bluuebunny/crossref_metadata_2025 huggingface dataset:
Bedside Placement of Inferior Vena Cava Filters in the Intensive Care Unit
Authors: Tola Juan C. , Holtzman Robert , Lottenberg Lawrence
Published: November 2022

The objective of this study was to determine the feasibility, cost-effectiveness, and complications of bedside placement of inferior vena cava (IVC) filters in the intensive care unit (ICU) in the trauma patient. A prospective trial involving 25 trauma patients admitted to Memorial Regional Hospital (Hollywood, Florida), a Level I trauma center, from April 1997 to April 1998, meeting the criteria for insertion of a prophylactic IVC filter according to Eastern Association for the Surgery of Trauma trauma practice guidelines was conducted. IVC filters were placed in the ICU with the use of a digital C-arm (Siemens) and strict adherence to sterile technique. Renal vein anatomy and size of the IVC were documented for every case. Charges for equipment and supplies were analyzed and compared with those placed in the radiology suite and the operating room. Of 810 patients admitted as trauma alerts during the study period, 25 had an IVC filter placed at the bedside in the ICU. The indications for filter placement included a contraindication to anticoagulation and one of the following: severe pelvic fracture and/or associated long-bone fracture (32%); bilateral lower extremity fractures (28%); spinal cord injury with para- or quadriplegia (16%); femoral vein thrombosis (16%); and severe brain injury (8%). There were no intraoperative nor postoperative complications; overall mortality was 20 per cent, unrelated to the IVC filter placement. Average time for insertion was 47 minutes for the series and 20 minutes for the last five cases. Savings of $1844 or $2245 per filter are obtained when IVC filters are placed in the ICU when compared with the operating room or radiology suite, respectively. Bedside placement of IVC filters in the ICU is a safe, cost-effective method that can be performed without compromising the patient and avoids the potential disasters involved in transporting critically ill patients.
Laparoscopic Repair of Bilateral and Recurrent Hernias
Authors: Frankum Charles E. , Ramshaw Bruce J. , White Jacqueline , Duncan Titus D. , Wilson Russell A. , Mason Edward M. , Lucas George , Promes John
Published: November 2022

The optimal inguinal hernia repair has been controversial for decades. Since the advent of minimally invasive surgery, laparoscopic techniques have added to the controversy. Laparoscopic hernia repair has been advocated by many experts for the repair of bilateral and recurrent inguinal hernias. This study reviews the experience of a single community-based teaching hospital using the total extraperitoneal (TEP)-approach laparoscopic hernia repair for treating patients with bilateral and/or recurrent inguinal hernias. Since the TEP approach was adopted in June 1993, a total of 457 patients were treated for bilateral (322 patients) and/or recurrent (175) inguinal hernias (40 patients had recurrent and bilateral hernias). A total of 779 hernias were repaired with this technique. The average age of this patient group was 47 years, and there were 413 males and 44 females. Operative time averaged 68.3 minutes per patient, and there were 26 (5.7%) minor complications. There were 2 (0.4%) major complications, an enterotomy and a cystotomy, both early in the series and both in patients with previous lower abdominal surgery. There have been no deaths. With an average follow-up of 30 months (range, 1–60 months), there have been three (0.2%) recurrences. These recurrences were due to technical problems (inadequate mesh coverage), and each was repaired with a laparoscopic transabdominal approach or an anterior open approach. The use of the TEP-approach laparoscopic hernia repair is safe and effective in patients with recurrent and/or bilateral inguinal hernias.
Lymphatic Mapping with Sentinel Lymph Node Biopsy in Patients with Breast Cancers <1 centimeter (T1A - T1B)
Authors: Bass Siddharth S. , Dauway Emilia , Mahatme Arvind , Ku Ni Ni , Berman Claudia , Reintgen Douglas , Cox Charles E.
Published: November 2022

