be a sign of malignancy, but the diagnosis is based on the pathology of the cyst. Initial treatment of thyroglossal duct carcinoma is the same surgical procedure used for removal of a thyroglossal duct cyst. Further surgery depends on the finding of thyroid nodules or positive lymph nodes but is rarely necessary. The recurrence rate after simple excision is low. Postoperative radioiodine ablation or radiation is considered in cases of recurrence or metastasis. In this report, we describe a patient with a new-onset, nontender, neck mass who had a Sistrunk procedure for a presumed thyroglossal duct cyst and was found to have papillary carcinoma.
(C) 1997 Southern Medical Association
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12/31/1969 03:59 PM
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Unilateral Adrenal Hyperplasia
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colon; A case of unilateral primary adrenal hyperplasia, without concomitant hypokalemia, is presented. After surgical removal of the gland, a complete remission occurred. This rare condition may, in fact, be more frequent than thought as it can coexist with normokalemia. We postulate that it is probably a new phase of the transformation between hyperplasia and adenomas that can also occur in the adrenal cortex similar to such transformations in other endocrine organs.
(C) 1994 Southern Medical Association
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12/31/1969 03:59 PM
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Thoracic Splenosis
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colon; Thoracic splenosis is rare, with fewer than two dozen reported cases. Patients uniformly have a history of splenectomy with combined abdominal and thoracic trauma. Clinical signs and symptoms are usually absent, and the condition is most often discovered on routine chest radiography. The interval between trauma and clinical discovery has ranged from 2.7 to 42 years. There is no documented benefit to removal of the splenic nodules unless the patient is symptomatic.
(C) 1998 Southern Medical Association
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12/31/1969 03:59 PM
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Surgical Management of Palmar Hyperhidrosis
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colon; Hyperhidrosis is an idiopathic pathologic condition characterized by excessive sweating beyond that required to cool the body. Disturbance of the central nervous system, endocrine system, or obesity has been associated with this condition. Patients have a history of several years of occupational or social embarrassment. Individuals of Japanese ancestry and Jews of Northern African, Yemeni, or Balkan descent are predisposed to the condition. Nonoperative therapy is merely temporizing and unacceptable because of lack of efficacy or side effects. Surgical intervention provides effective and permanent control. The key to surgical correction appears to be the division of the sympathetic chain above the T-2 ganglion and below the T-3 ganglion of the involved side with removal of the entire T2-3 segment with its corresponding spinal nerves. This paper presents our experience with the dorsal thoracic approach for interruption of sympathetic innervation for severe palmar hyperhidrosis. We also review surgical efficacy of various approaches to the sympathetic chain, as well as possible side effects of operative intervention
(C) 1990 Southern Medical Association
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12/31/1969 03:59 PM
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Arsenic Exposures in Mississippi: A Review of Cases
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colon; Arsenic poisonings occur in Mississippi despite public education campaigns to prevent poisonings in the home. We reviewed 44 Mississippi cases of arsenic exposures occurring from January 1986 to May 1990. We compared the epidemiologic differences between unintentional and intentional poisonings. Cases were found and characterized through the two toxicology laboratories and hospital records. Arsenic-based rodenticides were the arsenic source in 23 of the 44 exposures. Other sources were monosodium methylarsenate (4 cases), dodecyl ammonium methane arsonate (5 cases), and other compounds (12 cases). Of the 44 exposures, 27 were unintentional, 7 were suicide attempts, 6 were homicide attempts, and 4 were of unknown intent. Of the 27 unintentionally exposed patients, 19 were black and 14 were male; their median age was 3 years. Of the 13 intentionally poisoned persons, 9 were male and 10 were black, with a median age of 28 years. Six of the seven patients who attempted suicide were white; four of the six victims of attempted homicide were black. We recommend removal of remaining bottles of arsenic-based rodenticides from store shelves, and we urge practicing physicians to warn patients of the dangers of using such rodenticides.
(C) 1991 Southern Medical Association
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12/31/1969 03:59 PM
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Hemangioma of the Temporal Bone in a Patient Presumed to Have Meniere's Syndrome
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colon; This case report describes a patient with a facial nerve hemangioma of 8 years' duration that initially caused most of the symptoms of Meniere's syndrome: fullness, sensorineural hearing loss, dizziness, tinnitus, and disruption of balance. The hearing loss was in the high-frequency range (>=3,000 Hz); typically, the initial hearing loss in Meniere's syndrome is in the low-frequency range. Mild facial nerve weakness and punctate keratitis due to corneal exposure appeared 8 years later. Contrast-enhanced magnetic resonance imaging and high-resolution computed tomography depicted the lesion and made preoperative diagnosis possible. With meticulous surgical removal of the tumor, which was intertwined with the facial nerve, facial nerve function was preserved.
(C) 1997 Southern Medical Association
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12/31/1969 03:59 PM
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Prospective Survey of Continuous Versus Single-Injection Spinal Anesthesia in Obstetrics
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colon; Prior to the removal of spinal microcatheters from the market in 1992, these catheters were used extensively in the Obstetric Anesthesia Service at the Medical Center of Louisiana. We report on a prospective survey of the clinical application of single-injection versus continuous-catheter spinal anesthesia. Two hundred sixteen patients had single-injection anesthesia, and 218 had continuous-catheter anesthesia. No neurologic complications other than postdural puncture headache (PDPH) were encountered in either group. Five patients had PDPH after single-injection technique, and 8 patients had PDPH from continuous spinal anesthesia. Patients with diabetes were at higher risk for PDPH, and blacks were at lower risk (relative risks 4.35 and 0.31, respectively). Additionally, PDPH was associated with lower intraoperative urine output. No increased risk of complications was found after continuous spinal anesthesia with microcatheters.
(C) 1995 Southern Medical Association
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12/31/1969 03:59 PM
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Krukenberg Tumors: CT Features and Growth Characteristics
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We reviewed the computerized tomographic features of pathologically proven metastases to the ovary in 12 patients. Serial CT scans were available in nine of the 12 patients-before removal of the ovaries in five cases (showing typical growth characteristics of these metastases) and afterward in six (showing common patterns of tumor progression). Primary neoplasms metastasizing to the ovary included adenocarcinoma of the colon (seven), stomach (two), appendix (one), and endometrium (one), and carcinoid tumor (one). On CT, metastases to the ovary were large lobulated or oval masses with cystic and solid components. Nine were bilateral and three were unilateral. Three patterns of ovarian enlargement were seen: macrocystic (six), microcystic (three), and predominantly solid enlargement with necrosis (three). Other associated CT findings included carcinomatosis, hydronephrosis, ascites, liver metastases, and lymphadenopathy. The primary tumor in patients without a prior history of malignancy was identifiable retrospectively on CT in four of the five cases.
