Evidence-Based Workflows for Thyroid and Parathyroid Surgery.

A need exists to reduce care variations by standardizing the practice of thyroid and parathyroid surgery. During the course of a year, a task force developed algorithms representing decision points and workflows based on American Thyroid Association guidelines and three internal studies of surgical practices in the Northern and Southern California Regions of Kaiser Permanente conducted in collaboration with Health Information Technology Transformation & Analytics (HITTA).

ON THE ANALYST'S IDENTIFICATION WITH THE PATIENT: THE CASE OF J.-B. PONTALIS AND G. PEREC.

The writer Georges Perec was in psychoanalysis with Jean-Bertrand Pontalis for four years in the early 1970s. In this essay, the author presents the exceptional interest this analyst took in this patient and the ways in which that interest manifested itself in his work, psychoanalytic and otherwise. Many correlative factors suggest that identificatory processes persisted beyond the treatment and were maintained into Pontalis's later life. While this paper is primarily intended to provide evidence to support this view of a specific case, the author closes by reflecting that this may be a more general phenomenon and the reasons for this.

THE ONEIRIC AUTOBIOGRAPHY OF GEORGES PEREC.

Georges Perec's book La Boutique Obscure (1973; translated into English in 2012) serves as the basis for this paper. The book is a collection of dreams that its author dreamed from May 1968 to August 1972. The present author treats these dreams as chapters in a bizarre autobiography, elaborating Perec's life through a discussion of those dreams and using them as a starting point with which to discuss his views of dream interpretation and the role of dreams in psychoanalysis.

Neutrality in the field: alpha-function and the dreaming dyad in psychoanalytic process.

Analysts have interpreted the concept of neutrality in a variety of ways, beginning with Strachey's use of that word to translate Freud's (1915) term, Indifferenz. In this paper, neutrality is linked to Freud's notions of free association and evenly suspended attention. A history of psychoanalytic attempts to clarify the concept are presented, with special attention to issues of ambiguity and the patient's role in the determination of neutrality. Neutrality is further elaborated in relation to the bipersonal field as described by the Barangers and contemporary field theorists. Understood in terms of the field, neutrality becomes a transpersonal concept, here conceived in terms of alpha-function and a dreaming dyad. Two clinical examples cast in the light of a Bionian perspective are discussed to suggest an alternative understanding of analytic impasses and their relation to alpha-function and neutrality.

Roy Schafer: a beginning.

The author provides a biographical overview of Schafer's life, culled from his published work and focused primarily on his professional development. This biography is used to demonstrate some of Schafer's central theoretical insights on narrativity and language, and reveals the consistency of his thinking over his long career. A brief discussion of his writing on King Lear provides a bridge between theoretical and biographical material.

Impact of pneumoperitoneum on renal perfusion and excretory function: beneficial effects of nitroglycerine.

BACKGROUND: Increased intra-abdominal pressure (IAP) (pneumoperitoneum) during laparoscopic surgery may result in adverse effects on kidney function. The mechanisms underlying this phenomenon have not been fully determined. OBJECTIVE: The present study was designed to: (1) investigate the effects of incremental increases in IAP on renal function in normal rats and (2) evaluate whether the nitric oxide (NO) system is involved in renal dysfunction characterizing pneumoperitoneum. METHODS: Male rats were organized into two groups. The first group was subjected to IAP of 0 (baseline), 7 or 14 mmHg, over 1 h for each pressure, followed by a deflation period of 60 min (recovery). Two additional groups were pretreated with: (1) non-depressor dose of nitroglycerine (NTG) and (2) nitro-L-arginine-methylester (L-NAME), an NO synthase inhibitor, before applying 14 mmHg for 1 h. Urine flow rate (V), Na+ excretion (U(Na)V), glomerular filtration rate (GFR), renal plasma flow (RPF), and blood pressure were determined throughout the experiments. RESULTS: There were no significant changes in V, U(Na)V, GFR, and RPF during 7 mmHg insufflation. However, significant reductions in these parameters were observed during 14 mmHg: V from 8.49 +/- 0.92 to 6.12 +/- 0.54 microl/min, U(Na)V from 1.29 +/- 0.28 to 0.39 +/- 0.09 microEq/min, and FE(Na) from 0.37 +/- 0.11 to 0.27 +/- 0.04%. These alterations in excretory functions were associated with a considerable decline in GFR from 1.85 +/- 0.09 to 0.88 +/- 0.09 ml/min, p < 0.05, (-46.3 +/- 5.2% from baseline) and RPF from 8.66 +/- 0.62 to 4.33 +/- 0.49 ml/min, p < 0.05, (-51.93 +/- 5.24% from baseline), without a significant change in mean arterial blood pressure (MAP). When the animals were pretreated with NTG, the adverse effects of pneumoperitoneum on V, U(Na)V, GFR, and RPF were substantially improved, suggesting that NO system plays a beneficial counter-regulatory role during laparoscopy. In line with this notion, pretreatment with L-NAME remarkably aggravated pneumoperitoneum-induced renal hypoperfusion and dysfunction. CONCLUSION: Decreased renal perfusion and function are induced by IAP pressure of 14 mmHg. These adverse effects are probably related to interference with the NO system, and could be partially ameliorated by pretreatment with NTG.

