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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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