(C) 1989 Southern Medical Association
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12/31/1969 03:59 PM
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Indications for Fiberoptic Colonoscopy
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In certain clinical situations, fiberoptic colonoscopy has proved most useful and effective as a diagnostic and therapeutic tool. Colonoscopy is indicated to remove polyps when feasible and to rule out the presence of other polyps or tumors undetected by barium enema. Patients with cancer of the colon should have preoperative colonoscopy to rule out the presence of undetected polyps or metachronous cancer. Follow-up examinations are important to insure against residual cancer or recurrence after colonoscopic removal of sessile, premalignant, or malignant polypoid lesions, and to evaluate certain patients who have increased risk of polyp or tumor formation. Colonoscopy usually can explain persistent, localized abnormalities detected by barium enema (ie, "filling defects") and provide a definitive diagnosis in cases of unexplained rectal bleeding or diarrhea despite negative sigmoidoscopic and barium studies. In experienced hands, this technic is safe, comfortable, and effective in avoiding laparotomy to remove clinically significant polyps and in providing definitive diagnosis in many clinical situations.
(C) 1975 Southern Medical Association
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12/31/1969 03:59 PM
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Laparoscopic Cholecystectomy: A Community Experience
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colon; Minimally invasive surgery appears to be gaining popularity, and removal of the gallbladder by laparoscopic methods is one such procedure for which there is recent enthusiasm. The concerns about safety, morbidity, and mortality in contrast to standard cholecystectomy are being evaluated. To address these concerns we reviewed the first 230 laparoscopic cholecystectomies done by one surgical group from October 1990 to September 1991. There were 161 women and 69 men with an average age of 50 years. The average length of stay was 2.1 days, most patients being discharged in 24 hours. Complications occurred in 14 patients (6%). The one death was unrelated to the gallbladder surgery. Operative cholangiograms were done as frequently as possible. It appears that laparoscopic cholecystectomy can be done safely and with a shorter hospital stay. Complications are similar to those seen with standard cholecystectomy
(C) 1992 Southern Medical Association
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12/31/1969 03:59 PM
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Abdominal Wall Reconstruction After Temporary Abdominal Wall Closure in Trauma Patients
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colon; We retrospectively analyzed 36 patients requiring temporary abdominal wall closure on admission to a level I trauma center from 1988 to 1992. There were 10 deaths (28%) in the study population. Of the 26 survivors, 8 patients (31%) had primary fascial closure at initial hospitalization, whereas 18 patients (69%) required split-thickness skin grafting to visceral granulation tissue. Of these 18 patients, 13 have had ventral herniorrhaphy at subsequent admission. Eight of these patients had primary fascial closure, 4 required primary fascial approximation with prosthetic onlay reinforcement, and 1 required multiple operations including prosthetic reconstruction and eventual complex tissue transfer. Complications occurred in 3 patients (14%) and included two wound seromas, which were drained nonoperatively, and a wound infection necessitating removal of prosthetic material and subsequent reconstruction with complex tissue transfer. Follow-up reveals no recurrent hernia at 24 months. Abdominal wall reconstruction after temporary closure can be done safely and promptly, with good functional and esthetic results.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Duodenal Obstruction in Thyroid Storm
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colon; A 35-year-old, previously healthy woman, known to be thyrotoxic, was transferred from a community hospital for "acute abdomen." Abdominal pain, distention, and hyperemesis resolved with placement of nasogastric tube (NGT) and return of 2,600 mL of bilious fluid. Continued high NGT output made oral or NGT administration of antithyroid drugs impossible. We gave propylthiouracil (PTU) by retention enemas with therapeutic serum levels and sublingual saturated solution of potassium iodide (SSKI) with 70% absorption based on 24-hour free iodine urinary excretion. The patient's thyroxine (T4) and triiodothyronine (T3) radioimmunoassays were normal on hospital days 10 and 12, respectively. However, free T4 and T3 resin uptake did not normalize until hospital day 31. On hospital day 32, she tolerated removal of NGT without nausea and 4 days later was taking a regular diet. We conclude that our patient's gastrointestinal symptoms were a prominent feature of her thyrotoxicosis and that rectal PTU and sublingual SSKI are effective in administration of antithyroid drugs.
(C) 1997 Southern Medical Association
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12/31/1969 03:59 PM
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Current Controversies in Pouch Surgery
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Restorative proctocolectomy with ileal pouch anal anastomosis has become the most commonly used procedure for elective treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis. Since its original description, the procedure has been modified in an attempt to obtain optimal functional results with low morbidity and mortality, and yet provide a cure for the disease. These modifications of the technique are discussed in this review, limited to the current points of controversy. We reviewed the current literature describing restorative proctocolectomy with ileal pouch anal anastomosis. The current "hot topics" for debate are transanal mucosectomy with hand-sewn anastomosis versus the double-stapled technique, the use of diverting ileostomy, indeterminate colitis, the role of laparoscopy, and indications for pouch surgery in the elderly. Longer follow-up of patients and increased knowledge and experience with pouch surgery, coupled with active prospective evaluation of the procedure are required to settle these issues. Patients must be fully informed to understand inherent risks of each choice.
(C) 2003 Southern Medical Association
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12/31/1969 03:59 PM
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The Water Jet Deformation Sign: A Novel Provocative Colonoscopic Maneuver to Help Diagnose an Inverted Colonic Diverticulum
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Colonoscopic differentiation of an inverted colonic diverticulum from a true colonic polyp is important because a true colonic polyp usually requires colonoscopic snare polypectomy or at least biopsy, whereas these maneuvers are contraindicated for an inverted diverticulum due to the risk of colonic perforation. Previously described diagnostic maneuvers to evert an inverted diverticulum include probing it with a closed biopsy forceps or intraluminal air insufflation during colonoscopy. On colonoscopy, a 59-year-old female had two intraluminal colonic projections. Probing these projections and using air insufflation failed to indent or evert them. Spraying these lesions with a water jet, however, flattened or partly everted them. This novel maneuver provided conclusive evidence that these intraluminal projections represented inverted diverticula. The proposed pathophysiology is that water pressure causes an inverted diverticulum to indent or evert due to its thin wall. The currently reported maneuver may be easier and safer than probing an inverted diverticulum with biopsy forceps and may prove a more reliable diagnostic maneuver than air insufflation.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Patient's Page
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McKinney, Jennifer March 2006 uvh 0404522 English Special Section 324 Article Clinical Medicine 25 99 3 Success Turn on more accessible mode Skip to main content Southern Medical Journal Content Issue
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12/31/1969 03:59 PM
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Screening Preferences for Colorectal Cancer: A Patient Demographic Study
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Background: Colorectal cancer is a leading cause of cancer-related death. Screening for colorectal cancer is a rational and cost-effective strategy for reducing the incidence of colorectal cancer and related mortality. Despite endorsement by academic and health care organizations, patient awareness and compliance with screening is low, partly because of patient-related barriers to screening.
