bluuebunny/crossref_metadata_2025_split huggingface dataset:
Methods of decision analysis: Protocols, decision trees, and algorithms in medicine
Authors: Greep J. M. , Siezenis L. M. L. C. 
Published: May 2005

AbstractAlgorithms, decision trees, and protocols are defined and explained since they constitute an accepted part of clinical decision analysis and application to clinical care. Algorithms are particularly useful for common clinical problems where uncertainties are unlikely. Decision trees are helpful when—as usually occurs in difficult clinical decisions—there are problems in probability. Clinical protocols, which, at best, are based on algorithms and decision trees, provide instruction of how to best treat a patient given the strict definitions of the clinical problem. These techniques are, in essence, merely graphic representations of a logical scientific approach to clinical problems. Criticisms of these techniques center on their rigidity and the automatic unthinking cookbook medicine they might sponsor. It is concluded that if these techniques are wisely designed and, even more importantly, wisely administered with an understanding flexibility, they can lead to both economy and patient benefit.
Cost‐effective diagnostic test sequencing
Authors: Eiseman B. , Jones R. , McClatchey M. , Borlase B. 
Published: May 2005

AbstractProper diagnostic test selection and logical sequencing can minimize cost without compromising care. This study analyzes the logic for sequencing tests either in series (one after another) or in parallel (simultaneously). A model is created using 2 diagnostic tests for 2 diseases. Tests are assumed to have perfect performance characteristics.Factors involved in cost‐effective test sequencing include cost of each test, test performance characteristics, per diem hospital charge, and the clinician's prior probability of the suspected diagnosis based on history, physical examination, and previous laboratory data. At a given point of clinical suspicion, cost‐effective sequencing strategy should shift. In general, a cheap test can effectively be used in parallel even at low diagnostic probabilities; an expensive test should, in general, be used in series only when there is a high prior probability of diagnosis. High per diem hospitalization costs—such as for a patient in the intensive care unit—favor in parallel testing.Clinical acumen and suspicion of diagnosis (prior probability) primarily direct cost‐effective diagnostic test sequencing. Decision analysis of diagnostic test sequencing represents a technique for making cost‐effective decisions for sequencing and, thereby, minimizing costs while achieving optimal patient care.
Subjectivity in decision making: Common problems and limitations
Authors: Ravitch Michael M. 
Published: May 2005

AbstractSubjectivity is an inescapable part of the diagnostic and decision making process. Limitations on memory are compensated for by invoking “diagnoses” as devices for managing information during diagnosis. Thus, large amounts of information can be stored as confirmations and departures from the diagnostic hypotheses. Well‐documented limitations in probabilistic reasoning interfere with diagnosis and patient management. Uncommon diagnoses may be invoked inappropriately. Misconceptions of chance may lead to erroneous conclusions about health care. Most perplexing is that physicians attempting to incorporate patient preference in decision making are confronted with problems of subjective inconsistencies in patient valuation of outcomes of health care. The major problems of quantification and analysis are amenable to management through education, computing, and better patient data management. Problems of utility elicitation will require further research.
Decision analysis in surgical education
Authors: Elstein Arthur S. 
Published: May 2005

AbstractSurgical education can no longer be considered adequate if limited to description of surgical diseases and methods of management. Due to the growth in numbers of surgical diagnostic and therapeutic procedures, the surgeon of the future will find it increasingly necessary to understand the principles by which algorithms are constructed and by which individualized decisions should be made. Several systematic approaches for assisting clinical decision makers have been developed. Decision analysis is particularly appealing because it is flexible and readily adapted to a wide range of clinical situations. It explicitly guides the decision maker in determining the crucial variables in a clinical decision, and permits both objective data and personal preferences to play a part in decision making. Because it provides for personal estimates and preferences, decision analysis is not dehumanizing, even though it is quantitative, explicit, and mathematically rigorous. Topics for a series of seminars or case conferences are suggested. Decision analysis should be part of the intellectual preparation of every clinician.
Theoretical surgery: A new specialty in operative medicine
Authors: Lorenz Wilfried , Rothmund Matthias 
Published: May 2005

