Giant duodenal diverticulum: presentation by blunt trauma.

Most duodenal diverticula are asymptomatic, small (i.e., less than 5 cm in greatest dimension), acquired, extraluminal, and false. The only report of a massive or giant duodenal diverticulum (i.e., 10 cm or more), in the current literature, included severe nocturnal diarrhea. The present case report is the incidental finding of a massive duodenal diverticulum in a 34-year-old male trauma victim. The insidious nature of this case and the patient's age suggest a congenital etiology. We believe this is the first report of such a case.

Inferior vena caval filter use in U.S. trauma centers: a practitioner survey.

Questionnaires were mailed to 620 U.S. "trauma surgeons" to determine a consensus regarding indications for inferior vena caval (IVC) filter placement; 210 (34%) responded. Eighty-seven percent of respondents practiced in Level I trauma centers; 78% were in urban areas and 75% reported more than 1,000 trauma admissions per year. One-half (52%) of those responding were "trauma directors" at their centers. Filter insertion was done by radiologists at 81% of centers, by trauma surgeons at 34%, by vascular surgeons at 33%, and by general surgeons at 13%. Each month, 60% of trauma centers inserted zero or one filter, whereas 27% inserted two to three filters. Complications per year were reported as one or fewer in 85% of trauma centers. Respondents agreed that "absolute indications" for inserting IVC filters were pulmonary embolism while anticoagulated (93%), deep venous thrombosis present and anticoagulation contraindicated (89%), and free-floating ileofemoral thrombus by venogram (54%) and by duplex imaging (45%). "Relative indications" for placement were deep venous thrombosis by duplex imaging (41%) or by venogram (38%), spinal cord injury (40%), pelvic fractures (39%), multiple lower-extremity fractures (29%), concurrent cancer (19%), prolonged bed rest (14%), and obesity (10%). The permanent nature of the filter affected its rate of application. For example, potential removability would significantly (p < 0.01) increase prophylactic placement from 29 to 53% in the patient with multiple lower-extremity fractures. Only 12% considered sepsis and 10% young age as contraindications to IVC filter insertion. Contraindications and complications were few, yet frequency of use was surprisingly low. Radiologists insert the filter more than twice as often as surgeons.

Influence of HIV-infection risk on resident physicians.

PURPOSE: To determine the influence of the risk of contracting the human immunodeficiency virus (HIV) on the attitudes and behavior of resident physicians. METHOD: A 15-item questionnaire was sent in January 1994 to the 268 residents in the major specialty training programs at the three clinical campuses of the University of Medicine and Dentistry of New Jersey. The residents' responses about HIV were analyzed in light of their specialty, postgraduate-year level, and training location. Z-tests were used to determine the statistical significance of the responses, and Yates corrections were applied to all calculations. RESULTS: A total of 121 residents (45%) responded. These residents were similar demographically to the non-respondents. Fifty-one of the responding residents (42%, p < .02) reported that they tended to minimize performing invasive procedures on HIV-positive patients. A surprisingly high number-73 (60%, p < .005)-had been tested for HIV. Only 14 had sustained needle-stick injuries. The risk of HIV infection had not appreciably affected the residents' choices of specialty, but it did dampen their enthusiasm for the practice of medicine. It also influenced their choices of training location, with 34 (28%, p < .001) listing HIV as an important factor. Given the hypothetical situation that they themselves were infected with HIV, 89 (75%, p < .001) of the residents reported that they would not terminate their careers, but 70 (61%, p < .005) indicated that they would refrain from performing invasive procedures. CONCLUSION: The residents' responses show a high level of emotional stability as well as a practical acceptance of the reality of HIV in the workplace. The impact on resident physicians of HIV requires further attention by medical educators and program directors.

Cushing's syndrome in postburn children following intralesional triamcinolone injection.

Intralesional triamcinolone acetonide has been used extensively for the treatment of hypertrophic and keloid scars. Complications are few, usually being local skin color changes, prominent vascular markings, or subcutaneous atrophy. Cushing's syndrome following intralesional administration of triamcinolone acetate has only been described twice, both in adult patients. This paper reports on two pediatric cases of Cushing's syndrome following treatment of hypertrophic burn scars with intralesional triamcinolone acetonide. The first child, 10 years of age, was treated for hypertrophic burn scars of the back. The second child, age 21 months, was treated for hypertrophic burn scars of the face. In both, intralesional triamcinolone acetate therapy was initiated 3 months postburn injury and in neither child was the maximum recommended dose exceeded. In both children, Cushing's manifestations developed 1 to 2 weeks postinjection and resolved in 6 to 8 weeks with no treatment or permanent sequelae. Consultation with endocrinologists revealed no concurrent disease process. It appears that these two pediatric patients may have had a form of hypersensitivity to triamcinolone acetonide, as Cushing's syndrome was not the result of an overdose. In conclusion, intralesional triamcinolone acetonide should be used with an increased degree of caution in the pediatric population.

Metastatic endometrial carcinoma: rare cause of extrahepatic obstructive jaundice.

We report a very rare case of endometrial carcinoma causing extrahepatic bile duct obstruction. Management of this case and probable mechanism of spread are presented.

A rare association of fibromuscular dysplasia of the femoral artery with aneurysm and occlusion treated alternatively.

A unique case of fibromuscular dysplasia of the femoral artery with aneurysm and occlusion of the superficial femoral artery component is presented. This aneurysm was treated by dacron wrap. External dacron grafts have been previously reported and used with success in a variety of arterial aneurysms. The authors present their rationale and indication for its use in this unusual arterial problem.

Cost containment in the operating room: use of reusable versus disposable clothing.

The need for fiscal austerity has prompted the re-evaluation of many aspects of medical care. Recent events in the northeastern United States have caused an increased awareness of the need for environmental responsibility as well. With these considerations in mind, the costs incurred by the operating suites of two comparable teaching hospitals in New Jersey, one of which uses disposable operating room attire, were examined; the other employs reusable scrub suits and gowns. The reusable scrub suits and gowns resulted in a savings in excess of $100,000 compared to the center using disposables. The authors conclude that hospitals should re-evaluate their use of disposable operating room attire to reduce operating costs and the amount of medical waste generated.