Because of its high cost and attendant morbidity, the necessity of axillary dissection in patients with small invasive primary tumors has been questioned. Lymphatic mapping with sentinel lymph node (SLN) biopsy is an alternative to complete axillary dissection; however, researchers have excluded patients with T1A–T1B lesions. Seven hundred patients with newly diagnosed breast cancers underwent an Institutional Review Board-approved prospective trial of intraoperative lymphatic mapping using a combination of Lymphazurin and filtered technetium-labeled sulfur colloid. An SLN was defined as a blue node and/or hot node with a 10:1 ex vivo radioactivity ratio in the SLN verus non-SLNs. All SLNs were evaluated by both hematoxylin and eosin and cytokeratin immunohistochemical stains. Of the 700 patients, 665 (95.0%) were mapped successfully. One hundred ninety-six (28.0%) had T1A–T1B tumors. Forty patients (20.4%) with T1A–T1B tumors had metastases to the SLNs. We conclude that breast cancer SLN mapping is highly accurate and sensitive when combined dye techniques (radiocolloid and vital blue dye) are utilized. This technique is particularly useful in patients with small invasive primary tumors, which, despite their size, still demonstrate a significant rate of axillary metastasis. These patients should not be excluded from lymphatic mapping protocols.
Traumatic Fracture of the Hyoid Bone: Three Case Presentations of Cardiorespiratory Compromise Secondary to Missed Diagnosis
Authors: Kaufman Henry J. , Ciraulo David L. , Burns R. Phillip
Published: November 2022

Hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326–8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missed diagnosis. We submit three cases with varying presentations and management strategies. All three of our cases incurred injury by blunt trauma to the anterior neck. Two patients required emergent surgical airway after unsuccessful attempts at endotracheal intubation. One patient presented without respiratory distress and was managed conservatively. After fracture, the occult compressive forces of hematoma formation and soft tissue swelling may compromise airway patency. It is our clinical observation that hypoxia develops rapidly and without warning, leading to cardiorespiratory collapse. With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.
Trends in Indications and Outcomes in the Whipple Procedure over a 40-Year Period
Authors: Rios Gloria , Conrad Andrew , Cole David , Adams David , Leveen Margaret , O'brien Paul , Baron Paul
Published: November 2022

There have been increasing changes in the role of pancreatoduodenectomy (PD) in the management of benign and malignant pancreatic disease. The aim of this paper was to compare the current role of PD with that of our earlier experience. The records of patients undergoing PD at our institution between 1983 and 1996 (Group A) were reviewed and compared with cases between 1956 and 1982 (Group B). Student's t test was used to analyze differences between groups. A total of 153 PDs were performed with 98 (64%) in Group A (88% of these in the last 6 years) and 55 (36%) in Group B. Carcinoma of the head of the pancreas was the most common indication for surgery in both periods (43% and 47% for Groups A and B, respectively). In Group A, the next most common indication was chronic pancreatitis, accounting for 28 per cent versus 13 per cent in Group B. Carcinoma of ampulla of Vater was also a common indication, making up 21 per cent of the cases in Group A and 20 per cent in Group B. Preoperative biliary drainage was performed in 62 per cent of Group A and 3 per cent of Group B patients (P < 0.001). Postoperative complications were comparable in both groups: delayed gastric emptying (22%), wound infection (17%), pancreatic fistula (13%), gastrointestinal bleeding (8%), and intestinal obstruction (3%). The perioperative mortality rate was significantly different between the two groups: 1 per cent in Group A versus 16 per cent in Group B (P < 0.001). Mean postoperative length of stay was 17 days in Group A (22 days for benign disease) and 25 days for Group B (P < 0.01). In the last 40 years, there has been a rise in the use of PD for chronic pancreatitis and a significant decrease in postoperative mortality and hospital length of stay. These data support the safety of PD in the management of patients with both benign and malignant periampullary disease.
Gastroduodenostomy after Gastric Resection for Cancer
Authors: Kim Bill J. , O'Connell Theodore
Published: November 2022

Gastrojejunostomy after resection for gastric cancer has been associated with a variety of complications, including bile reflux gastritis, marginal ulcers, and afferent loop syndrome. Gastroduodenostomy, although more physiologic, has not been recommended because of the fear of obstruction due to tumor recurrence. A review of 62 patients with gastric adenocarcinoma who underwent gastric resection from 1986 to 1996 was performed. Of the 62 patients, 52 (83%) underwent subtotal gastric resection and 10 (17%) underwent total gastrectomy with Roux-en-Y reconstruction due to tumor location. Forty-seven (90%) of the 52 patients underwent gastroduodenostomy, and 5 (10%) of these patients underwent gastrojejunostomy due to operative findings of excessive tumor burden or the inability to create a safe tension-free anastomosis. Patients who underwent gastroduodenostomies were followed for a period of 6 months to 5 years and had a median survival of 2.5 years. Two (4.2%) of the 47 patients obstructed due to tumor recurrence at 2 and 4 years postoperatively. One patient (2%) had symptomatic bile reflux gastritis, which was treated conservatively without reoperation. There were no incidences of marginal ulcers. In conclusion, gastroduodenostomy should be considered for patients undergoing resection for gastric cancer due to its physiological benefits and acceptable rate of obstruction.
Abnormal Esophageal Body Function: Radiographic-Manometric Correlation
Authors: Fuller Leah , Huprich James E. , Theisen Jorg , Hagen Jeffrey A. , Crookes Peter F. , Demeester Steven R. , Bremner Cedric G. , Demeester Tom R. , Peters Jeffrey H.
Published: November 2022