Methods: A convenience sample of adults attending the internal medicine and family practice clinics of a community teaching hospital was studied. A description of fecal occult blood testing (FOBT), sigmoidoscopy, and colonoscopy procedures was given in a packet along with a questionnaire. The questionnaire focused on screening procedures followed in our hospital (i.e., yearly FOBT and sigmoidoscopy every 5 years or colonoscopy every 10 years for average-risk individuals).
Results: Of the 193 patients who responded, 55% preferred sigmoidoscopy and FOBT, 29% chose colonoscopy, and 16% wanted no screening. Those with knowledge of someone with colon cancer or colon polyps reported a significantly higher preference for screening than those without such knowledge. Catholics were most likely to prefer no screening compared with non-Catholics. Ex-smokers (compared with all others) were more likely to want screening. Catholics were least likely to want colonoscopy. Patients with previous experience of colorectal screening preferred future screening. Those preferring no screening were significantly younger than those who expressed a preference for screening.
Conclusion: The results of this study demonstrate diversity in patient choices for colorectal cancer screening. A focus on people's preferences rather than on the test itself may help develop and target appropriate intervention for prevention of colorectal cancer.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Prevalence of Intra-abdominal Surgery: What Is an Individual's Lifetime Risk?
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Background: The lifetime risk of intra-abdominal surgery is unknown. The objectives of this study were to derive this information from our local population, and to consider the role of incidental surgery.
Methods: Over an 8-year period, 2648 autopsy and clinical records from a public and private hospital were reviewed for evidence of intra-abdominal surgery.
Results: 2262 (85%) cases were from the public hospital and 386 (15%) from the private hospital. The adjusted intra-abdominal surgical rate was 43.8% in those over the age of 60. With the exception of the age group 21-40, there were no statistical significant differences in operative rates between hospitals. The intra-abdominal surgical rate over the age of 60 was used as an estimate of the lifetime risk of intra-abdominal surgery.
Conclusions: The lifetime risk of intra-abdominal surgery can be used to assess the utilization of healthcare among ethnic groups and in considering the role of incidental surgery.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Colorectal Cancer Screening: Today and Tomorrow
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Colorectal cancer remains a disease with significant morbidity and mortality. However, the prognosis can be greatly improved with early detection. Here, we review the current screening modalities and guidelines for patients at average, moderate, and high risk for colorectal cancer. New experimental modalities are also introduced.
(C) 2006 Southern Medical Association
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12/31/1969 03:59 PM
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Surveillance of the Colorectal Cancer Disparities Among Demographic Subgroups: A Spatial Analysis
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Objective: The literature suggests that colorectal cancer mortality in Texas is distributed inhomogeneously among specific demographic subgroups and in certain geographic regions over an extended period. To understand the extent of the demographic and geographic disparities, the present study examined colorectal cancer mortality in 15 demographic groups in Texas counties between 1990 and 2001.
Methods: The Spatial Scan Statistic was used to assess the standardized mortality ratio, duration and age-adjusted rates of excess mortality, and their respective p-values for testing the null hypothesis of homogeneity of geographic and temporal distribution.
Results: The study confirmed the excess mortality in some Texas counties found in the literature, identified 13 additional excess mortality regions, and found 4 health regions with persistent excess mortality involving several population subgroups.
Conclusion: Health disparities of colorectal cancer mortality continue to exist in Texas demographic subpopulations. Health education and intervention programs should be directed to the at-risk subpopulations in the identified regions.
(C) 2006 Southern Medical Association
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12/31/1969 03:59 PM
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Comparison of Pediatric Airway Foreign Bodies Over Fifty Years
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colon; Prevention and early recognition remain critical factors in the treatment of foreign body inhalation in children. Accidental inhalation of both organic and nonorganic foreign body material continues to be a cause of childhood morbidity and mortality. The University of North Carolina Department of Otolaryngology has collected foreign bodies acquired from the airways of young children since its inception in 1954. The authors reviewed 26 foreign bodies removed bronchoscopically from the airways of children during the years 1955 to 1960, and compared these to 27 foreign bodies collected from 1999 to 2003. Findings showed remarkable similarities in the types of foreign bodies aspirated. Organic foreign bodies were most commonly found. Differences existed in the type of organic foreign body aspirated, with popcorn being retrieved in 15% of cases during the later time period. Also, an increase in bronchoscopically removed small toy parts was found in the later group.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Evolution of Brunner Gland Hamartoma Associated with Helicobacter pylori Infection
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The pathogenesis of Brunner gland hamartoma of the duodenum is unknown. This case report describes the chronology of the development of Brunner gland hamartoma from Brunner gland hyperplasia over a 12-year interval. The study subject, a 64-year-old man with chronic iron deficiency anemia, underwent serial upper endoscopies during this period. Repeated endoscopies demonstrated the evolution of Brunner gland hyperplasia, as manifest endoscopically by a submucosal mass, to a pedunculated polyp with histologic features of Brunner gland hamartoma. The duodenal polypoid mass was removed by snare polypectomy. The patient also had a chronic Helicobacter pylori infection of the stomach. This report details the time-dependent evolution of Brunner gland hyperplasia to hamartoma in association with chronic gastric H. pylori infection.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Unusual Presentation of Pheochromocytoma with Ischemic Sigmoid Colitis and Stenosis
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A 45-year-old woman with poorly controlled hypertension and diabetes mellitus presented with left iliac fossa pain, constipation alternating with diarrhea, and weight loss. She had been diagnosed with idiopathic cardiomyopathy five years previously. Echocardiogram had shown a left ventricular ejection fraction (LVEF) of 35%; coronary angiogram was normal. Colonoscopy revealed sigmoid colitis with stenosis. Abdominal computed tomography revealed a 5 cm right adrenal tumor. Twenty-four hour urinary free catecholamines and fractionated metanephrine excretion values were elevated, confirming pheochromocytoma. Her colitis resolved after one month of adrenergic blockade. Repeat echocardiogram showed improvement of LVEF to 65%. After laparoscopic right adrenalectomy, the patient's hypertension resolved, and diabetic control improved. Timely management avoided further morbidity and potential mortality in our patient.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Percutaneous Drainage for Treatment of Infected Pancreatic Pseudocysts
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Background: Infection of pancreatic pseudocysts is a potentially fatal complication that must be treated immediately. Despite numerous published reports about percutaneous treatment, the effectiveness of percutaneous catheter drainage (PCD) of infected pancreatic pseudocysts is still under discussion.
Methods: In this study, 30 patients (17 women) with 30 infected pancreatic pseudocysts were administered local anesthesia and underwent PCD performed with the use of a single-step trocar technique with computed tomographic guidance. The patients' ages varied from 27 to 74 years (mean age, 45 yr). The etiology was acute pancreatitis in 18 patients, chronic pancreatitis in 11 patients, and surgical trauma in 1 patient.
Results: No complications related to the procedure occurred in our series. The success rate was 96% (29 of 30 patients), with no recurrence during follow-up, which ranged from 2 to 58 months (mean follow-up, 27.2 mo). One patient had unsuccessful PCD and was subsequently treated surgically.
