Breast and cervical carcinoma screening services: physicians' perceptions of need.

The Mississippi Breast and Cervical Cancer Control Coalition conducted a survey of health care professionals to assess current practices in the areas of breast and cervical cancer screening. A 22% response rate was obtained, with family practitioners having the highest response rate. Cost was cited as a major barrier to access to screening mammography. Some discrepancies between provider perceptions and currently accepted guidelines were identified.

Familial juvenile polyposis: patterns of recurrence and implications for surgical management.

BACKGROUND: Familial juvenile polyposis predisposes to the development of carcinoma of the colon. Optimum surgical management and recommended surveillance of affected individuals are still being defined. STUDY DESIGN: A retrospective review of experience with a kindred identified in 1988 was carried out. RESULTS: Of 34 living members, 15 have been investigated, and histologically typical juvenile polyps were found in 11. In each instance, polyps were most numerous in the right colon, with few polyps in the descending colon and none in the rectum. Eight patients have had subtotal colectomies with ileorectal anastomoses; the remaining patients were managed by polypectomy (with one recurrence after ten years). In addition to juvenile polyps, polyps with adenomatous or villous elements were identified in three patients. One of these patients had invasive adenocarcinoma in a large mixed polyp of the cecum. Two patients with polyps had coexisting carcinoma of the stomach. All patients have been followed up with periodic upper and lower gastrointestinal endoscopy. Polyps have recurred in the rectal remnants of three patients at a mean of 36 months after subtotal colectomy. Two patients have undergone conversion to total proctocolectomy with ileoanal anastomosis and J pouch; one patient was found to have juvenile polyps in the pouch 40 months after surgery. CONCLUSIONS: Despite the preponderance of right-sided polyps at initial diagnosis, the rapid recurrence of polyps after subtotal colectomy argues in favor of performing proctocolectomy with preservation of anal sphincter function (restorative proctocolectomy) at the time of initial surgery. Patients with a small number of polyps may choose instead to undergo periodic colonoscopy with colonoscopic polypectomy. An algorithm for surveillance and follow-up is proposed.

The integration of laparoscopy into a surgical residency and implications for the training environment.

Although laparoscopic cholecystectomy is now an accepted part of resident training, the impact of operative laparoscopy (OL) upon the residency environment has not been examined in detail. We reviewed the first 3 years' experience with OL and the process by which it was introduced into our residency program. Data were obtained from our prospective computerized surgical laparoscopic registry as well as from a survey conducted midway in this experience. At that time, a questionnaire was sent to current residents in the program and residents who graduated after the inception of the OL program were interviewed by telephone. OL cases increased each year and comprised a progressively greater percentage of total cases. Residents performed over 97% of cases, with attending surgeons as first assistants. Initially, only senior-level residents participated as surgeons; however, after the first year we noted a significant tendency for cases to filter down the ranks. Junior-level residents have already participated in more laparoscopic than open cholecystectomies and expressed considerable concern about training in open procedures. Graduated residents without exception were able to obtain privileges to perform OL without additional training. They did not feel that resident education was compromised by the advent of laparoscopy. Both current and graduated residents considered didactic sessions including animal laboratories and simulators an important part of training.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic appendectomy. Initial experience in a teaching program.

From February 1990 to December 1991, 16 laparoscopic procedures were performed for right lower quadrant pain. There were nine men and seven women, aged 16 to 47 years (mean, 27.2 years). All procedures were performed by surgical chief residents with prior experience in laparoscopic cholecystectomy, first-assisted by an attending surgeon. The appendix was visualized and a definitive diagnosis was made in all patients. One patient with acute salpingitis underwent diagnostic laparoscopy only; two patients underwent laparotomy (perforated appendicitis, perforated diverticulitis). A fourth patient had an acute torsion of an ovarian cyst managed laparoscopically. Laparoscopic appendectomy was successfully performed in 12 patients (acute appendicitis, 9; fibrosis or chronic inflammation, 2; normal appendix, 1). Mean operative time for laparoscopic appendectomy was 95.7 minutes, and mean postoperative stay was 2.5 days. The authors conclude that operative time, diagnostic accuracy, and complication rates for laparoscopic appendectomy are acceptable. Within the context of a training program, laparoscopic appendectomy provides an opportunity for surgical residents to expand laparoscopic skills.

Hypertonic saline resuscitation: efficacy in a community-based burn unit.

Many have discussed hypertonic saline for resuscitation in burned patients only to discourage its use or to emphasize it only as a research tool and not as standard resuscitation. We reviewed the records of 47 adults with burns over 20% or more of the total body surface area (TBSA) in whom hypertonic saline was used as standard resuscitation fluid in a large community burn unit. The solution consisted of sodium, 300 mEq/L, acetate, 200 mEq/L, and chloride, 100 mEq/L, with an osmolality of 600 mOsm/L. The mean TBSA burned was 37% and the mean patient age was 44.8 years. Eighteen patients (mean age 39.7 years, mean TBSA burned 27%) received hypertonic saline alone. They required an average of 75% of the Parkland calculated volume to achieve a urinary output of 1 mL/kg/hr. The mean hematocrit value over the first 48 hours was 44.2% and the mean serum sodium level was 141.6 mEq/L. Twenty-nine patients (mean age 51.8 years, mean TBSA burned 47.8%) received hypertonic saline plus colloid (albumin or fresh frozen plasma). Colloid was used in older patients with more serious burns. This group required 57% of the Parkland calculated volume to achieve a urinary output of 1 mL/kg/hr. The mean hematocrit value was 45.1% and mean sodium level was 143.8 mEq/L. The mean weight gain for both groups was 7.3% of the admission weight. None of the patients had changes in pH or renal function. All patients survived the resuscitation phase of their injury; the overall death rate was 49%. We conclude that hypertonic saline is a safe, effective means of resuscitation even in a community-based unit. It allows less fluid to be delivered for adequate resuscitation. The usual hyponatremia, hemoconcentration, and significant weight gain associated with administration of isotonic solutions was avoided. Colloid may further improve the resuscitation capabilities of hypertonic saline.