Stationary manometry is the gold standard for the evaluation of patients with suspected esophageal motility disorders. Comparison of videoesophagram in the evaluation of esophageal motility disorders with stationary motility has not been objectively studied. Two hundred two patients with foregut symptoms underwent stationary motility and videoesophagram. Radiographic assessment of esophageal motility was done by video recording of five 10-cc swallows of barium. Abnormal esophageal body function was defined by stasis of barium in the middle third of the esophagus on at least four swallows or stasis on at least three swallows in the distal third. Stationary manometry was performed using a five-channel water perfused system. Contraction amplitudes <25 mm Hg in any of the last two channels or the presence of simultaneous or interrupted waves in 10 per cent or more were considered to be abnormal. Sixty-two patients had abnormal manometry. Thirty-four patients also demonstrated abnormal videoesophagrams for an overall sensitivity of 55 per cent. The positive predictive value was 53 per cent; specificity was 79 per cent; and negative predictive value was 80 per cent Sensitivity was greatest in patients with achalasia (94%) and scleroderma (100%) and in patients presenting with dysphagia (89%). Sensitivity was poor for nonspecific esophageal motility disorders. A videoesophagram is relatively insensitive in detecting motility disorders. It seems most useful in the detection of patients with esophageal dysfunction, for which surgical treatment is beneficial, and in those patients presenting with dysphagia.
Same Admission Colon Resection with Primary Anastomosis for Acute Diverticulitis
Authors: Maggard Melinda A. , Thompson Jesse E. , Schmit Paul J. , Chandler Charlie F. , Bennion Robert S. , Au Ahn , Hines O. Joe
Published: November 2022

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate.
A Mortality-Free Decade of Pancreatoduodenectomy: Is Quality Independent of Quantity?
Authors: Schwarz Roderich E. , Keny Hemant , Ellenhorn Joshua D. I.
Published: November 2022

Pancreatoduodenectomy (PD) for periampullary cancer is a procedure of high morbidity and poor long-term survival. Superior clinical outcome has been described in high-volume institutions or for surgeons with a high case load. All patients undergoing pancreatectomy at the City of Hope National Medical Center (Duarte, CA) between 1987 and 1998 were analyzed retrospectively for postoperative outcome, and correlating or predictive clinicopathological factors were identified. Fifty-four patients underwent pancreatectomy [PD, n = 43; pylorus-preserving PD, n = 8; total pancreatectomy, n = 3]. There were 26 males and 28 females, with a median age of 63 years (range, 19–86). Fifty patients had a malignant diagnosis, and four patients had a benign diagnosis. Nine surgical oncologists performed an average of six pancreatectomies (range, 2–8). There was no perioperative death. Postoperative complications occurred in 30 patients, and infections predominated (n = 17). The median hospital stay was 16.5 days. The median postoperative actuarial survival by cancer site was 56 months (ampullary/bile duct), 32.5 months (duodenal), 22.5 months (pancreatic), and 23.2 months (others). In this 11-year single institutional experience, PD and total pancreatectomy have been performed without lethal complication. In the setting of an exclusive oncology practice, operative mortality rates and survival outcome can be generated that compare favorably to large center experiences. Quality of outcome after pancreatectomy can be independent of quantity.
Perforated Appendicitis is Not a Contraindication to Laparoscopy
Authors: Khalili Theodore M. , Hiatt Jonathan R. , Savar Aaron , Lau Christine , Margulies Daniel R.
Published: November 2022