Conclusion: Our findings indicate that PCD is a safe and effective front-line treatment for patients with infected pancreatic pseudocysts.
(C) 2003 Southern Medical Association
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12/31/1969 03:59 PM
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Preferable Colonic Investigations for Isolated Abdominal Pain
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Objectives: Isolated abdominal pain is seen as a poor indication for colonic investigations. The yield of serious pathology detected by optical colonoscopy (OC) has differed greatly in published series. This study aims to establish the yield of colonic investigations for isolated abdominal pain.
Methods: A retrospective analysis of the endoscopy database was undertaken on all OCs performed from 2000 to 2008. The yield of OCs for detection of pathology (polyps, cancers, and inflammatory bowel disease) was compared for the symptoms of abdominal pain, chronic diarrhea, or anemia. Data on computed tomographic colonographies (CTC), performed for isolated abdominal pain in 2008, were used to compare the yield of CTCs and OCs.
Results: Of the 8564 OCs and 525 CTCs performed, 5.4% and 8.2% were undertaken for isolated abdominal pain, respectively. The yield of OCs for overall pathology detection was not significantly different for abdominal pain (23.87%), compared to other indications (20.34–24.85%). The yield of pathology detection was not significantly different for CTC (20.93%) and OC. Colonic polyps were the most common pathology (OC 16.05%, CTC 18.6%).
Conclusion: Colonic investigations undertaken for isolated abdominal pain had a high yield of incidental colonic pathology. The detection of polyps could be beneficial, but it does not explain the symptoms. CTC offers a less invasive way of detecting colonic pathology in such patients, while maintaining the same yield. If CTC is used as a first line of investigation, it could spare 75% of patients the colonoscopy procedure.
Key Points
* Colonic investigations undertaken for isolated abdominal pain have a high yield of incidental colonic pathology.
* Colonic investigations will not explain isolated abdominal pain in 92% of patients and pathology requiring further medical attention is only found in 24% of patients.
* Optical colonoscopy (OC) is generally perceived as more invasive to patients.
* Though computer tomographic colonography (CTC) exposes patients to a small risk from radiation, it is considered less invasive, and requires no sedation.
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12/31/1969 03:59 PM
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Unusual Metastases to Soft Tissue of Chest and Abdominal Wall from Head and Neck Squamous Cell Carcinoma
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Department of Surgery (Yeh) 4. Kim CJ, Day S, Yeh KA is an important risk factor for this type of carcinoma in Taiwan. The most common site of metastases from head and neck squamous cell carcinomas
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12/31/1969 03:59 PM
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J. Marion Sims, the Father of Gynecology: Hero or Villain?
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colon; J. Marion Sims (1813-1884) has been called the "Father of Gynecology" for his revolutionary approach to treating the diseases of women. He rose from humble origins to become a successful surgeon, teacher, and writer. His innovations included the first successful treatment for vesicovaginal fistula, the first gallbladder surgery, and the introduction of antiseptic principles in all areas of surgical treatment. The "Sims position" and "Sims speculum" are eponymic tributes to his accomplishments. In recent years Sims has, however, become a focus of controversy because of his experimental surgeries on slave women. His powerful personality and messianic attitude led him to minimize moral problems, and to bristle against opposition. Ethical principles of autonomy and beneficence are important criteria for evaluating Sims' research. An exploration of the nature of Sims' work and the atmosphere in which he practiced will illuminate the critical ethical questions surrounding Sims' use of slave women as experimental subjects.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Interventional Magnetic Resonance Image-guided Percutaneous Cryoablation of Renal Tumors
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We describe the first two cases of percutaneous cryoablation under magnetic resonance imaging guidance. To date, this minimally invasive procedure has been used for the treatment of renal cell tumors in patients who cannot tolerate or refuse surgical nephrectomy. The two patients described showed no evidence of recurrence or complications 35 and 36 months after the procedure.
(C) 2003 Southern Medical Association
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12/31/1969 03:59 PM
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Tuberous Sclerosis Complex in a Young Woman Diagnosed Incidentally on the Basis of Pregnancy Ultrasonography
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colon; Tuberous sclerosis complex (TSC) is more prevalent than previously believed and most cases result from new mutations and, hence, do not have affected relatives. Many patients who meet the new diagnostic criteria have unrecognized skin lesions and/or occult lesions in internal organs. As early diagnosis and appropriate intervention can reduce morbidity and mortality from the neurologic, renal, and pulmonary complications of TSC, physicians should be alert for the dermatological signs of the condition and for the incidental finding of TSC lesions during diagnostic testing. Patients with TSC may be asymptomatic and of normal intelligence. We report a case of TSC diagnosed by the incidental finding of renal lesions in a young woman during pregnancy ultrasonic examination.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Platypnea-orthodeoxia: Report of Two Cases and Review of the Literature
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colon; We describe two unusual cases of platypnea. The first patient had chronic obstructive pulmonary disease, but platypnea did not respond to chronic obstructive pulmonary disease therapy. He was found to have multiple pulmonary emboli, and symptoms rapidly improved on anticoagulation therapy. The second patient had Parkinson disease and developed severe platypnea, an association that has not been previously described. She had significant postural hypotension and responded to therapy with fludrocortisone.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Detecting and Preventing Colorectal Cancer in Specific Communities
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and colonoscopy facilitate the detection and removal of premalignant polyps and have been clearly shown in just those ADDs with the highest incidence of risk factors. The authors plausibly explain this
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12/31/1969 03:59 PM
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Vancomycin Therapy and the Progression of Methicillin-resistant Staphylococcus aureus Vertebral Osteomyelitis
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colon; Vancomycin therapy is the standard treatment for methicillin-resistant Staphylococcus aureus (MRSA), the most common cause of vertebral osteomyelitis, an increasingly frequent complication of nosocomial bacteremia. We report five recent cases suggesting that, while giving the appearance of success by conventional clinical and laboratory criteria (eg, resolution of fever and leukocytosis), vancomycin monotherapy may in fact be insufficient to prevent or reverse the progression of hematogenous MSRA vertebral osteomyelitis. A review of the literature and possible therapeutic alternatives are also discussed.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Approach to Communicating with Patients About the Use of Nutritional Supplements in Cancer Care
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In recent years, complementary and alternative medicine has become popular among the general population in the Western world. Cancer patients have joined this global trend, often seeking supplements to conventional oncologic care, usually without their physicians' knowledge. Among the most common forms of complementary and alternative medicine used by cancer patients are natural products such as herbs and megavitamins. The extensive use of nutritional supplements by cancer patients raises multiple questions and challenges for the physician. Since there are limited scientific data on the efficacy and safety of many nutritional supplements, advising patients about when to use them during the course of illness is difficult. This is true for each stage of cancer care: prevention, acute active care (radiation, chemotherapy, surgery), and post-acute care (follow-up visits and prevention of recurrence). The authors describe a patient-centered approach to the use of nutritional supplements in cancer care.
