Does neck extension elevate the thyroid gland cephalad to potentially improve access during thyroidectomy?

BACKGROUND: Patients undergoing thyroidectomy are positioned with the neck extended to facilitate exposure of the neck. Computed tomography (CT) scanning of the thyroid, without i.v. contrast, is often used preoperatively to investigate the extent of large goitres. Currently, patients are scanned in the neutral position rather than the surgical position of neck extension. The aim of the present study was to determine the degree, if any, of movement of the thyroid, as measured by CT, achieved by neck extension. METHODS: A trial was designed using CT scanning of the neck. Fourteen patients were studied. Patients attended for the usual CT thyroid. In addition, they were then rescanned with their neck extended. The position of the inferior aspect of the gland in relation to the sternal notch was measured in both positions. The degree of neck extension was measured and correlated with the extent of thyroid gland movement. The data were analysed with the Wilcoxon signed rank test and Spearman correlation coefficients. RESULTS: Results showed a median difference between the two positions of 5 mm (P = 0.0002). CONCLUSION: The minimal cephalad movement of the thyroid achieved by neck extension, although statistically significant, is of doubtful clinical use, and overextension of the neck should be avoided because of its associated risks of pain, vomiting and spinal damage.

US graduate medical education, 2000-2001.

For the last three quarters of a century, the American Medical Association's national collection of graduate medical education (GME) data has evolved in its scope and methods. This year's GME survey involved new technology. The National GME Census for 2000-2001, jointly administered by the American Medical Association and the Association of American Medical Colleges, was part of an Internet-based product called GME Track. Because of technical problems, data collection was less complete than in previous years. Similar to the 1999-2000 survey, we observed an increase in the number of subspecialty programs, with 79 more than last year (2.1% increase), and a decrease in the number of specialty programs, with 40 (0.9%) fewer. Parallel to this continuing trend was a decrease in the number of graduates of US medical schools who were matched into primary care residencies, particularly family practice programs (20% decrease compared with 1996-1997). The number of graduates of osteopathic medical schools training in allopathic programs continued to rise, increasing 7.9% from last year. Numbers of Hispanic and Asian graduates from US allopathic medical schools (USMDs) in graduate year 1 (GY1) positions increased numerically to 887 and 2356, respectively, and proportionally by 7.2% and 17.3%, respectively. Although the number of white USMDs in GY1 positions increased, their proportion decreased slightly among those with known race or ethnicity from 72.2% to 71.7%, and the number of black USMD GY1 residents, numbering 859, declined from the previous year. Although we observed an overall decline in the average number of on-duty hours expected of residents in their first year in a program (from 55 in 1996-1997 to 54 in 2000-2001; P<.001), the average number of hours reported by the majority of programs that typically report the most on-duty hours did not decrease. The issues of resident work hours and the diversity and specialty distribution of the physician workforce continue to foster debate.

US graduate medical education, 1999-2000.

This report examines data collected through the American Medical Association Annual Survey of Graduate Medical Education Programs for 1999-2000 and compares these data with similar data collected during the past several years. The number of resident physicians enrolled during 1999-2000 was 606 more than during the previous year; graduates of US osteopathic medical schools (USDOs) had the greatest proportional increase (5.2%). The number of physicians entering graduate medical education (GME) for the first time in 1999-2000 (n = 22,320) also increased, with the number of USDOs increasing the most, by 14.5%, followed by international medical graduates (IMGs) at 6.5%. Between academic years 1998-1999 and 1999-2000, the number of physicians with prior US GME occupying first-year positions for which prior GME was not required (GY1 positions) increased by more than 300 (12%). Compared with graduates of US allopathic and osteopathic medical schools (USMGs), IMGs were more likely to seek additional training after graduating from a program. However, this was not true of IMGs who were US citizens or who had been naturalized or had permanent residency status. For the second year in a row, the number of white graduates of US allopathic medical schools (USMDs) entering GME has declined (2.0%), while the number of Hispanic GY1 USMDs has increased by 10.5%. The number of Asian GY1 USMDs increased steadily (11.0%) but the number of blacks decreased by 7.1% from 1998-1999. Growth continues, both in numbers and in heterogeneity of physicians in training, and must be considered in the future development of policy to guide US GME. JAMA. 2000;284:1121-1126

Evaluation of computer case simulations for teaching clinical pathology to second-year medical students.

A computer-assisted learning program for teaching clinical pathology to second year medical students has been developed and evaluated. These programs are designed to be used as supplements to formal lectures, laboratory exercises, and small group discussions. Students are given case histories and asked to select differential diagnoses, order and interpret laboratory and diagnostic tests, and make final diagnostic conclusions. In some cases, laboratory monitoring of treatment, e.g., drug therapy, is emphasized. The performance of the student is objectively evaluated during each stage. In addition, the amount spent for each workup is recorded with penalties given for excess or inappropriate test ordering. Separate evaluations are performed to assess the effectiveness of these programs as an alternative teaching format to (1) formal lectures and reading assignments, and (2) faculty-directed small group discussions. It is concluded that the computer-assisted learning method is equivalent to lectures and group discussions and is a format that is well accepted by students.

Leiomyomas in pregnancy.

Although the growth of uterine leiomyomas is influenced by estrogens, growth during pregnancy has been documented in only a small fraction of cases. Degeneration or torsion of a pedunculated leiomyoma can cause pain. The cesarean section rate is not increased. Pregnant patients with leiomyomas should be followed with serial ultrasound to document the location, size and growth of the tumors, as well as fetal growth. The majority of pregnancies in women with leiomyomas have good outcomes.

Immunologic and biologic evaluation of insulin degradation following prolonged storage in plastic syringes.

Insulin potency during storage in plastic disposable syringes for short periods of time is a concern of diabetics as well as syringe manufacturers. Previous studies have indicated that leaching of organic materials from rubber gaskets may have cytotoxic effects. The purpose of this study was to evaluate the immunologic and radioreceptor degradation of insulin storage in commercial plastic syringes. Insulin syringes were filled with insulin and stored at 4 degrees C for 2 weeks. Immunologic potency was assessed by radioimmunoassay while biologic potency was evaluated by binding to hepatic insulin receptors. Recoverable insulin was measured on days 1, 3, 7, and 14 and compared with highly purified porcine insulin. Insulin content of samples stored in all three plastic syringes showed no statistically significant (p less than 0.05) loss of immunologic or biologic potency for 2 weeks compared with stock controls. Lente insulin gave more variability in storage in the radioimmunoassay, possibly due to settling, and was less effective in displacing labeled insulin in the radioreceptor assay. We conclude that premeasured insulin may safely be stored in plastic disposable syringes under selected conditions, especially in blind and handicapped diabetic patients, for 2 weeks.

Reevaluation of neonatal Hemophilus influenzae infections.

Hemophilus influenzae infections are increasing in frequency in the general population. As a result this organism must be considered an etiologic agent of disease in the neonate. Proper culture technics must be routinely employed to isolate this fastidious organism, and appropriate antimicrobial therapy must be instituted in infants suspected of having sepsis or meningitis. Three cases of H influenzae infection occurring in neonates are presented.

Acute yellow phosphorus poisoning. "Smoking stool syndrome".

Three cases of acute phosphorus poisoning are reported. The source of this poison was a rodenticide, which may be in more common use presently because of the increasing resistance of rodents to warfarin derivatives. The safest method of managing poisoning from this highly toxic substance is prevention. Two of the patients had a history of previous medicine overdose.