AbstractTheoretical surgery is defined as a nonoperative decision analysis and clinical and basic research supporting system for surgery. It developed to meet the needs of academic surgeons to coordinate communication with basic science disciplines.This article summarizes the development of this idea at the University of Marburg where theoretical surgery has reached departmental and institutional proportions. Its objectives and methods are described. Central to its operation are permanent working teams of 2 clinical surgeons, 1 basic scientist (theoretical surgeon), 1–2 technicians, and 1–2 students focusing on one problem in a joint interdisciplinary manner. Decision analysis with classification methods and the creation of decision trees and algorithms are central to the operation of this experiment.Lessons learned from this academic experiment and the accomplishments during the past 20 years are summarized on 3 levels of efficacy: performance, changing strategies, and outcome.
Repeated hepatic ischemia as a treatment for carcinoid liver metastases
Authors: Persson Bo G. , Nobin Anders , Ahrén Bo , Jeppsson Bengt , Månsson Bertil , Bengmark Stig 
Published: May 2005

AbstractHepatic ischemia has been used in the treatment of bilobar malignant carcinoid tumors in the liver. Hepatic artery ligation, hepatic dearterialization, and embolization with nondegradable micromaterial have been followed by collateral formation and are associated with a high complication rate. To reduce this, an implantable vascular occluder permitting intermittent occlusion of the hepatic artery was used in 3 patients with bilateral malignant carcinoid in the liver, with high urinary excretion of 5‐hydroxyindoleacetic acid (5‐HIAA). Following a thorough dearterialization of the liver and division of all attachments, except for the hepatic artery, portal vein, and common duct, the vascular occluder was placed around the hepatic artery and connected to an implantable subcutaneous port. The hepatic artery was occluded by injecting a few milliliters of saline into the port and flow was released by withdrawal of the same amount of saline. Two patients had an anomalous blood supply to the right lobe and the arterial branch was transposed to the proper hepatic artery. One patient had the hepatic artery regularly occluded for 16 hours at 4–6 week intervals. Two patients managed to do the occlusions by themselves at home for 1 hour twice daily. Two patients had a normalization of the urinary excretion of 5‐HIAA after 4 and 9 months. On follow‐up with computed tomographic scanning, tumor regression was noted in one, however, there was no change in the other. The third patient has already had a 75% reduction of urinary excretion of 5‐HIAA after 2 months of treatment. This new technique has the advantage of being performed on repeated occasions and on an ambulant basis over a long period of time.
Hepatic abscess
Authors: Donovan Arthur J. , Yellin Albert E. , Ralls Philip W. 
Published: May 2005

AbstractHepatic abscess—amebic or pyogenic—can be diagnosed with great accuracy by either ultrasonography or computed tomographic (CT) scanning. Ultrasound is the modality of choice and will detect almost 100% of abscesses. Confirmation of a diagnosis of amebic liver abscess is made by the indirect hemagglutination test that should be positive in almost 100% of cases. Cultures of pus from the abscess and from the blood must be obtained in cases of pyogenic liver abscess. A positive culture of pus from the abscess has been achieved in 90% of cases. Ultrasound or CT guidance is utilized in aspiration of a hepatic abscess.In the treatment of an amebic liver abscess, metronidazole is the amebicide of choice. Open drainage is contraindicated. For cases that fail to respond to therapy with amebicides, closed drainage guided by CT or ultrasound is performed. Secondary bacterial infection of an amebic liver abscess is an extremely rare event.The identification and determination of the antibiotic sensitivity of organisms responsible for pyogenic liver abscess is a crucially important step. Unless a celiotomy is necessary to correct an intraabdominal process or the abscess is extremely large, the initial treatment of pyogenic liver abscess is a 2 week course of appropriate antibiotics followed by a 1 month course of oral antibiotics. The majority of pyogenic liver abscesses will respond to such treatment. If drainage of a pyogenic abscess is required, the preferable technique is with a percutaneous CT‐ or ultrasound‐directed catheter. Open surgical drainage should be reserved for those cases in which a celiotomy is required for other purposes or for the patient who has failed a course of appropriate antibiotic therapy and closed percutaneous drainage is not feasible.The mortality for treatment of amebic liver abscess should be approximately zero and for pyogenic liver abscess should be less than 10%.
Portal hypertension in mansonic schistosomiasis
Authors: Raia Silvano , Mies Sergio , Alfieri Fernando 
Published: May 2005