(C) 2005 Southern Medical Association
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12/31/1969 03:59 PM
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CT Angiogram and Endovascular Stent Graft for an Axillary Artery Gunshot Wound
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A patient with an axillary artery gunshot wound pseudoaneurysm was evaluated and managed with computed tomographic angiogram and endovascular stent graft. Vascular injuries resulting from penetrating trauma or interventional vascular procedures are relatively uncommon. Subclavian and axillary arterial injuries may be associated with substantial morbidity and mortality if not managed expeditiously. The inaccessibility of these arteries makes stent graft treatment particularly attractive. The stable patient with a pseudoaneurysm or an arteriovenous fistula seems to be the ideal candidate to treat in this way. As computed tomography (CT) technology has evolved, CT angiography has become an integral part of the initial assessment of proximal extremity vascular injuries.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Exenatide: A Novel Approach for Treatment of Type 2 Diabetes
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Exenatide (synthetic exendin-4) is the analog of glucagon-like peptide 1 (GLP-1), the major physiologic incretin. The latter is an intestinal hormone that enhances glucose-induced insulin secretion after meals. In addition, GLP-1 stimulates insulin synthesis, inhibits glucagon secretion, delays gastric emptying, and may promote satiety. These glucoregulatory actions help control plasma glucose in the postprandial period. However, in diabetes, the GLP-1 response to nutrient intake is impaired, leading to exacerbation of postprandial hyperglycemia. Exenatide was recently approved as adjunctive therapy in diabetic patients failing sulfonylureas and/or metformin. In clinical trials lasting 30 weeks, exenatide therapy was associated with moderate reduction in mean hemoglobin A1c (HbA1c) levels of approximately 0.8%, and an average weight loss of approximately 2 kg compared with baseline. Hypoglycemia was generally mild and occurred more commonly when exenatide was used in conjunction with sulfonylureas. The requirement of subcutaneous injections twice a day, and the frequent occurrence of nausea and vomiting, represent the main limitations of exenatide. Nevertheless, this agent may be a useful add-on therapy in obese diabetic patients with suboptimal control as a result of continuing weight gain and/or severe postprandial hyperglycemia. The introduction of GLP-1-based antidiabetic drugs is a novel and promising strategy to treat diabetes.
(C) 2006 Southern Medical Association
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12/31/1969 03:59 PM
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Critical Care Aspects of Alcohol Abuse
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The authors reviewed MEDLINE and references of major articles in the published literature over the last 30 years regarding the complications of alcohol abuse and discuss the critical care aspects of alcohol abuse. This article discusses the severe medical conditions associated with alcohol abuse that lead to admission to the medical intensive care unit. The clinical manifestations, pathophysiology, diagnostic studies, and management of these conditions are discussed in detail.
(C) 2005 Southern Medical Association
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12/31/1969 03:59 PM
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Periampullary Leiomyosarcoma Presenting with Cutaneous Metastases: A Rare Entity
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biliary drainage was done. In the setting of widespread cutaneous lesions and visceral metastases to ribs and lungs, along with poor health of the patient, surgery was deferred and focus shifted on
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12/31/1969 03:59 PM
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Thoracic Packing for Uncontrolled Bleeding in Penetrating Thoracic Injuries
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colon; We present a series of three patients who suffered penetrating thoracic injury, and in whom thoracic packing was used as a life-saving procedure. Survival among these patients paralleled the severity and extent of the original injuries. Restriction of cardiac filling and lung expansion are potential deterrents from using this technique; however, its use seems to be a valid adjunct, especially in the setting of chest wall bleeding coming from the intercostal arteries. Damage control surgery in pentrating thoracic trauma, including thoracic packing, is a sound alternative when uncontrollable bleeding, hypothermia and coagulopathy compromises the survival of a patient.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Actinomycosis: Diagnosis and Management
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Actinomycosis is an uncommon, chronic bacterial infection that induces both suppurative and granulomatous inflammation. Localized swelling with suppuration, abscess formation, tissue fibrosis, and sinus drainage characterizes this disease. The infection spreads contiguously, often forming draining sinuses that extrude characteristic but not pathognomonic "sulfur granules." Infections of the oral and cervicofacial regions are most common; however, any site in the body can be infected and it often mimics malignancy. Other regions that are often affected are the thoracic and abdominopelvic, as well as the central nervous system. Musculoskeletal and disseminated disease can also be seen, albeit rarely. Prolonged antimicrobial therapy with penicillin has typically been recommended for patients with all clinical forms of actinomycosis to prevent disease recrudescence.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Nephrolithiasis: Evaluation and Management
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Nephrolithiasis is a major cause of morbidity involving the urinary tract. The prevalence of this disease in the United States has increased from 3.8% in the 1970s to 5.2% in the 1990s. There were nearly two million physician-office visits for nephrolithiasis in the year 2000, with estimated annual costs totaling $2 billion. New information has become available on the clinical presentation, epidemiologic risk factors, evaluative approach, and outcome of various therapeutic strategies. In this report, we will review the epidemiology and mechanisms of kidney-stone formation and outline management aimed at preventing recurrences. Improved awareness and education in both the general population and among health-care providers about these modifiable risk factors has the potential to improve general health and decrease morbidity and mortality secondary to renal-stone disease.
Key Points
* Nephrolithiasis is a major cause of morbidity involving the urinary tract.
* Increasing daily fluid intake is very important in preventing recurrent stone disease.
* The cornerstone of the evaluation is 24-hour urine collection.
* The mostly commonly-used noninvasive procedure for smaller stones is lithotripsy.
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12/31/1969 03:59 PM
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Entecavir Therapy in a Hepatitis B-Related Decompensated Cirrhotic Patient
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A 58-year-old Arab-American male with HBeAg-negative chronic hepatitis B (HBV), presented with decompensated cirrhosis and a high HBV DNA level. He responded to entecavir with a significant reduction in serum HBV DNA level after 15 weeks of therapy with entecavir. However, he developed a progressive rise in prothrombin time/international normalized ratio (PT/ INR) and bilirubin and underwent liver transplantation after receiving 22 weeks of entecavir therapy. Furthermore, with the continued use of combination entecavir and hepatitis B immunoglobulins (HBIG), he showed improvement in his clinical status with a nondetectable serum HBV DNA level 12 weeks after transplantation. He continued to maintain nondetectable serum HBV DNA 2 years following transplantation. To the best of our knowledge, this is the first reported case of a patient with decompensated chronic HBV who responded to entecavir both before and after transplantation without showing any evidence of recurrent HBV. Larger clinical trials are recommended to compare both short-term and long-term efficacy using entecavir among nucleoside-naive decompensated chronic HBV patients before and after liver transplantation.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Photodynamic Therapy and Endoscopic Mucosal Resection for Barrett's Dysplasia and Early Esophageal Adenocarcinoma
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Background: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas.
Materials and Methods: All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT.
Results: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia.