Recent studies have reported an increased risk of intra-abdominal abscess formation following laparoscopic operation for perforated appendicitis. We undertook this study to compare laparoscopic versus open appendectomy in the treatment of perforated appendicitis. Records of all patients undergoing an appendectomy between January 1994 and June 1997 were reviewed, classifying appendicitis as acute, gangrenous, or perforated based on the intraoperative findings. Operative procedures were categorized as open, laparoscopic converted to open, or laparoscopic. The study group included 690 patients; four hundred fourteen (60%) were acute, 77 (11%) were gangrenous, and 199 (29%) were perforated. Although mean length of stay was shorter for all patients undergoing laparoscopic appendectomy, patients with perforated appendicitis had similar length of stay between treatment groups. Mean operative time for open appendectomy was significantly shorter than for converted or laparoscopic appendectomy regardless of diagnosis (P < 0.01). Ten patients (1.4%) developed an intra-abdominal abscess: six after open appendectomy (1.7%), one after converted appendectomy (3.7%), and three after laparoscopic appendectomy (1%). There was no significant difference in rate of abscess formation in patients with perforated appendicitis undergoing open, converted, or laparoscopic appendectomy. We conclude that laparoscopic appendectomy for perforated appendicitis is not associated with an increased rate of intra-abdominal abscess formation.
Abdominal Computed Tomography Scan in Pediatric Blunt Abdominal Trauma
Authors: Sievers Eric M. , Murray James A. , Chen David , Velmahos George C. , Demetriades Demtrios , Berne Thomas V.
Published: November 2022

The purpose of this study was to evaluate the role of abdominal CT scans in pediatric patients and correlate the findings with the clinical examination. A 2-year retrospective review of 88 patients with an abdominal CT scan after blunt trauma was performed. Seventy-two patients were identified with complete clinical examination data available. In its ability to predict the need for surgery, the CT scan had a sensitivity of 67 per cent and a negative predictive value of 98.7 per cent. The combination of the clinical examination and the CT scan findings did not miss any significant injuries. No patient with a soft, nontender abdomen and a negative CT scan required an abdominal operation. We conclude that the CT scan alone may miss clinically significant injuries. In blunt abdominal trauma in the pediatric population, the CT scan findings should be coupled with the clinical examination to ensure that no significant abdominal injuries are missed.
Determinants of Survival after Inferior Vena Cava Trauma
Authors: Kuehne Jonathan , Frankhouse Joseph , Modrall Greg , Golshani Shapour , Aziz Ihab , Demetriades Demetrios , Yellin Albert E.
Published: November 2022

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6–54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P < 0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.
Percutaneous Dilatational Tracheostomy: Still a Surgical Procedure
Authors: Suh Richard H. , Margulies Daniel R. , Hopp Martin L. , Ault Mark , Shabot M. Michael
Published: November 2022

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1 ± 1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.
Nosocomial Infections in the Surgical Intensive Care Unit: A Difference between Trauma and Surgical Patients
Authors: Wallace William C. , Cinat Marianne , Gornick Wendi B. , Lekawa Michael E. , Wilson Samuel E.
Published: November 2022

In 1970, the Centers for Disease Control and Prevention (CDC) established the National Nosocomial Infection Surveillance System to assist institutions with infection surveillance, data collection, and processing. This facilitates interinstitutional comparison for nosocomial infection rates. Nosocomial infection rates in the surgical intensive care unit have been shown to be different from the medical intensive care unit. Whether there exists a difference in infection rates between trauma and surgical patients in the intensive care unit has not been established. Our objective was to determine whether there is a difference in rates of nosocomial infections between trauma and surgical patients in the surgical intensive care unit. From January 1995 through December 1997, we reviewed 3715 admissions to the surgical intensive care unit and separated them into trauma (1272) or surgical (2443) cases. We documented all nosocomial pneumonias, urinary tract infections, bloodstream infections, and surgical site infections. From these data we determined infection rates per 100 admissions. We also identified all device-related nosocomial infections and calculated infection rate by current CDC standards using number of device infections divided by number of device-days times 1000. We found that the overall trauma patient infection rate was 11.64 per cent compared with 6.43 per cent for surgical patients (P < .001). Using conventional infection rate criteria, trauma patients had higher frequency in the rate of ventilator-associated pneumonia (6.13% vs 2.50%; P < 0.001), urinary tract infection (2.36 versus 1.76; P < 0.2), and bloodstream infection (2.52% versus 1.27%; P < 0.01). However, when using the CDC guidelines, which correct for the number of device-days for infections, only the difference in rate of pneumonia between the two groups reached statistical significance (23.9 rate for trauma patients vs 16.7 for the surgery group; P < 0.005). We conclude that trauma patients are at higher risk for nosocomial infections than routine surgical patients. Because of this difference, centers should collect and report data separately for trauma and surgical patients in the intensive care unit. Specific attention should be focused on the causes and prevention of increased rates of nosocomial pneumonia in trauma patients.
Doppler Ultrasound Accurately Screens Patients with Appendicitis
Authors: Gutierrez Charles J. , Mariano Myron C. , Faddis David M. , Sullivan Richard R. , Wong Raymond S. , Lourie David J. , Stain Steven C.
Published: November 2022

