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Iodine Research
Our data suggest a complex relationship between iodine nutrition and thyroid tumorigenesis. Factors such as a long latency between changes in iodine nutrition and thyroid tumorigenesis, a dose threshold for the effect of iodine ..... Iodine also reduces thyroid cellularity and vascularity and therefore is used in the preparation of the patient for thyroidectomy. Finally, by exploiting the failure of escape from the Wolff-Chaikoff effect, iodine may also be used in the ...
thyroid cancer and the liver
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KIDNEY AND PANCREAS TRANSPLANTATION
CONTROVERSIES
13. Is HLA (human leukocyte) matching still important?
Show answer
It is somewhat important. Historically, HLA matching was an important consideration when matching cadaver kidneys to recipients. With today’s improved immunosuppressive agents, many transplant surgeons believe that HLA matching is no longer critical. Six antigen match kidneys are still shared nationally and do enjoy some improvement in long-term graft survival. Donor organ quality remains the primary determinant in how well the transplanted organ functions. For example, a poorly matched living-donor kidney will still usually outlast a well-matched cadaveric kidney.
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Basic Care Of Hand Injuries
34 BASIC CARE OF HAND INJURIES
Michael J.V. Gordon M.D., Lawrence L. Ketch M.D.
1. What are the goals of hand repair?
Show answer
Functional considerations override cosmesis in the treatment of hand trauma. There are no minor hand injuries. Initial diagnosis and management determine the final result; expert secondary repair cannot overcome primary errors in diagnosis or decision making.
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Queries 2
Hyperthyroidism
58 HYPERTHYROIDISM
Robert C. McIntyre Jr., M.D.
1. What are the symptoms and signs of hyperthyroidism? Show answer
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General:
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Heat intolerance, perspiration, flushing, tremor, sleep disturbance
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Psychological:
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Nervousness, emotional lability, anxiety, aggressiveness, delusions
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Cardiovascular:
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alpitations, tachycardia, supraventricular dysrhythmias
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Respiratory:
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Breathlessness, hoarseness
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Gastrointestinal:
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Increased appetite, weight loss, increased frequency of bowel movements
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Reproductive:
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Gynecomastia, irregular menses
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Bone:
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Osteoporosis
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Other:
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Ophthalmopathy, dermopathy
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2. What causes hyperthyroidism?
Incoming search terms
dexamethasone guideline hypertyroid,Thyroid Nodules & Cancer
59 THYROID NODULES AND CANCER
Robert C. McIntyre Jr., M.D.
1. What is the prevalence of thyroid nodules and cancer?
Show answer
Thyroid nodules increase throughout life. Nodules are four times more common in females than in males, and 50% of 50-year-old women have a palpable nodule. After exposure to radiation, nodules develop at approximately 2% annually, reaching a peak at 25 years. Nodules are 10 times more frequent in glands examined by ultrasound, at surgery, or at autopsy. Fewer than 50% of thyroid nodules that appear solitary on physical examination are truly solitary.
Each year in the United States, there are approximately 15,000 new cases and 1000 deaths due to thyroid cancer. Up to 35% of thyroid glands examined at autopsy contain occult papillary cancer (< 1.0 cm).
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8 NUTRITIONAL ASSESSMENT AND ENTERAL NUTRITION
Margaret M. McQuiggan M.S., R.D., CNSD, Frederick A. Moore M.D.
NUTRITIONAL ASSESSMENT
1. What does a nutritional assessment include? Show answer
Incoming search terms
chilocalorie diprivan,Nutritional Assessment & Enteral Nutrition. Enteral Nutrition
ENTERAL NUTRITION
10. When should enteral nutrition be considered?
Show answer
Always, but especially when a patient is unlikely to meet > 70% of nutritional needs by mouth. Patients who have sustained major head injury (Glasgow Coma Scale score < 8), major torso trauma, major trauma to the pelvis and long bones, or major chest trauma benefit from enteral nutrition. Approximately 85% of postoperative patients (even those undergoing gastrointestinal [GI] surgery) tolerate early enteral feeding (within 24 hours).
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Top 100 Secrets
These secrets are 100 of the top board alerts. They summarize the concepts, principles, and most salient details of surgical practice.
