Total thyroidectomy for management of thyroid disease.

Total thyroidectomy is a logical treatment for many patients with thyroid disease, including patients in whom the pathologic process requiring surgery involves both lobes of the thyroid or the risk of recurrence is a significant consideration, as in benign multinodular goiter, Graves' disease, and cancer. In earlier times the risks of extensive surgery and problems of adequate hormone replacement deterred surgeons from performing total thyroidectomy. However, as we enter the twenty-first century we are confident that the technical aspects of safe total thyroidectomy are established and that thyroid hormone replacement and monitoring are readily available and accurate. In the future total thyroidectomy is likely to be performed increasingly commonly for both benign and malignant disease.

Parathyroid cysts.

Parathyroid cysts are relatively uncommon. They may be non-functioning or associated with primary hyperparathyroidism. Three patients are presented, including one with a large mediastinal parathyroid cyst, and these cases illustrate the range of pathological and clinical features.

Quality of life as an outcome variable in oncology and surgery.

The major objective of all health interventions is to improve the quality of life. Assessment of the results of treatment for cancer has traditionally included tumour response, treatment toxicity, patient's physical performance status and length of survival. More recently, attempts have been made to incorporate quality of life assessment in oncology research and practice. The audit of surgical treatment includes the evaluation of process and outcome. Although prominence has often been given to the relatively readily identified negative features of operative mortality and complications, both positive and negative effects need to be assessed. Elective surgery may be intended to reduce the risk of future disease-specific mortality but it may be extremely difficult to establish whether this objective has been achieved. We therefore need to recognize that the main and legitimate aims of elective surgery are to relieve disability, discomfort and disfigurement. These are quality of life issues. Minimally invasive surgery and day surgery are examples of current practice where quality of life assessment is important in the thorough evaluation of their role. In this review the available methods of assessment of quality of life are examined and a case is made for their routine inclusion in the evaluation of treatment in oncology and surgery.

Why do levels of human welfare vary among nations?

This article investigates what factors explain the wide differences in human welfare among nations. Applying the theory of human need developed by Doyal and Gough, the authors construct a series of indicators of need satisfaction and use these to map contemporary national levels of welfare. They criticize past cross-national studies of welfare outcomes for using a single index of welfare, usually the Physical Quality of Life Index. A comprehensive model of national differences in need satisfaction is then developed. Seven theories are deployed and are tested against the evidence using path analysis, which permits different causal patterns to be simultaneously considered. The authors conclude that per capita incomes are only one of several factors explaining cross-national variations in need satisfaction: the degree of economic and political independence, the extent of democracy and human rights, the capacity and dispositions of the state, and relative gender equality all positively and independently affect a nation's level of welfare. Economic development alone cannot guarantee social development.

Do medical students remember multiple choice questions?

The values of pre-testing senior medical students at the start of their surgical terms are the perception that they acquire of the scope of the subject and the extra practice they gain in the technique of sitting multiple choice question (MCQ) exams. The purpose of this study was to determine whether MCQ in a pre-test that were repeated in a post-test were answered more accurately than questions that had not been repeated. For the past 3 years at the University of Queensland, fifth year medical students have been voluntarily sitting pre- and post-tests in each of the four surgical terms. Each examination consisted of 60 clinically oriented surgical questions of a difficulty appropriate for senior medical students. A total of 404 students did both the pre- and post-tests during 1990 and 1991. The two examinations were carefully chosen for comparability. Of the 60 questions in each examination, 30 were repeated in the post-test and 30 were fresh questions in the post-test. The pre- and post-tests were reversed for the second of the two years to increase consistency. There was a general improvement in the standard of results from the pre-test to the post-test. There was also a small improvement for the repeated questions compared to the non-repeated questions (P < 0.0001). The authors conclude that the marked improvement of the post-test compared to the pre-test is mostly attributable to the students increasing their knowledge base through learning during their surgical term.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer assisted diagnosis of the acute abdomen.

Computer assisted diagnosis (CAD) has been claimed to improve the accuracy of assessment of the acute abdomen. Alternative techniques that may improve decision making are briefly reviewed and CAD is examined critically. The structured collection of complete clinical data with performance feedback, results in improvements comparable to CAD. Computer systems are costly and when installed are used selectively and variably by clinicians. Their place in surgical practice remains to be established.

Malignant ascites. A comparison of peritoneovenous shunting and nonoperative management.

BACKGROUND: Effective palliation of malignant ascites remains a difficult management problem. METHODS: Eighty-five patients with malignant ascites were studied. Forty-two patients had peritoneovenous shunts (PVS) inserted (16 LeVeen, 17 single-valve Denver, 9 double-valve Denver). RESULTS: Shunt patency was not related to the type of shunt, type of cancer, or any characteristic of the ascitic fluid. Ascites was controlled in 64% of patients with shunts and serum albumin levels were preserved. Survival and quality of life were not significantly different in comparison with those of patients treated by abdominal paracentesis. CONCLUSIONS: PVS allowed many patients to be treated successfully outside the hospital and are indicated in carefully selected cases.

Metastatic carcinoid tumour: stability throughout pregnancy.

A patient with asymptomatic histologically proven extensive hepatic metastases of carcinoid tumour had no progression of disease for over 4 years without specific treatment. Throughout a normal pregnancy the hepatic metastases remained stable by clinical, computerized tomography and biochemical criteria.