The challenge of type 1 diabetes mellitus.

Diabetes mellitus is a heterogeneous group of diseases characterized by high blood glucose levels due to defects in insulin secretion, insulin action, or both. With the number of cases expected to increase rapidly in the years to come, diabetes is a growing health challenge worldwide. Of the approximately 16 million diabetics in the United States, about 1.5 million suffer from type 1 diabetes. In this catabolic disorder afflicting predominantly young individuals, blood insulin is almost completely absent, leading to hyperglycemia and alterations in lipid metabolism. Type 1 diabetes is thought to be induced by a toxic or infectious insult that occurs in genetically predisposed individuals. With recent advances in the understanding of the involved immunology and cellular and molecular mechanisms, researchers strive to battle the disease with new preventive and corrective strategies.

Abdominal aortic aneurysm in Behçet's disease: new treatment options for an old and challenging problem.

BACKGROUND: Arterial involvement in Behçet's syndrome is rare. Aneurysms are common among the arterial lesions, affecting various arteries but mostly the abdominal aorta. Surgical interposition graft insertion is the treatment of choice for large aneurysms. However, vasculitis in these patients is the reason for the notorious surgical complications that result in up to 50% false aneurysms in anastomotic sites. Recently, endovascular repair for abdominal aortic aneurysms has been established. OBJECTIVES: To learn more about vascular Behçet's and, specifically, to compare the results of surgical treatment and endovascular repair of AAA in patients with Behçet's syndrome. METHODS: We retrieved the medical records of all 53 patients with Behçet's disease admitted to Rambam Medical Center during the years 1985 and 2001, and analysed the results and follow-up of open surgery versus endovascular repair of AAA in patients with known Behçet's syndrome. RESULTS: Of the 53 patients with Behçet's disease 18 had vascular manifestations (34%). AAAs were encountered in 8 patients (15%) and 5 were treated. Open surgery (group 1), under general anesthesia, lasted less than 3 hours with an average aortic damping time of 34 minutes (range 26-41 min) after which the patients were transferred to the intensive care unit for 24-48 hours. Endovascular treatment (group 2), although lasting about the same time without the need for intensive care, necessitated contrast media and fluoroscopy. The length of hospital stay was considerably shorter for patients after endovascular repair compared to open surgery (3 days vs. 6 days). Combined mortality and morbidity was higher in patients who underwent open surgery compared to endovascular repair (one death, one major amputation and three anastomotic pseudoaneurysms compared to one temporary contrast-induced nephropathy). CONCLUSIONS: Vasculo-Behçet's patients with AAA are better candidates for endovascular treatment than atherosclerotic patients. Combined morbidity (especially anastomotic pseudoaneurysms) and mortality of Behçet's patients after endovascular repair is considerably lower than after open surgery.

[Therapeutic implications of endothelin antagonists for cardiovascular diseases].

The endothelin system plays an important role in the pathophysiology of a variety of cardiovascular diseases including: congestive heart failure, essential and pulmonary hypertension, renal failure, and cerebrovascular disease. The biological effects of endothelin-1 on its target organs are mediated by two receptors: ETA and ETB. It is widely accepted that the vascular, cardiac, and renal adverse effects of ET-1 are mediated by ETA, while activation of ETB receptors leads to beneficial effects such as: attenuating the vascular and cardiac hypertrophic effects of ET-1 as well as the vasodilatory action of this peptide. In the last decade, a whole range of peptide and non-peptide ET-1 antagonists has been developed, some selective to ETA and others nonselective with dual antagonistic activity against both ETA and ETB. Several clinical studies have revealed that ET-1 antagonists are clinically beneficial therapeutic agents for the treatment of several cardiovascular diseases, leading to the approval of bosentan (ETA/ETB antagonist) for the treatment of pulmonary hypertension. The current review will focus on the recent developments in the endothelin field, with special emphasis on the ET-1 antagonist and their clinical use.

Multidetector CT angiography of peripheral vascular disease: a prospective comparison with intraarterial digital subtraction angiography.

OBJECTIVE: The purpose of this study was to determine the accuracy of CT angiography using a multidetector scanner in the evaluation of patients with peripheral vascular disease. SUBJECTS AND METHODS: Eighteen patients with peripheral vascular disease who were referred for elective digital subtraction angiography (DSA) also underwent CT angiography. We scanned patients from the level of the superior mesenteric artery to the pedal arteries in a single helical scan. CT angiograms were produced using maximum-intensity-projection reconstructions. Findings were graded according to six categories: 1, normal (0% stenosis); 2, mild (1-49% stenosis); 3, moderate (50-74% stenosis); 4, severe (75-99% stenosis); 5, occluded; and 6, nondiagnostic. CT angiography findings were compared with DSA findings for each arterial segment. RESULTS: We found agreement for the degree of stenosis in 77.7% of the arteries and discrepancy for 22.3% of the arteries when all categories were considered. Grouping the six categories according to the threshold for treatment (categories 1 and 2 as one group and categories 3, 4, and 5 as the second group) resulted in an agreement of 91.95%. Compared with DSA, CT angiography yielded a sensitivity of 90.9% and a specificity of 92.4%. CONCLUSION: Multidetector CT angiography is an accurate, noninvasive technique for the imaging of peripheral vascular disease.