- Clinical determinants of brain death are the loss of the
papillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and
respiratory reflexes for > 6 hours. The patient should also undergo
an apnea test, in which the pCO2 is allowed to rise to at
least 60 mmHg without coexistent hypoxia. The patient should be
observed for the absence of spontaneous breathing. - The estimated risks of HBV, HCV, and HIV transmission by
blood transfusion in the United States are 1 in 205,000 for HBV, 1 in
1,935,000 for HCV, and 1 in 2,135,000 for HIV. - The most common location of an undescended testicle is the
inguinal canal. - The most common solid renal mass in infancy is a congenital
mesoblastic nephroma and in childhood a Wilms’ tumor. - Ogilvie’s syndrome is acute massive dilatation of the cecum
and the ascending and transverse colon without organic obstruction. - The best screening method for prostate cancer is digital
rectal exam combined with serum prostate-specific antigen. - The most common histologic type of bladder cancer is
transitional cell carcinoma. - Carcinoma in situ of the bladder is treated with
immunotherapy with intravesical bacillus Calmette-Guérin. - Localized renal cell carcinoma is treated with surgery
(radical nephrectomy). - The most common cause of male infertility is varicocele.
- The most common nonbacterial cause of pneumonia in
transplant patients is cytomegalovirus. - Chimerism is leukocyte sharing between the graft and the
recipient so that the graft becomes a genetic composite of both the
donor and the recipient. - OKT3 is a mouse monoclonal antibody that binds to and
blocks the T-cell CD3 receptor. - The most common disease requiring liver transplant is
hepatitis C. - Cystic hygroma is a congenital malformation with a
predilection for the neck. It is a benign lesion that usually presents
as a soft mass in the lateral neck. - In neuroblastomas, age at presentation is the major
prognostic factor. Children younger than 1 year have an overall
survival rate > 70%, whereas the survival rate for children older
than 1 year is < 35%. - The most feared complication of diaphragmatic hernia is
persistent fetal circulation. - The three most common variants of tracheoesophageal fistula
are (1) proximal esophageal atresia with distal tracheoesophageal
fistula, (2) isolated esophageal atresia, and (3) tracheo-esophageal
fistula with esophageal atresia. - Atresia can occur anywhere in the GI tract: duodenal (50%),
jejunoileal (45%), or colonic (5%). Duodenal atresia arises from
failure of recanalization during the 8th-10th week of gestation;
jejunoileal and colonic atresia are caused by an in utero mesenteric
vascular accident. - The types of aortic dissection are ascending (type A)
dissection, which involves only the ascending or both the ascending and
descending aorta, and descending dissection (type B), which involves
only the descending aorta. - A solitary pulmonary nodule is < 3 cm and is discrete on
chest radiograph. It is usually surrounded by lung parenchyma. - Mediastinal staging is indicated in patients with apparent
or documented lung cancer who have (1) known lung cancer with
mediastinal nodes > 1 cm accessible by cervical mediastinal
exploration, as assessed by CT scan; (2) adenocarcinoma of the lung and
multiple mediastinal lymph nodes < 1 cm; (3) central or large (>5 cm) lung cancers with mediastinal lymph nodes < 1 cm; and (4) lung
cancer with risk of thoracotomy and lung resection. - The most common causes of aortic stenosis are now
congenital anomalies and calcific (degenerative) disease. - In mitral regurgitation, the left ventricle ejects blood
via two routes: (1) antegrade, through the aortic valve, or (2)
retrograde, through the mitral valve. The amount of each stroke volume
ejected retrograde into the left atrium is the regurgitant fraction. To
compensate for the regurgitant fraction, the left ventricle must
increase its total stroke volume. This ultimately produces volume
overload of the left ventricle and leads to ventricular dysfunction. - The indications for CABG are (1) left main coronary artery
stenosis; (2) three-vessel coronary artery disease (70% stenosis) with
depressed left ventricular (LV) function or two-vessel coronary artery
disease (CAD) with proximal left anterior descending (LAD) involvement;
and (3) angina despite aggressive medical therapy. - Hibernating myocardium is improved by CABG. Myocardial
hibernation refers to the reversible myocardial contractile function
associated with a decrease in coronary flow in the setting of preserved
myocardial viability. Some patients with global systolic dysfunction
exhibit dramatic improvement in myocardial contractility after CABG. - The surgical treatment of ulcerative colitis is total
colectomy with ileoanal pouch anastomosis. - Dieulafoy’s ulcer is a gastric vascular malformation with
an exposed submucosal artery, usually within 2-5 cm of the
gastroesophageal junction. It presents with painless hematemesis, often