What value is given to quality of life assessment by health professionals considering response to palliative chemotherapy for advanced cancer?

A study was designed to obtain information on the importance of quality of life assessment (QL) during palliative chemotherapy. A questionnaire was answered by 542 health professionals (392 general practitioners, 20 specialist oncologists, and 130 oncology nurses). In both simulated patient situations and multiple-choice questions, all groups rated QL higher than other standard methods of assessment. General practitioners and oncologists appeared to weight the assessment criteria more equally than nurses who gave strong emphasis to QL. In the simulated patient situation, there was a small degree of interaction between QL and other assessment criteria. However, the analysis showed that QL was regarded as an independent variable and was considered to be the most important objective of palliative chemotherapy for advanced cancer.

Aetiology of branchial cysts.

The aetiology of branchial cysts is unknown. It is possible that they arise by more than one mechanism. The major theories are that they originate either from the branchial apparatus or from lymphoid tissues. A retrospective review was conducted of 61 cases occurring over a recent 14-year period. Eighty-five percent were diagnosed after the age of 10 years, 80% occurred in the 'classical' position, 80% had a squamous epithelial lining and 87% had lymphoid tissue in the wall. The clinical and histological features strongly support the lymphoid aetiology theory for the majority of branchial cysts.

Long-term follow-up of patients with benign thyroid fine-needle aspiration cytologic diagnoses.

Reliance on fine-needle aspiration (FNA) of the thyroid as the key determinant whether to observe only or proceed surgically is predicated on achieving a minimal false-negative error rate (the incidence of malignant disease in nodules diagnosed benign by means of FNA). To provide convincing data that malignant disease has not been overlooked requires extended follow-up on a large number of patients with cytologically benign lesions. The intent of our study was to assess the long-term accuracy of thyroid FNA-based diagnoses--particularly with respect to false-negative errors. From our total experience of more than 8000 patients, we reviewed the cases of 680 patients who underwent FNA in 1980, the first year we used it clinically. Follow-up information was obtained on 641 (94%) of the patients with a mean time since FNA of 6.1 years. Benign cytologic findings were reported on 439 (68%) of these patients, and only three (0.7%) had false-negative diagnoses. The false-positive rate was 0% for the 24 (4%) patients with positive aspirates. FNA is a safe, reliable, effective means of accurately discriminating benign from malignant thyroid lesions.

Surgery for thyroglossal cysts: Sistrunk's operation remains the standard.

Surgical techniques for thyroglossal cysts still vary considerably. In this review, one-third of patients treated by simple cyst excision had recurrence and this operation cannot be recommended. There should be consensus that excision of the mid-portion of the hyoid bone be performed routinely. However, variations have been described in the syprahyoid dissection. The present review indicated that the classic Sistrunk operation provided the lowest rate of recurrence and should remain the standard procedure.

Chylous ascites in cirrhosis: a case report and review of the literature.

Chylous ascites is an uncommon clinical entity which results from the accumulation of fat, predominantly chylomicrons, in the ascitic fluid. Conventional treatment methods are unsatisfactory. A patient is reported with chylous ascites associated with cirrhosis and portal hypertension in whom the ascites, the renal insufficiency and the fluid and electrolyte disturbances were corrected by the insertion of a Denver peritoneovenous shunt.

Papillary thyroid carcinoma in children and adults: long-term follow-up of 1039 patients conservatively treated at one institution during three decades.

Fifty-eight children (18 boys, 40 girls) less than 17 years of age, undergoing initial surgery because of papillary thyroid carcinoma (PTC) at Mayo Clinic from 1946 through 1975 and followed up for a median time of 27.6 years were compared with 981 adults (323 men, 658 women) treated during the same period and followed up for a median period of 19.5 years. At initial evaluation, mean tumor size (+/- SD) was greater in children (3.1 +/- 1.7 cm) than in adults (2.1 +/- 1.7 cm) (p less than 0.001); tumor DNA content was nondiploid in 10% of 39 children and in 25% of 110 adults (p = 0.047). Neck node metastases at diagnosis were detected in more children (89.7%) than adults (34.7%) (p less than 0.0001), but extrathyroidal invasion was not significantly more frequent in children (24.1%) than adults (15.8%) (p = 0.095). Distant metastases at diagnosis were detected in more children (6.9%) than adults (2.1%) (p = 0.022). Postoperatively, neck node metastases recurred more frequently in children (30%) than in adults (7%) (p less than 0.001), but local neck recurrences were not significantly more frequent in children (12%) than in adults (5%) (p = 0.083). Postoperative distant metastases occurred with similar frequency in children (6%) and adults (5%) (p = 0.98). Survival (all causes of death) for both adults and children up to 30 years after the initial surgery was no different from expected survival rates. Only adults aged more than 40 years had a significantly higher mortality from PTC than did children (p less than 0.0001). Fourteen percent of children had died of PTC by 15 years after diagnosis of distant metastases, whereas 68% of similarly affected adults were dead at 15 years (p = 0.014). PTC was more often metastatic to neck nodes and lungs before initial surgery and more often recurrent in neck lymph nodes postoperatively. However, PTC tended to be less fatal in children, and this may be related to the infrequency of nondiploid DNA content in the childhood PTC tumors.