Conclusions: The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Neoadjuvant Therapy: An Emerging Concept in Oncology
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Neoadjuvant therapy, an adjunctive therapy given before the main therapy, has become an integral part of modern multidisciplinary cancer management. Organized by the primary organ involved by cancer, this review summarizes the outcomes of neoadjuvant therapy for common malignant solid tumors, based on large, randomized, controlled trials. In locally advanced rectal, laryngeal, and breast cancer, neoadjuvant therapy enables organ preservation; however, it does not improve overall survival when compared with definitive treatment followed by adjuvant therapy. In locally advanced bladder and cervical cancer, patients who undergo neoadjuvant therapy before radical surgery appear to have better survival than those receiving definitive therapy alone; however, it is unclear if the neoadjuvant approach will be superior to definitive therapy followed by adjuvant therapy. To date, the survival benefits of neoadjuvant therapy for resectable non-small cell lung, esophageal, gastric, and prostate cancer remains under investigation.
(C) 2005 Southern Medical Association
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12/31/1969 03:59 PM
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Calcium Abnormalities in Hospitalized Patients
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Abstract: Depending upon the method of measurement, hypocalcemia occurs in 15% to 88% and hypercalcemia occurs in 15% of hospitalized patients. Ionized calcium should be measured in place of total serum calcium to avoid errors related to hypoalbuminemia, which is seen commonly in acutely ill patients. Symptomatic hypocalcemia requires prompt intravenous calcium administration. Symptomatic hypercalcemia (most often caused by hyperparathyroidism or malignancy) warrants aggressive intravenous hydration to correct volume depletion and, usually, additional therapy with diuretics, bisphosphonates, calcitonin, or corticosteroids. Identification and treatment of the underlying cause of the calcium derangement must be addressed after the acute electrolyte abnormality is stabilized.
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12/31/1969 03:59 PM
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Diagnostic Value of Clinical Examination and Various Imaging Techniques for Breast Implant Rupture as Determined in 81 Patients Having Implant Removal
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colon; To determine sensitivity and specificity of magnetic resonance imaging (MRI) and ultrasonography (US) in the detection of breast implant rupture, and also to determine the relative merits of clinical examination and mammography, we studied 81 patients (160 implants). All patients had implants removed, thus allowing confirmation of the presence or absence of rupture. Clinical examination positively identified only one patient with implant rupture, and mammography detected only two implant ruptures (both extracapsular). The sensitivity for US was 70% and specificity was 90%, while for MRI it was 75.6% and 94%, respectively. These differences between MRI and US were not statistically significant. Combining the results of US and MRI did not seem to add to the diagnostic discrimination. The most cost-effective method of diagnosing implant rupture was US in our study.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Primary Malignant Melanoma of the Duodenum: Aggressive Management and Long-Term Survival of an Unusual Oncologic Entity
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Primary malignant melanoma originating in the small bowel is extremely rare. We report the case of a 55-year-old man who presented with a preoperative bleeding duodenal tumor. A standard pancreaticoduodenectomy was performed. Histopathological examination ascertained the diagnosis of a duodenal malignant melanoma with locoregional lymphatic spread. A thorough postoperative investigation did not reveal any primary melanotic lesions. Thus, the diagnosis of a primary melanoma originating from the duodenum was suggested. Fourteen months after surgery, the patient had no evidence of recurrence. Primary malignant melanoma of the duodenum is an existing, though unusual, oncologic entity. Aggressive surgery remains the treatment of choice offering both symptom palliation and long-term survival.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Carcinoid Tumors of the Gastrointestinal Tract
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The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Four Cases of Patients with Gastrointestinal Granular Cell Tumors
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We present four cases of gastrointestinal granular cell tumors (GCT) with a literature review. Gastrointestinal granular cell tumors, a benign neural tumor thought to arise from Schwann cells, can occur in several areas, including the gastrointestinal tract. Studies suggest that endoscopic ultrasound and endoscopic removal is the treatment of choice for esophageal GCTs if they are small in size (<2 cm) and do not involve the muscularis propria. GCTs are malignant less than 2% of the time. Although most GCTs are benign and can be followed endoscopically without resection, the malignant potential warrants evaluation with endoscopic ultrasound for possible endoscopic or surgical resection.
(C) 2007 Southern Medical Association
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12/31/1969 03:59 PM
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Catheter-Related Bacteremia Due to Mycobacterium smegmatis
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colon; Rapidly growing mycobacteria have occasionally been reported to cause catheterrelated infections. We report a case of a central venous catheter-related bacteremia, caused by Mycobacterium smegmatis, in a patient with cancer. Cultures of the catheter tip and blood cultures grew M smegmatis and Enterococcus faecalis. The patient responded to catheter removal and a 3-month course of antibiotics (doxycycline and ciprofloxacin). Based on our experience and the reported experience with other rapidly growing mycobacteria, M smegmatis catheterrelated bacteremia should be treated with catheter removal and a course of appropriate antibiotics, based on in vitro susceptibility testing
(C) 1998 Southern Medical Association
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12/31/1969 03:59 PM
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Increased Infection Rate in Double-Lumen Versus Single-Lumen Hickman Catheters in Cancer Patients
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colon; Over the 48-month period from January 1983 through December 1986, 51 single-lumen (SL) and 94 double-lumen (DL) indwelling central venous (Hickman) catheters were placed in 118 patients with malignant disease. We reviewed these cases retrospectively to determine the types and frequency of complications requiring catheter removal. The catheters were in place a total of 18,397 days. Overall, 14% (7/51) of SL and 21% (20/94) of DL catheters were removed due to infection. Of those catheters becoming infected, DL catheters were infected earlier. SL catheters that became infected averaged 213 days of use before removal, whereas DL catheters becoming infected averaged only 78 days before removal (P <= .02). The infection rate was significantly less in SL (one infection per 1,210 days) than in DL catheters (one infection per 496 days) (P <= .02). Thus because of its significantly reduced risk of infection, the single-lumen Hickman may be the preferred catheter for long-term venous access in many patients.
(C) 1990 Southern Medical Association
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12/31/1969 03:59 PM
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Tissue Expansion in Reconstruction
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colon; Tissue expansion offers a new alternative in plastic surgery. Its applications are numerous for reconstruction of the scalp, head and neck, trunk, breast, and extremity. Over the past year I have used tissue expansion for reconstruction in 13 patients, with multiple expanders in six patients. Complications included two exposed expanders requiring early removal, and two mechanical malfunctions requiring replacement. Expansion of previously irradiated tissue has been unsatisfactory.