AbstractMansonic schistosomiasis is an endemic disease in Brazil, with an estimated 10–12 million people infested. Among its clinical manifestations, the hepatosplenic form causes portal hypertension which, in turn, brings about severe digestive hemorrhage, the most serious complication of the disease. Normally, the patients are young, and have hepatosplenomegaly, hypersplenism without clinical manifestations, and slightly reduced hepatic function. The angiographic findings are characteristic, differing from those of hepatic cirrhosis.In Brazil, the definitive treatment for gastrointestinal hemorrhage is surgery, which should be done under elective conditions whenever possible. During a short period of time, known as the “risk period” (the time between the hemorrhagic episode and the surgery), propranolol has been used to prevent further bleeding. Surgical treatment is indicated only after the first episode, and never on a prophylactic basis.In 1977, a prospective, randomized trial was begun in order to assess the delayed results of the 3 surgical operations most widely used in this country. The study was interrupted after 94 patients had been operated on due to the high incidence of encephalopathy in the group who underwent classical splenorenal shunt. After a follow‐up of at least 60 months and, at most, 130 months, the results showed that classical splenorenal shunt caused encephalopathy in 39.3% of the cases and distal splenorenal shunt in 14.8%. None of those submitted to esophagogastric devascularization with splenectomy developed encephalopathy. The 3 procedures showed similar rates of hemorrhagic recurrence.
Surgery of chagasic megacolon
Authors: Cutait Daher E. , Cutait Raul 
Published: May 2005

AbstractChagas' disease is an endemic clinical entity caused byTrypanosoma cruzi,a parasite that is transmitted to humans by the hematophagic Triatominae insects. It affects several million persons in Latin America, mostly in Brazil, Argentina, Chile, Paraguay, and Bolivia. Megacolon, the most common complication of intestinal trypanosomiasis, results in severe constipation, for which surgery is indicated. A variety of procedures have been proposed for the correction of this disabling condition including sigmoidectomy, abdominal rectosigmoidectomy, left colectomy, and subtotal colectomy. On long‐term follow‐up, however, these operations have proved to be inadequate in a significant number of cases, apparently due to preservation of the dyskinetic rectum which continues to act as a functional obstacle to the progression of the fecal bolus. On the other hand, pull‐through operations, which include the removal of all or almost all of the dyskinetic rectum, or the exclusion of the rectum, as in the Duhamel‐Haddad operation, have been demonstrated to be superior.The abdominoperineal endoanal pull‐through resection with delayed colorectal anastomosis and the Duhamel‐Haddad operation are the most accepted procedures in Brazil and other Latin American countries; their technical details are illustrated. Functional results are satisfactory. Anal continence is normal in the vast majority of cases and sexual disturbances are rare. Routine treatment of 2 main complications—fecaloma and volvulus of the sigmoid colon—are discussed.
Surgical complications of Chagas' disease: Megaesophagus, achalasia of the pylorus, and cholelithiasis
Authors: Pinotti Henrique Walter , Felix Valter Nilton , Zilberstein Bruno , Cecconello Ivan 
Published: May 2005