Ultrasound (US) has been reported as a useful aid to increase the sensitivity and specificity of the diagnosis of appendicitis. To determine the accuracy of US, we performed a prospective study of patients evaluated in the emergency department for acute appendicitis. US results of 125 consecutive patients over an 11-month period were correlated with operative and pathologic findings and clinical follow-up. The appendix was visualized as a noncompressible structure in 19 patients, and 18 had appendicitis (95%). Ten of the 12 patients with abnormal Doppler activity in the appendix had appendicitis (83%). Conversely, the appendix could not be visualized in 102 patients, and 100 did not have appendicitis (98%). One hundred five of the 113 patients (93%) with absent abnormal Doppler activity did not have appendicitis. Ninety-four of the 125 patients had neither visualization of the appendix nor abnormal activity, and 2 had appendicitis. The sensitivity of US for appendicitis was 90 per cent, and the specificity was 94 per cent. Visualization of the noncompressible appendix or abnormal Doppler activity strongly suggests appendicitis. More importantly, the absence of both of these ultrasonographic findings defines a patient subset that may be safely discharged from the emergency department without admission.
Initial Experience with Beating Heart Surgery: Comparison with Fast-Track Methods
Authors: Ott Richard A. , Gutfinger Dan E. , Steedman Robert , Tanner Teresa M. , Hlapcich Wendy L.
Published: November 2022

Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8 ± 2.4, 3.9 ± 1.8, and 5.2 ± 2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.
Relationship between Method of Detection of Breast Cancer and Stage of Disease, Method of Treatment, and Survival in Women Aged 40 to 49 Years
Authors: Maibenco Douglas , Daoud Yahya , Phillips Eduardo , Saxe Andrew
Published: November 2022

The optimal breast cancer screening program for women 40 to 49 years of age remains controversial. To help assess the value of screening mammography for this age group, we studied the relationship between the method of breast cancer detection and stage, therapy, and survival. Cases of breast cancer diagnosed at Sinai Hospital (Detroit, MI) between January 1985 and December 1994 were reviewed. A total of 181 cases involving 40- to 49-year-old women were available for analysis. The distribution of stage of disease significantly differed among the three methods of detection (P < 0.0001). Breast-conserving surgery was more commonly performed in cases detected by screening mammography and clinical breast examination than in cases detected by breast self-examination (P = 0.001). Variation in the stage of disease resulted in improved survival for cases detected by screening mammography and clinical breast examination when compared with those detected by breast self-examination (P = 0.019). Women diagnosed with breast cancer between the ages of 40 and 49 years had earlier stage disease, were more likely to be treated with breast-conserving therapy, and had better survival if their disease was first recognized by screening mammography. Screening mammography has an important role for women of this age.
Vascular Rings of the Thoracic Aorta in Adults
Authors: Grathwohl Maj Kurt W. , Afifi Maj Alaa Y. , Dillard Col Thomas A. , Olson Maj James P. , Heric Ltc Blaine R.
Published: November 2022