(C) 1987 Southern Medical Association
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12/31/1969 03:59 PM
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Management of Catheter Emboli
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colon; Catheter emboli are a significant risk to patient well-being. With a 49% complication rate for indwelling catheter emboli, the consensus is that these foreign bodies should be removed. Preferably, the emboli are removed by percutaneous extraction; however, if the emboli are in the heart or central vasculature and percutaneous extraction fails, then thoracotomy with operative removal is necessary. We analyze the literature on catheter emboli and present a case showing that extraction of embolized fragments is not always possible.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Peritonitis Due to Penicillium sp in a Patient Receiving Continuous Ambulatory Peritoneal Dialysis
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colon; Infectious peritonitis is a common complication of continuous ambulatory peritoneal dialysis (CAPD). Only one case of CAPD-related peritonitis due to Penicillium sp has previously been reported. We present a second case in which fungal colonies were observed on the inner surface of the CAPD catheter. The infection was successfully treated with catheter removal and intravenous amphotericin B
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Burnout and Other Stress Syndromes
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colon; Psychiatry has long recognized stress syndromes. The acute posttraumatic stress syndrome occurring in war is well known. Those occurring as a result of accidents in civilian life are less well known. Burnout is a recently described addition to this group of illnesses. The stress that is etiologic differs in many ways from that found in the acute syndromes. The stress that causes burnout is chronic, and is either self-imposed or inherent in a work situation. The illness responds to rest or removal from the work situation, but restructuring of the person's motivations and relationships is necessary if the person is to remain symptom free.
(C) 1986 Southern Medical Association
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12/31/1969 03:59 PM
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Pectus Excavatum: A 15-Year Perspective
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colon; Pectus excavatum is relatively uncommon. Our experience with 177 children during a 15-year period produced changes in our surgical technique, which now includes a small transverse incision, minimal subcutaneous flap elevation, a muscle-relaxing incision over the fifth costal cartilage, complete resection of involved cartilage, use of Adkins' strut, suspension of sternum to strut, taut reefing of intercostal muscle, no tubes or drains, epidural analgesia, a patient-controlled analgesia device postoperatively, and eventual strut removal. Use of the evolved technique gives excellent cosmetic results, good functional results with minimal discomfort, and a shorter convalescent period.
(C) 1991 Southern Medical Association
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12/31/1969 03:59 PM
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Foreign Bodies of the Upper Gastrointestinal Tract: Current Mangement
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colon; The popularity of the flexible esophagogastroduodenoscope prompted us to reevaluate our management of foreign bodies. In this paper we report our experience and update treatment guidelines. In our series (from December 1975 to May 1982), 74 foreign bodies were removed: 12 with the rigid endoscope, 60 with the' flexible endoscope, and two surgically. There was no morbidity or mortality. In the age group 1 to 10 years, there were 15 patients, while the age group 11 to 88 years had 59 patients. Although the rigid endoscope is less expensive and has a larger operating channel, the advantages of the flexible instrument are numerous. Foreign bodies of the pharynx and at the level of the cricopharyngeus muscle are best managed with a rigid endoscope; foreign bodies of the esophagus can be managed with rigid or flexible instruments, but are more easily managed with the latter. Foreign bodies of the stomach and duodenum that require removal can be managed only with the flexible panendoscope.
(C) 1984 Southern Medical Association
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12/31/1969 03:59 PM
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Eye Patch Treatment for the Pain of Corneal Abrasion
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colon; The traditional use of patching and topical antibiotics in the treatment of corneal abrasion has recently been challenged, particularly after foreign body removal. In a prospective, controlled, randomized study of 33 patients treated in the emergency department for eye pain and corneal abrasion, we attempted to determine whether eye patching affected the pain of simple corneal abrasions. After fluorescein examination with magnification (x 5), a visual analog pain score was recorded and the patient was randomized to either the patched or nonpatched group. A standard analgesic was supplied, and all patients had follow-up at 24 hours, when repeat pain scores and analgesic use were recorded. The groups were compared by using the Wilcoxon's rank sum test, Student's t test, and analysis of covariance as required. There was no significant difference in the mean changes in pain scores between the patched and nonpatched groups. Analgesic use was also similar. We conclude that routine eye patching does not favorably affect the pain associated with the treatment of simple corneal abrasion.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Colorectal Intussusception Secondary to Sigmoid Carcinoma in an Adult
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Although intussusception is relatively common in children, it is clinically rare in adults A 54-year-old woman who presented with cramping abdominal pain and rectal bleeding was found to have sigmoid rectal intussusception secondary to adenomatous polyps of the sigmoid colon. Following confirmation of intussusception by CT scan, surgical resection was performed after manual reduction.
(C) 2007 Southern Medical Association
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12/31/1969 03:59 PM
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Esophageal 'Stars': A Sinister Foreign Body Ingestion
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colon; This paper describes an "epidemic" of foreign body ingestion in six consecutive prisoners from the same jail. The resulting esophageal perforations won all patients "temporary vacations" from prison. The nature of the ingested foreign body (hypodermic needles fashioned into a "star") guaranteed perforation of the esophagus. All six patients had emergency esophagotomy for foreign body removal. In the only case of significant morbidity, suture line disruption with mediastinitis and empyema led to esophagectomy, cervical esophagostomy, and tube gastrostomy. This patient survived and subsequently had uncomplicated esophagocoloplasty. Foreign objects of this type have not been described in the literature. Because of their specific design, they necessitate immediate and aggressive surgical management.
(C) 1997 Southern Medical Association
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12/31/1969 03:59 PM
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Human Adjuvant Disease: Presentation as a Multiple Sclerosis-like Syndrome
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colon; Twenty-six women had a systemic disease with central nervous system (CNS) involvement at a mean age of 39.2 years (range, 23 to 64 years) after receiving silicone breast implants (n=25) or silicone fluid injections into breasts (n=1). The median latency period between breast surgery and onset of symptoms was 5.71 years (range, 3 months to 15 years). All patients had evidence of disseminated CNS lesions; 20 patients also had evidence of peripheral neuropathy. Additional problems included myalgia (n=24), joint stiffness (n=23), arthralgia (n=22), sicca complex (dry eyes and dry mouth) (n=19), headache (n=16), skin rash (n=15), joint swelling (n=14), Raynaud's phenomena (n=14), fever (n=13), hair loss (n=12), allergies (n=11), sensitivity to sunlight (n=10), and lymphadenopathy (n=9). Magnetic resonance imaging brain scans were abnormal in 22 of 26 patients (21, white matter lesions; 1, ischemic lesions; 4, cerebral atrophy). Spinal tap revealed oligoclonal bands in 18 of 23 patients. Visual evoked responses were delayed in 14 of 23 patients, and autodirected antibodies were detected in 16 of 26. Sural nerve biopsy results showed loss of myelinated fibers in 15 of 15. Seventeen of 24 patients (71%) who had implant removal were found to have grossly ruptured implants. We believe our patients had a new syndrome triggered by the foreign material in their body. This syndrome appears as a systemic inflammatory autoimmune disease with central nervous system involvement resembling multiple sclerosis.