massive. - The role of blind subtotal colectomy in the management of
massive lower gastrointestinal bleeding is limited to a small group of
patients in whom a specific bleeding source cannot be identified. The
procedure is associated with a 16% mortality rate. - Colorectal polyps < 2 cm have a 2% risk of containing
cancer, 2 cm polyps have a 10% risk, and polyps > 2 cm have a cancer
risk of 40%. Sixty percent of villous polyps are > 2 cm, and 77% of
tubular polyps are < 1 cm at the time of discovery. - Patients with colorectal cancer with lymph node involvement
(Dukes’ C) should receive chemotherapy postoperatively to treat
micrometastases. - Goodsall’s rule states the location of the internal opening
of an anorectal fistula is based on the position of the external
opening. An external opening posterior to a line drawn transversely
across the perineum originates from an internal opening in the
posterior midline. An external opening, anterior to this line,
originates from the nearest anal crypt in a radial direction. - Incarcerated inguinal hernia: structures in the hernia sac
still have a good blood supply but are stuck in the sac because of
adhesions or a narrow neck of the hernia sac. Strangulated inguinal
hernia: hernia structures have a compromised blood supply because of
anatomic constriction at the neck of the hernia. - Chvostek’s sign is spasm of the facial muscles caused by
tapping the facial nerve trunk. Trousseau’s sign is carpal spasm
elicited by occlusion of the brachial artery for 3 minutes with a blood
pressure cuff. - The two surgical options for Graves’ disease are subtotal
thyroidectomy or near-total thyroidectomy. - The only biochemical test that is routinely needed to
identify patients with unsuspected hyperthyroidism is serum
thyroid-stimulating hormone concentration. - The surgically correctable causes of hypertension are
renovascular hypertension, pheochromocytoma, Cushing’s syndrome,
primary hyperaldosteronism, coarctation of the aorta, and unilateral
renal parenchymal disease. - The “triple negative test” or “diagnostic triad” for
diagnosing a palpable breast mass includes physical examination, breast
imaging, and biopsy. - Chest wall radiation is indicated after mastectomy in
patients with greater than 5 cm primary cancers, positive mastectomy
margins, or more than four positive lymph nodes, all of which are
associated with heightened locoregional recurrence rates. - Sentinel lymph nodes are the first stop for tumor cells
metastasizing through lymphatics from the primary tumor. - The most common site of origin of subungual melanomas is
the great toe. Amputation at or proximal to the metatarsal phalangeal
joint and regional sentinel lymph node biopsy are advised by most
authors. - Ramus marginalis mandibularis, the lowest branch of the
nerve that innervates the depressor muscles of the lower lip, is the
most commonly injured facial nerve branch during parotidectomy. - Waldeyer’s ring is the mucosa of the posterior oropharynx
covering a bed of lymphatic tissue that aggregates to form the
palatine, lingual, pharyngeal, and tubal tonsils. These structures form
a ring around the pharyngeal wall. This may be the site of primary or
metastatic tumor. - A patient in whom the head and neck examination is
completely normal but FNA of a cervical node reveals squamous cancer
should have examination of the mouth, pharynx, larynx, esophagus, and
tracheobronchial tree under anesthesia (triple endoscopy). If nothing
is seen, blind biopsy of the nasopharynx, tonsils, base of tongue, and
pyriform sinuses should be done at the same sitting. - The microorganisms implicated in atherosclerosis include Chlamydia
pneumoniae, Helicobacter pylori, streptococci, and Bacillus
typhosus. - The cumulative 10-year amputation rate for claudication is
10%. - The absolute reduction in risk of stroke is 6% over a
5-year period in asymptomatic patients with > 60% stenosis who
undergo carotid endarterectomy plus aspirin versus patients treated
with aspirin alone (5.1% versus 11%). - Abdominal aortic aneurysm’s average expansion rate is 0.4
cm/year. - Heparin binds to antithrombin III, rendering it more
active. - The patient with suspected intermittent claudication should
initially be evaluated by obtaining ankle brachial index or segmental
limb pressures at rest. - Shock is suboptimal consumption of O2 and
excretion of CO2 at the cellular level. - Nitric oxide is synthesized in vascular endothelial cells
by constitutive nitric oxide synthase and inducible NOS, using arginine
as the substrate. - Saliva has the hightest potassium concentration (20 mEq),
followed by gastric secretions (10 mEq), then pancreatic and duodenal
secretions (5 mEq). - Basal caloric expenditure = 25 kcal/kg/day with a
requirement of approximately 1 g protein/kg/day. - 6.25 g of protein contains 1 g of nitrogen.
- Dextrose has 3.4 kcal/g, protein 4 kcal/g, fat 9 kcal/g
(20% lipid solution delivers 2 kcal/mL). - