Participation of the general gynecologist in surgical staging of endometrial cancer: analysis of cost and perioperative outcomes.

OBJECTIVE: To compare the cost and perioperative outcomes of endometrial cancer staging when the procedure is performed by a gynecologic oncologist alone or when a general gynecologist participates in the procedure. METHODS: A retrospective analysis was performed on a series of women with clinical stage I endometrial cancer treated at a single institution between 1/98 and 12/00. The patients were grouped according to the participation of a general gynecologist in their surgery. The 48 patients in Group 1 underwent surgery with a general gynecologist who consulted a gynecologic oncologist intraoperatively. Group 2 included 77 patients whose procedure was performed completely by a gynecologic oncologist. The two groups were compared with the chi-square, Fisher's exact, and Wilcoxon rank sum tests. Cost analysis included total hospital costs (room, pharmacy, and ancillary services) and total surgical costs (anesthesia, operating room, procedure, and perioperative physician evaluation costs). RESULTS: The groups did not differ in age, type of surgeries performed, distribution of surgical stage, proportion of patients undergoing lymph node sampling (LNS), and length of follow-up. When LNS was performed, Group 2 had a significantly shorter median operative time (170 vs. 180 min; P=0.05) and shorter total time in the operating room (204 vs. 224 min; P=0.02). This group had a lower procedure cost when considered both in terms of payor's cost ($1,414 vs. $2,134; P<0.0001) and physician charge ($7,106 vs. $11,116; P<0.0001). Perioperative physician evaluation was reduced by almost half ($685 vs. $424; P<0.0001) in Group 2. Group 2 had a savings in total surgical cost by payor's cost ($9,142 vs. 10,294; P=0.005) or physician's charge ($14,546 vs. $19,276; P<0.0001), and in combined hospital and surgical cost by payor's cost ($15,664 vs. $17,346; P=0.004) or physician charge ($21,311 vs. $26,328; P<0.0001). Total hospital costs, however, did not differ between groups. CONCLUSION: Operative time and costs increase when general gynecologists participate in the surgical procedure of patients with clinical stage I endometrial cancer. Although perioperative outcomes are similar, the involvement of two surgeons increases the length of the procedure as well as the cost of operating room time and physician reimbursement. The efficient use of limited health care resources must be considered as we plan the surgical approach to endometrial cancer.

Extensive calvarial tuberculosis: rare complication of tuberculous mastoiditis.

Tuberculous mastoiditis is a well-documented entity with decreasing incidence in recent years. Tuberculous osteitis of the skull is even rarer. The case of a 58-year-old male with tuberculous mastoiditis complicated by extensive tuberculous osteitis of the skull is presented. This case serves to demonstrate both the difficulty in establishing the diagnosis of tuberculosis and the potentially disastrous consequences of the disease.

Nasopharyngeal lipoma--a rare clinico-pathological entity.

A lipoma situated within the posterior wall of the nasopharynx is reported. Only three lipomas of the nasopharynx in adults have previously been reported. The value of CT scan and cytology in making the preoperative diagnosis of a lipoma at this location is discussed.

Appendicitis: an unusual cause of infected abdominal aortic aneurysm.

An unusual case of appendicitis, which presented as an infected aortic aneurysm is described. Gas was noted in the wall of the aneurysm on abdominal radiographs and computed tomography, due to the formation of an appendico-aortic fistula. Computed tomography also demonstrated a contained rupture of the aneurysm.

Morphology and physiology of cells in slice preparations of the posteroventral cochlear nucleus of mice.