AbstractThree surgical complications of Chagas' disease—megaesophagus, achalasia of the pylorus, and cholelithiasis—were evaluated within the framework of the experience acquired in the management of 840 cases of megaesophagus—722 in the nonadvanced stage of the disease and 118 with advanced disease (dolichomegaesophagus).In the group of the 722 patients with nonadvanced disease, achalasia of the pylorus was present in 140 (19.4%), and in the total of 840 patients, uncomplicated cholelithiasis without chagasic involvement of the gallbladder and/or papilla was observed in 58 (6.9%).The 722 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy performed at the level of the anterior esophagogastric junction, combined with an antireflux valvuloplasty procedure. We recorded no mortality, and 95% excellent and good results in long‐term follow‐up. On the other hand, dolichomegaesophagus required esophageal resection with reconstruction by means of an esophagogastroplasty placed in the esophageal bed. The mortality rate was 4.2% (5/118); the main postoperative complications were pleural effusion (22%) and fistulas of the esophagogastric anastomosis (8.4%). Postoperatively, the patients adapted well to their new anatomy and gained weight. Achalasia of the pylorus was confirmed by delayed gastric emptying time. This entity was managed by concomitant antropyloromyectomy without mortality. Cholelithiasis was managed by cholecystectomy and radiologic exploration of the bile ducts.
Endemic goiter and endemic thyroid disorders
Authors: Gaitan Eduardo , Nelson Norman C. , Poole Galen V. 
Published: May 2005

AbstractThe primary role of iodine deficiency in goitrogenesis and the prevention and treatment of endemic goiter by iodine supplementation is firmly established. Unfortunately, implementation of iodine prophylaxis programs has met with considerable technical and socioeconomic difficulties. Besides, lack of knowledge concerning some of the other causative factors of endemic goiter has prevented development of appropriate measures for its complete eradication in those areas where goiter persists in spite of prolonged and adequate iodine supplementation. At present, no less than 5% of the world's population have goiters and associated disorders, resulting in a public health and socioeconomic problem of major proportions. Seventy‐five percent of people with goiter live in less developed countries where iodine deficiency is prevalent. Goiter prevalence rates of more than 50% and the highest frequency of severe cases of iodine deficiency disorders, namely, cretinism, congenital hypothyroidism, and various degrees of impairment of growth and mental development are found in endemic areas with extreme iodine deficiency. Goiters are usually multinodular and of very large size, producing, on occasion, signs of compression that require surgery. Recurrence rates are as high as 25–30% and second surgery accounts for 16% of all thyroidectomies. Unfortunately, most of these goiters occur in areas with highly restricted medical and surgical facilities. Twenty‐five percent of people with goiters live in more developed countries where goiter continues to occur in certain areas despite iodine prophylaxis. Iodine‐sufficient goiters are associated with autoimmune thyroiditis, hypothyroidism, hyperthyroidism, and thyroid carcinoma. Goiter is of considerable surgical significance in iodine‐sufficient endemic areas and, to a lesser degree, in nonendemic areas where it is called “sporadic” goiter. Recurrence rates of iodine‐sufficient goiter are 10–19% following thyroidectomy. Since most of these goiters grow by mechanisms other than increased thyrotropin (TSH) stimulation, treatment with suppressive doses of L‐thyroxine is inefficient and, because of possible complications, not recommended. Although Graves' hyperthyroidism is not directly related to endemic goiter, it does relate adversely with ingestion or administration of iodine. At present, Graves' disease is treated with131I or antithyroid drugs in more than 90% of the cases. The incidence rates of papillary, follicular, and anaplastic thyroid carcinomas appear to be related to endemic goiter and iodine supplementation, with surgery being required in essentially all of these cases.
Fulminant amebic colitis
Authors: Aristizábal Humberto , Acevedo Jairo , Botero Mario 
Published: May 2005

AbstractAmebiasis is the acute and chronic disease produced byEntamoeba histolytica,an entity which occurs in endemic fashion in many of the tropical and subtropical areas of the world, capable of affecting diverse organs of the body, especially the colon. Amebiasis has different clinical forms of presentation, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, characteristically associated with high morbidity and mortality. We hereby report a series of 50 adult patients with fulminating amebic colitis managed at our institution between January, 1971 and July, 1989, with a global mortality of 60%. Early diagnosis, treatment with effective antiamebic agents—specifically metronidazole—and opportune aggressive surgical intervention have resulted in better survival rates. We had no survivors prior to 1970; our current survival rate is still a dismal 40%, indicating the very severe nature of the disease.
The epidemiology of gastric cancer
Authors: Correa Pelayo 
Published: May 2005

AbstractThe etiology of gastric carcinoma, especially its “epidemic” or “intestinal” type is reviewed. The prevailing etiologic hypothesis, based on the selective targeting of etiologic agents in different points of the chain of causation, is described. Support for the hypothesis is updated, based on descriptive and analytical epidemiologic studies as well as on recently obtained laboratory and experimental evidence. Primary and secondary prevention measures are briefly discussed.
Necrotizing lesions of soft tissues: A review
Authors: Patiño José Félix , Castro Daniel 
Published: May 2005

AbstractNecrotizing lesions of the soft tissues are grave entities not infrequently seen in daily surgical practice. They may occur with epidemic proportions after natural disasters, representing a serious challenge to the surgeon since they are characteristically associated with high mortality rates unless an early diagnosis is made and prompt aggressive surgical management is initiated. Necrotizing fasciitis is the currently accepted generic term to encompass into a single category the diverse syndromes of progressive gangrenous infections of the skin and subcutaneous tissues. Necrotizing fasciitis must be viewed as a clinical entity rather than a specific type of infection: it is a clinical infection most commonly caused by a mixed aerobic/anaerobic synergistic polymicrobial combination. Zygomycetes may appear as major causal organisms (mucormycosis) and they should be actively searched for. Initial diagnosis of necrotizing fasciitis is established through the characteristic physical signs, Gram stain, and, in some doubtful cases, through frozen‐section tissue biopsy. Aggressive and urgent radical debridement is the key to survival, combined with widespectrum antibiotic therapy.
Necrotizing soft tissue lesions after a volcanic cataclysm
Authors: Patiño José F. , Castro Daniel , Valencia Alvaro , Morales Pedro 
Published: May 2005

AbstractA volcanic cataclysm of major proportions, the fourth largest in terms of total casualties in the history of mankind, wiped out the town of Armero, Colombia, in 1985 resulting in over 23,000 deaths and 4,500 wounded. Among the hundreds of survivors who were transferred to hospitals in the capital city of Bogotá, there was as overwhelming number who developed necrotizing fasciitis. These patients constitute, perhaps, the single largest group of this type of lesions in the recorded literature. Thirty‐eight patients with well established necrotizing fasciitis were identified at 4 selected hospitals in Bogotá; 8 of them presented with zygomycetic infection (mucormycosis), a highly lethal entity. Many additional cases were treated at other hospitals in Bogotá and several cities in Colombia. The main clinical features of these 38 patients affected by necrotizing fasciitis are reviewed, with special emphasis on the patients with mucormycosis. Patients with necrotizing fasciitis had an overall mortality rate of 47.7%; patients with mucormycosis, 80%. A plea is made for an early diagnosis, utilizing tissue sampling and microbiological studies, so that prompt and radical treatment can be instituted. This is especially pertinent in situations of natural disasters resulting in massive numbers of casualties and seriously injured survivors.
Recurrent pyogenic cholangitis: Current management
Authors: Fan S. T. , Choi T. K. , Wong J. 
Published: May 2005

AbstractSuccessful treatment of recurrent pyogenic cholangitis depends on the ability to delineate the pathology of the entire biliary system and to eradicate all stones, strictures, and destroyed liver segments. Recent advances in imaging techniques and stone fragmentation technology have been applied successfully in the management of this condition. Apart from direct cholangiography and ultrasonography, valuable information can be obtained from computed tomography which is particularly helpful in patients with recurrent disease after previous biliary surgery. Application of electrohydraulic lithotripsy in this disease solves the problem of difficult stone retrieval due to large size, impaction behind relative strictures and inside angulated segmental bile ducts. Together with construction of a hepaticocutaneous jejunostomy serving as a permanent access to the bile duct, it is anticipated that the incidence of recurrence and reoperation in the future can be reduced.