Vascular rings have been well documented to cause respiratory and gastrointestinal symptoms in infants and children. Few reports document symptomatic vascular rings in adults, and most have emphasized dysphagia as the predominant symptom. We present the case of a 36-year-old white male with a double aortic arch and progressive dyspnea on exertion. This led us to review previous reports of vascular rings in adults. Criteria for review consisted of anatomically complete vascular rings of the aortic arch in adults age 18 years or older. We identified 25 prior cases for review and included our recent patient. The most common vascular ring anomalies in our review of adults is double aortic arch (n = 12; 46%) followed by right aortic arch with aberrant left subclavian artery and ligamentum arteriosum (n = 8; 30%). Of 24 patients (66%), 16 were symptomatic. Reported symptoms involving the respiratory tract (n = 10 of 24; 42%) included dyspnea on exertion (n = 5), bronchitis (n = 2), recurrent pneumonia, stridor, and unspecified respiratory ailment (n = 1 each). Dysphagia was less common, occurring in eight patients (33%). Previously proposed mechanisms for respiratory tract symptoms include tracheomalacia, static or dynamic compression of the airways, intravascular volume infusion, and aspiration. We also propose exercise-induced dilatation of the aortic arch and age-dependent changes in thoracic compliance as potential mechanisms of dyspnea.
Acute Pancreatitis Secondary to Dehydration: Case Report and Review of the Literature
Authors: Raper Steven E.
Published: November 2022

Recent reports have documented the potentially catastrophic consequences of dehydration induced by vigorous exercise in otherwise healthy individuals. A case of acute pancreatitis secondary to exercise-induced dehydration is presented, and the literature of dehydration-induced syndromes, both research and clinical, is reviewed. The goal of this case report is to heighten awareness of dehydration as a potential cause of acute pancreatitis.
Life-Threatening Nail Gun Injuries
Authors: Beaver Anne-Corinne , Cheatham Michael L.
Published: November 2022

The use of pneumatic and explosive cartridge-activated nail guns is common in the construction industry. The ease and speed of nailing these tools afford enhance productivity at the cost of increased potential for traumatic injury. Although extremity injuries are most common, life-threatening injuries to the head, neck, chest, or abdomen and pelvis may occur. During a 20-month period, eight potentially life-threatening nail gun injuries were admitted to a Level I trauma center, including injuries to the brain, eye, neck, heart, lung, and femoral artery. Mechanism of injury included nail ricochet, nail gun misuse due to inadequate training, and successful suicide. Nail guns have significant potential for causing severe debilitating injury and death. These findings indicate a need for improved safety features and user education. The various types of nail guns, their ballistic potential, and techniques for operative management are discussed.
Ingested Endotracheal Tube in an Adult following Intubation Attempt for Head Injury
Authors: Block Ernest F. J. , Cheatham Michael L. , Parrish Gary A. , Nelson Loren D. , Beam Nancy
Published: November 2022

General surgeons are often consulted for assistance in the management of ingested foreign bodies. Deglutition of an endotracheal tube is an unusual complication of airway management. In these cases, the artificial airway is “lost” when it becomes lodged deep into the esophagus. Endoscopic extraction has been described as therapeutic. We report a case in which prehospital endotracheal intubation attempt for the management of closed head injury resulted in a swallowed endotracheal tube. The tube remained undetected until radiographs were performed for a second unrelated traumatic event 2 years later. Endoscopic extraction was unsuccessful, due to rigidity of the tube. Surgical extraction via gastrotomy was uneventful. Surgeons involved in trauma and other emergency settings should be aware of this complication and options in management.
Primary Squamous Cell Carcinoma of the Breast Presenting as a Breast Abscess
Authors: Wrightson William R. , Edwards Michael J. , Mcmasters Kelly M.
Published: November 2022

Primary squamous cell carcinoma (SCC) of the breast is a very rare neoplasm, with only 75 cases reported in the English literature. Herein, we report four new cases and discuss the diagnostic and therapeutic challenges of this unusual tumor in a retrospective review of all cases of SCC of the breast at our institution from 1990 to 1998. Four patients with breast SCC were identified, with a mean age of 70 years. Two patients with “pure” SCC (no features of ductal carcinoma) were initially treated for breast abscess. Two other patients with features of both SCC and ductal carcinoma had skin erythema associated with an underlying mass, and infectious etiology was considered in each case. Mean tumor size was 4.9 cm. Both patients with pure SCC underwent extensive evaluation for primary tumors at other sites. Two patients developed early systemic metastasis. SCC of the breast is often diagnosed at an advanced stage and may be confused with breast abscess. For this reason, breast biopsy should be considered in cases of breast abscess. Treatment of primary SCC of the breast is similar to that of more common types of breast cancer (i.e., breast conservation is possible and lymph node dissection is recommended). Because metastasis to the breast from other primary tumor sites has been reported (lung, cervix, skin, and esophagus), patients with pure SCC should undergo evaluation to exclude this possibility.
Pulmonary Embolism in Veterans Affairs Medical Centers: Is Vena Cava Interruption Underutilized?
Authors: Kazmers Andris , Jacobs Lloyd A. , Perkins Anthony J.
Published: November 2022

