Unnecessary preoperative investigations: evaluation and cost analysis.

In keeping with national efforts to curb escalating health care costs, the necessity of multiple preoperative investigations was evaluated in 60 randomly selected ambulatory surgery patient records. Necessity for testing was assessed on clinical indications, and overall cost was calculated from the rates at both the local Department of Veterans Affairs Medical Center (VAMC) and a community hospital. Two thirds of the investigations were deemed to be inappropriate, with derived unnecessary average cost per patient of $47 and $80 for the VAMC and community hospital, respectively. Potential savings at the VAMC of $11,757.50 for the calendar year could have been realized. Education of staff and housestaff is crucial to changing obsolete practice habits. The quality and safety of care would not be compromised by limiting preoperative investigations to only those with clinical indications.

How not to practice geriatrics.

They're slow, they're hard-of-hearing, they don't get better--elderly patients can be a pain in the practice. Here's how to keep them away.

Leiomyoma of the male nipple. A case report and literature review.

A case of leiomyoma arising in the nipple of a 55-year-old male is presented. The patient had undergone two minor surgical procedures on the nipple and areola in prior years. It is not known whether biopsies were taken during these procedures.

Clinical correlations of one-carbon metabolism abnormalities.

1. Ninety psychiatric inpatients with a DSM III diagnosis of schizophrenia, mania, or major depression were studied. 2. Upon admission/transfer to the Clinical Studies Unit, and prior to discharge, measurements of symptom severity (BPRS, Ham-D, Young's Mania Scale) and blood samples were obtained. 3. Erythrocytes from these paired (admission and discharge) blood samples were assayed for methionine adenosyltransferase (MAT) activity and phosphatidylcholine (PC) content. 4. Comparisons were made between the changes in MAT Vmax, or % PC, and changes in symptom severity. 5. For the majority of the patients (79.3% of the schizophrenics; 84.6% of the depressives; and 93.8% of the manics), clinical improvement was associated with a "normalization" of enzyme activity. The association between changes in % PC and clinical response did not achieve significant correlation.

Pillars in the colon. Crohn's colitis with unusual endoscopic and morphologic appearances: report of a case.

A case of Crohn's colitis with unusual endoscopic and morphologic appearances is reported. The colitis was asymptomatic and discovered incidentally. Histologic confirmation was obtained following segmental colectomy.

The effects of high-nutrient urea on in vitro bullfrog fundic mucosa.

The effects of nutrient urea (240 mM) on H+ secretion, potential difference, and resistance were studied in isolated sheets of bullfrog fundic mucosa. H+ secretion was significantly reduced while transmucosal resistance was significantly increased and potential difference was significantly decreased. Measurement of CO2 utilization by, and distribution across, the mucosal sheets demonstrated that oxidative metabolism is increased (tCO2, 4.93 +/- 0.2 to 5.83 +/- 0.3 mumole/cm2 hr-1, P less than 0.05) and that generation of protons (H+) within the oxyntic cell is stimulated (delta CO2, 1.48 +/- 0.1 to 2.22 +/- 0.2 mumole/cm2 hr-1, P less than 0.05, and nutrient HCO-3 1.35 +/- 0.2 to 2.21 +/- 0.2 mueq/cm2 hr-1, P less than 0.05) in spite of paradoxically diminished H+ appearance on the secretory surface. Studies using 120 and 60 mM urea suggest that the effects may be dose dependent. Results with 240 mM sucrose on the nutrient surface would indicate that those seen with urea cannot be attributed entirely to the hyperosmolality. Pretreatment of the mucosal sheets with metiamide (10(-3) M) resulted in the expected decrease in titratable H+ (to 0) but had no effect on urea-stimulated oxidative metabolism (tCO2, 2.09 +/- 0.2 to 2.91 +/- 0.4 mumole/cm2 hr-1, P less than 0.02) or the generation of protons by the oxyntic cell (delta CO2, 0.68 +/- 0.1 to 1.35 +/- 0.3 mumole/cm2 hr-1, P less than 0.02, and nutrient HCO3- 0.83 +/- 0.1 to 1.65 +/- 0.3 mueq/cm2 hr-1, P less than 0.05). Both simultaneous or subsequent treatment with theophylline (5 X 10(-3) M) reversed the inhibitory effect of urea on H+ secretion. Transmission electron microscopy revealed involution of the secretory membrane following treatment with urea but maintenance of the microvillous secreting configuration of the membrane when theophylline was added to the nutrient solution. These results suggest that although nutrient urea stimulates the generation of H+ within the cell it simultaneously inhibits release of H+ by the secretory membrane. Failure to inhibit urea-stimulated generation of H+ within the cell by metiamide indicates that the increased oxidative metabolism and generation of protons stimulated by nutrient urea is probably not histamine-mediated. It is suggested that urea inhibits adenylyl cyclase and thus cAMP-mediated evolution of the secretory membrane with reduced H+ transport, an effect that can be reversed by inhibiting phosphodiesterase with theophylline.

Paracellular back-diffusion of H+ across bullfrog fundic mucosa resulting from Ca2+ depletion and its effects on taurocholate-induced mucosal injury.

The effects of calcium depletion (by washout and by chelation with EDTA) on the net appearance of hydrogen ions (H+) on the secretory surface of in vitro sheets of bullfrog fundic mucosa have been studied. A CO2 distribution method was used to distinguish between true and apparent inhibition of H+ secretion. Our data indicate that Ca2+ depletion produces apparent inhibition of H+ secretion by increasing paracellular back-diffusion of H+ across the mucosa. Ca2+ washout resulted in a decrement of measurable H+ (1.42 +/- 0.07 to 0.93 +/- 0.09 muEq/cm2 hr-1, P less than 0.05) without altering delta CO2 (1.18 +/- 0.15 to 1.26 +/- 0.17 muEq/cm2 hr-1, not significant). Chelation of Ca2+ with EDTA produced a similar decrease in H+ (1.61 +/- 0.09 to 0.78 +/- 0.12 muEq/cm2 hr-1, P less than 0.05) without affecting delta CO2 (1.60 +/- 0.13 to 1.68 +/- 0.22 muEq/cm2 hr-1, not significant). The possibility that H+ back-diffusion (induced by Ca2+ depletion) via a paracellular shunt might ameliorate injury was examined in bullfrog fundic mucosa exposed to a bile salt. H+ secretion, potential difference, resistance, and ultrastructural changes were studied in isolated mucosal sheets treated with 10 mM sodium taurocholate with or without Ca2+ depletion. Measurable H+, potential difference, and resistance were significantly lower in the Ca2+ depleted tissues. Scanning electron microscopy revealed identical changes in the surface epithelial cells of both depleted and nondepleted mucosae, but there was significantly less cell loss from depleted mucosae (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Psoas abscess resulting from perforating carcinoma of the sigmoid colon. Report of a case.

We report a case of a left psoas abscess resulting from a perforating carcinoma of the sigmoid colon. The chief complaints were edema of the left leg and pain in the left thigh. Single and double contrast barium-enema film demonstrated an extrinsic inflammatory mass distorting the sigmoid colon. A preoperative diagnosis of sigmoid carcinoma was not made on these examinations, nor on flexible colonoscopy. Carcinoma of the colon should be considered as a cause of an unexplained psoas abscess.

The role of injection sclerotherapy in the emergency and definitive management of bleeding esophageal varices.

Acute esophageal variceal hemorrhage remains a catastrophic event with a high mortality from either exsanguination or hepatic coma precipitated by shock and the stress associated with massive blood transfusion, increased protein load in the gut, and the trauma of various procedures employed in an effort to arrest the bleeding. Survival from such an episode is followed by an increased risk of recurrent hemorrhage and a poorer prognosis than that of a patient with portal hypertension who has not sustained a variceal bleeding episode. Endoscopic injection sclerotherapy, especially if performed via the flexible instrument, would seem to be the treatment of choice for the acute variceal hemorrhage. It may prove to have a role in the subsequent management for the prevention of recurrent hemorrhage in certain categories of patients, although its exact place has yet to be defined.

A radiological correlate for the feasibility of left thoracoabdominal esophagogastrectomy.

A measured distance of 10 cm between the upper shoulder of a distal esophageal tumor as seen on barium swallow and midbody of T7 suggests feasibility of esophagogastrectomy with adequate margins via a left thoracoabdominal approach, obviating a separate right thoracic incision. The use of the EEA Stapler is recommended to facilitate such a high anastomosis.

A case of acute esophageal variceal hemorrhage.

All those who deal with patients suffering from this discouraging and lethal disease are constantly searching for the ideal method in which to control active hemorrhage from esophageal varices. Continued nonoperative management in those whose hemorrhage does cease on purely conservative measures results in an unacceptably high mortality, the most common cause of which is recurrent bleeding. Those patients who undergo portoazygos disconnection via the transabdominal or transthoracic route are equally prone to recurrent hemorrhage unless an elective portosystemic shunt is performed. Whether such a shunt is done as an elective or as an emergency procedure, the postoperative mortality and morbidity are high. Although protection against recurrent bleeding can be expected in most, the natural history of liver disease progression (and prognosis therefrom) remains unaltered, if not occasionally aggravated. Resurgence of interest in injection sclerotherapy for immediate control of hemorrhage, with subsequent longterm control of varices by repeated injections at intervals of several months, has received enthusiastic support. Preservation of existing hepatocellular function, the simplicity of the technique, especially with the fibreoptic endoscope, and its likely impact on medical care costs in this disease are attractive benefits. It is not perfect, and prospective randomized controlled trials are required to prove its superiority over other forms of treatment, but it currently appears to be the most viable alternative. We are not alone in fervently hoping that portoazygos disconnection will rarely be required and that portosystemic shunting will become a superfluous procedure, comfortably consigned to the history books.

Injection sclerotherapy for control of acute variceal hemorrhage.

Acute variceal hemorrhage can be controlled effectively with injection sclerotherapy using the flexible gastroscope and endoscopic balloon tamponade. The complication rate is low; however, mortality from irreversible liver failure remains high. This technique is suggested as an alternative to standard medical and operative treatment.