(C) 1996 Southern Medical Association
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12/31/1969 03:59 PM
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Long-term Alimentation by a New Indwelling Tube Gastrostomy Technique
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colon; Use of a Gore-Tex peritoneal catheter as a feeding gastrostomy tube can virtually eliminate the complications associated with long-term feeding gastrostomy. The tube consists of a radiopaque 18 F silicone rubber catheter having a toadstool-shaped, expanded polytetrafluorethylene flange and cuff around its midportion. Epithelial tissue grows into the interstices of the Gore-Tex flange, and fibroplasia incorporates the cuff into the tissue, fixing the tube firmly in place and preventing its inadvertent removal. In addition, the tissue ingrowth creates a physiologic barrier that prevents efflux of intragastric contents and discourages influx of microorganisms or other contaminants along the gastrostomy tract. Thus far, Gore-Tex feeding gastrostomies have been placed for two to 11 months in six critically ill malnourished patients who required long-term or permanent gastrostomy feeding. No complications have occurred, patient safety and satisfaction have been greatly increased, efficacy of nutritional rehabilitation has been enhanced, and the patients' quality of life has been vastly improved.
(C) 1984 Southern Medical Association
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12/31/1969 03:59 PM
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Atypical Chest Pain Syndrome in Patients With Breast Implants
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colon; Eleven patients, aged 36 to 55 years, with silicone breast implants had episodes of severe chest pain similar to heart attacks 6 weeks to 7 years after breast implantation; one patient had a severe attack 1 month after explantation. The chest pain, which was not related to physical exertion, lasted from 15 minutes to 4 days, and descriptions of it varied from a "pressing" type of pain to "stabbing" pain with radiation to the shoulders, left arm, and jaw. The associated symptoms were diaphoresis, nausea, vomiting, dyspnea, and palpitations. All of the patients had a normal electrocardiogram (ECG) with the exception of one, whose ECG showed nonspecific ST changes. Ten had cardiac evaluations, all of which yielded normal results. All had implant removal, and five were found to have at least one ruptured implant. Nine had an implant capsule biopsy; all had chronic inflammatory rinds, and five had free silicone in tissue whether or not the implants were ruptured. All eight who had a pectoralis major muscle biopsy had abnormal results: (neurogenic atrophy [six], fasciitis [three], myositis [one], chronic inflammation [one], free silicone [one], and neuroma [one]). We concluded that silicone breast implants may cause an atypical chest pain syndrome, probably due to local inflammatory reactions and neuroma formation.
(C) 1994 Southern Medical Association
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12/31/1969 03:59 PM
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Doubled Left Ovary
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1. Vendeland LL, Shehadeh L. Incidental finding of an accessory ovary in a 16-year-old at 2. Dillon WP, Dewey M. A case of accessory ovary. Obstet Gynecol 1981;58:660-661 3. Litos MG, Furara S, Chin K
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12/31/1969 03:59 PM
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Heroin Body Packing: Clearly Discerning Drug Packets Using CT
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Background: To determine if heroin body packing has occurred using computed tomography (CT), and to evaluate the role of CT in screening such cases.
Methods: We collected 158 cases of suspected drug packers' imaging materials (all underwent CT, 42 cases were imaged using plain x-ray film) from September 5, 2005 to April 23, 2008. Abdominal-pelvic CT appearances (shape, size, number, location and density) and abdominal plain x-ray film manifestations were retrospectively observed for those who were finally confirmed as heroin body packers through the passing of evacuated drug packets.
Results: Among 158 cases of suspected drug packers in our study, 124 cases were finally diagnosed as heroin body packers. This was consistent with the CT results. However, there were 2 false-negative cases of abdominal imaging taken with plain x-ray film. All of the evacuated heroin body packets were produced mechanically. CT and plain film characteristic findings included the presence of uniform shape, varied density, and well-defined round or ovoid intra-luminal foreign-body shadows arranged closely along the gastrointestinal (GI) tract and/or vagina. We also found that the "air-ring sign" and "onion sign" were valuable characteristics that were seen on the CT scan, which helped to positively confirm the detection of heroin packets.
Conclusion: Heroin body packing has clearly defined diagnostic features that can be seen with CT. Furthermore, conventional abdominal-pelvic CT is the imaging modality of choice in the evaluation of suspected body packers.
(C) 2009 Southern Medical Association
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12/31/1969 03:59 PM
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Capsule Endoscopy: A Review
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Capsule endoscopy (CE) is a novel technology that allows direct noninvasive visualization of the entire small intestine. CE permits a detailed examination in the ambulatory setting, allowing identification of clinically relevant lesions, and it is appealing to both patients and providers. There are two types of capsules that are currently commercially available: one specifically designed to view the small bowel and the other for the esophagus. Common indications for small bowel CE include obscure gastrointestinal bleeding, initial diagnosis of suspected Crohn's disease, and other small bowel pathology. The esophageal capsule is currently used to evaluate Barrett esophagus and esophageal varices. It is a well-tolerated procedure with relatively few complications. Although CE performance may be superior to existing technologies, its impact on clinical decision-making and patient outcomes are of even greater importance. Herein lies a review of the latest information on CE, its indications, complications, future utilities, and developing technology.
(C) 2008 Southern Medical Association
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12/31/1969 03:59 PM
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Patients' Views About Discussing Spiritual Issues With Primary Care Physicians
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Objectives: The authors sought to explore patients' views about discussing spiritual issues with primary care physicians, including perceived barriers to and facilitators of discussions.
Methods: The study was a qualitative, semistructured interview of 10 chronically or terminally ill patients who were deliberately selected to represent a range of demographic factors (religious background, age, sex). We coded each interview and evaluated interviews for themes through content analysis.
Results: Themes included rationale for addressing spiritual issues; prerequisites for these discussions; roles in spiritual discussions; principles of spiritual assessment; and barriers to and facilitators of spiritual discussions. Patients justified spiritual assessment on the basis of importance of spirituality in life and health. They asserted that patients must feel honored and respected by their physician to risk discussing spiritual issues. They affirmed that physicians are helpful when legitimizing their spiritual concerns. Citing physicians' neglect of spirituality as a barrier, they affirmed that spiritual assessment in the context of other life issues facilitates spiritual discussions.
Conclusions: Patients' willingness to discuss spiritual issues may depend on their sense of physicians' respect for their spiritual views, attitudes about spiritual health, and qualities of openness and approachability.
(C) 2004 Southern Medical Association
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12/31/1969 03:59 PM
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Hand-foot Syndrome in a Patient with Multiple Fire Ant Stings
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colon; The case is reported of an elderly patient with known previous exposure to fire ant stings, and who presented with hand-foot syndrome (HFS) in the setting of multiple fire ant stings to the lower extremities. Both hands and both feet were red, swollen, and mildly tender. Treatment was with fluocinonide cream, and all symptoms resolved as the classic fire ant skin lesions regressed. HFS was initially reported in association with acute crisis in sickle cell anemia and thalassemia and more recently as a common toxicity of chemotherapy administration. This is the first report of its occurrence in the setting of fire ant envenomization. Although recent literature may indicate a potential therapeutic benefit from COX-2 antagonists, the process appears to be self-limited, and requires only conservative treatment.
(C) 2004 Southern Medical Association
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