Veterans with venous thrombosis or pulmonary embolism (PE) were evaluated using Veterans Affairs patient treatment file (PTF) data from fiscal years 1990–1995, inclusive, to define outcomes for those with PE. The specific aims of the study were to define how often those with PE underwent vena cava interruption (VCI) and whether VCI affected in-hospital mortality rates. Outcomes were defined using PTF data and Patient Management Category (PMC) software for 26,132 veterans discharged from all Veterans Affairs Medical Centers (VAMCs) with venous thromboembolism, which included a subset of 4,882 patients identified by both PTF data and PMC software to have PE. PMC software also generated measures of illness severity, patient complexity (PMC count), and resource utilization (called resource intensity scale) for each hospital admission. The in-hospital mortality rate for those with PE was 15.9 per cent (775 of 4882). Only 157 VCIs were performed in those with PE which constituted 3.2 per cent of the latter group. Those with PE who had VCI experienced a 13.4 per cent unadjusted in-hospital mortality rate (21 of 157) versus a 16 per cent unadjusted mortality rate without VCI (754/4725; not significant). In a logistic regression model of in-hospital mortality in those with PE, increasing age and illness severity were directly related to mortality, whereas VCI was independently associated with reduced mortality. The odds of death were reduced by 0.482 (0.287–0.807, 95% limits) for patients with PE who underwent VCI (P < 0.005). Utilization of VCI varied among VAMCs: the hospital rates that VCI were performed in those with PE ranged from 0 to 16.7 per cent. Mortality associated with PE was substantial in VAMCs, and VCI was independently associated with reduced in-hospital mortality. The low percentage of veterans with pulmonary embolism who underwent VCI was surprising. VCI may be underutilized in veterans with PE.
Hemoperitoneum from Spontaneous Bleeding of a Uterine Leiomyoma: A Case Report
Authors: Danikas Dimitrios , Theodorou Spero J.V. , Kotrotsios John , Sills Charles , Cordero Pedro E.
Published: November 2022

Bleeding from uterine leiomyoma is a rare cause of hemoperitoneum. In most cases bleeding is a result of trauma or torsion. Spontaneous rupture of a superficial vein is extremely rare. Fewer than 100 cases have been reported. Our patient is a 44-year-old black woman who presented in the emergency room with acute onset of epigastric pain. Past medical and surgical history was not contributory except for a uterine “fibroid.” In the emergency room, the patient's abdomen became diffusely tender. Her pregnancy test was negative, and the abdominal ultrasound showed fluid in the peritoneal cavity. The patient became hemodynamically unstable, and there was a significant drop of the hemoglobin/hematocrit. A surgical consultation was requested, and the patient underwent exploratory laparotomy. A subserosal uterine leiomyoma was found, with an actively bleeding vein on its dome. The leiomyoma was excised and 3 liters of blood and blood clots were evacuated from the peritoneal cavity. The patient was premenopausal and had a known leiomyoma. The clinical course was similar to that of previously reported cases. Although extremely rare, when there is no history of trauma, pregnancy, or other findings, spontaneous bleeding from uterine leiomyoma should be in the differential diagnosis. Emergent surgical intervention is recommended to establish the diagnosis and stop the hemorrhage.
The Emergence of Precarious Employment as a Determinant of Health in Europe and the Relevance of Contextual Factors: A Critical Research Synthesis
Authors: Pförtner Timo-Kolja
Published: November 2022

Precarious employment as a determinant of health remains on the rise in Europe, in contrast to the European Pillar of Social Rights. Research in epidemiology, public health, and occupational health research has debated the health impacts of precarious employment. A number of studies have concluded that precarious employment contributes to poor health. More recent research has focused on the contextual influences of the association between precarious employment and health. Accordingly, we argue that the welfare state and the specific institutional arrangements on the national level determine and mediate the extent of the association between precarious employment and health. This research synthesis: (a) debates explanations for the rise of precarious employment in Europe, (b) illustrates how precarious employment has risen in Europe since the 1980s, (c) indicates empirical findings of the association between precarious employment and health in Europe, (d) discusses how research explains between-country differences of the association between precarious employment and health, and (e) presents empirical findings on the contextual determinants of the association between precarious employment and health in Europe.
“A Natural Right to the Soil”: Black Abolitionists and the Meaning of Freedom
Authors: Lynerd Benjamin T. , Wartell Jack
Published: November 2022