In an effort to understand what integrative tasks are performed in the cochlear nuclei, the present study was undertaken to describe neuronal circuits in the posteroventral cochlear nucleus (PVCN) anatomically and physiologically. The cochlear nuclear complex receives auditory information from the cochlea through the auditory nerve. Within the cochlear nuclei, signals travel along several parallel and interconnected pathways. From the cochlear nuclei, transformed versions of the signals are passed to higher auditory centers in the brainstem. We have recorded electrophysiological responses from cells that were subsequently visualized with horseradish peroxidase (HRP). Responses to shocks to the auditory nerve root and to intracellularly injected current pulses were recorded and correlated with morphology. Two types of stellate cells and octopus cells were distinguished. T stellate cells project out of the cochlear nuclei through the Trapezoid body; D stellate cells do not. The axons of D stellate cells extend Dorsalward to the dorsal cochlear nucleus (DCN) but have not been traced out of the nucleus. Both T and D stellate cells have terminal collaterals in the multipolar cell region of the PVCN and in the DCN. The endings of one T stellate cell formed a narrow band rostrocaudally in the fusiform cell layer of the DCN that resembled an isofrequency band. The endings of one D stellate cell lay closely apposed to multipolar cells in the deep layer of the DCN. The dendrites of T stellate cells are often aligned along the path of auditory nerve fibers and end in tufts, whereas those of D stellate cells extend radially in the plane of the lateral surface of the PVCN toward granule cell areas and branch sparingly. Octopus cells have dendrites oriented perpendicularly to the path of auditory nerve fibers. Their axons were cut medially in the slices; none had collateral branches. Both T and D stellate cells were monosynaptically excited to threshold by shocks to the nerve root, indicating that they could participate in local circuits that we measure physiologically. T stellate cells have action potentials that peak at about 0 mV and are followed by single undershoots. The D stellate cell that was best impaled fired overshooting action potentials that were followed by double undershoots. Octopus cells were monosynaptically excited to threshold by shocks to the auditory nerve.

Gastrointestinal tuberculosis in patients with pulmonary tuberculosis.

Proven or suspected intestinal tuberculosis was diagnosed in 23 (46 per cent) of 50 patients with smear-positive, cavitating pulmonary tuberculosis. The diagnosis was regarded as proven in 14 patients and suspected in the remaining nine. The frequency of proven gastrointestinal disease increased with the severity of the pulmonary tuberculosis. Small intestinal disease was encountered in only two patients. Small mucosal lesions in the caecum were the most commonly detected pathological features. Colonoscopy was of particular value in establishing the diagnosis, which could not be predicted from the patients' abdominal signs or gastrointestinal symptoms.

Radionuclide scintigraphy in tuberculous enteritis.

Scintigraphy with indium-111 labeled leucocytes and gallium-67 citrate was performed on 6 patients with proven tuberculous enteritis. The ability of both techniques to visualize areas of disease in this condition was demonstrated. When compared with endoscopy (either upper gastrointestinal endoscopy or colonoscopy), Ga-67 citrate had a sensitivity of 0.80 and a specificity of 1.00. The sensitivity and specificity of In-111 labeled leucocytes was 0.60 and 0.96, respectively. The superiority of Ga-67 over In-111 was statistically significant. Positive scintigrams were obtained despite prior treatment with antituberculous chemotherapy.

The CT appearances of ruptured abdominal aortic aneurysms.

There is no place for investigative CT scans in patients who have the classical triad of abdominal aortic aneurysm rupture, namely excruciating abdominal pain or backache, a pulsatile mass and hypotension. These patients require immediate surgery. However, in the absence of this triad, CT scans play an important role in the diagnosis of abdominal aortic aneurysm rupture. The CT scan findings will dictate whether the patient requires immediate surgery as in the case of acute rupture, or, whether the surgery can be delayed up to 24 hours to allow for stabilisation and hydration, as in the case of subacute and chronic rupture.

Liquid-crystal thermographic mammography. A preliminary assessment of a controversial modality.

Thermography is a simple and safe technique for examination of the breast. An analysis of 200 subjects examined by means of this non-invasive investigation demonstrates that it is a reasonably sensitive method. Its main applications are in the young symptomatic patient, mass surveys and the annual assessment of the 30-50-year age group.