African American periodicals in the antebellum era advocated a fartherreaching agenda than just the abolition of slavery. Taking up a mantle of agrarian equality that runs through the English Commonwealthmen, Jefferson, Paine, and the Free-Soil movement of the 1840s, Black abolitionists—in contrast to the Garrisonians—targeted land monopolies as the economic foundation of the chattel system, whose elimination would be a necessary condition for the freedom of all Americans. While early platforms of the Republican Party also fused antislavery with the Free-Soil agenda, Republican leaders yielded to large-scale agrarian and industrial concerns after the War, a pivot which thinkers like W.E.B. DuBois would later implicate as the death-knell for racial equality. Our research indicates that for at least a decade before the Civil War, Black writers promoted land reform as an essential component of emancipation, embracing a neo-republican understanding of liberty that predicated civil rights on economic independence.
Revelatory Anxiety and Dissociative Disorders: An Existential-Humanistic Approach
Authors: Chavatel Walker
Published: November 2022

This article argues that an existential-humanistic approach to anxiety provides crucial insight to certain dissociative disorders, namely, depersonalization/derealization disorder (DPR/DRZ). Although reports suggest that nearly 200,000 people in the United States experience DPR/DRZ episodes each day, DPR/DRZ has remained understudied and misunderstood by the psychiatric community. This article argues that an existential-humanistic approach to the disorder informed by the work of Sartre, Heidegger, and May allows DPR/DRZ sufferers to understand their dissociative episodes as ontological engagements with the human condition that provides a shared sense of being-in-the-world. As rates of anxiety disorders continue to reach unprecedented levels and treatment plans have become increasingly equated with medication, the second portion of this article argues that an existential-humanistic approach might produce better therapeutic results while allowing DPR/DRZ sufferers to generate meaning out of their anxiety. The argument extends outside of the therapeutic setting and suggests that existential modes of thinking can be employed by the broader public when dealing with everyday experiences of anxiety.
Ignatius Loyola’s “Hierarchical Church” as Dionysian Reform Program
Authors: Pidel Aaron
Published: November 2022

This article argues that Ignatius Loyola, in proposing the “hierarchical Church” as norm for judgment and feeling, meant to evoke and commend aspects of the Dionysian tradition—especially its principle of hierarchical mediation and its affective portrait of spiritual perfection. Supporting this interpretation are considerations of the world behind the text (the reforming Dionysianism abroad in Ignatian Paris), the world of the text (the culminating position and concerns of the “hierarchical Church”), and the world in front of the text (its reception by Peter Faber and Jerome Nadal). Interpreted against a Dionysian backdrop, Ignatius’s hierarchical church becomes a charter for ecclesial mysticism.
Ethical Decision-making of Health Professionals Caring for People Living with HIV/AIDS in Hunan, China: A Qualitative Study
Authors: Lu Xiaoxiao , Huang Hangyu , Khoshnood Kaveh , Koniak-Griffin Deborah , Wang Honghong , Yang Min
Published: November 2022

Numerous ethical issues surged the moment acquired immunodeficiency syndrome (AIDS) was discovered. As advocates of people living with HIV/AIDS (PLWHA), health professionals encounter many ethical dilemmas in clinical practice. However, it remains unclear how health professionals solve these issues. The descriptive qualitative research was conducted through semi-structured interviews with 22 health professionals from May to August 2018. Three themes emerged from data analyses of the interviews: (1) real ethical dilemma experienced by health professionals, (2) factors influencing ethical judgment, (3) ethical motivations. About two-thirds of participants failed to recall ethical dilemmas experienced in their clinical practice. Emotions, gender, occupation, and difficulty balancing different roles may influence the ethical judgments of health professionals. In the ethical decision-making (EDM) process, most participants took other people’s interests into consideration and conformed to law and professional codes of conduct. However, the fear of medical disputes (conflicts with families and others) was experienced by many participants, influencing their ethical behaviors.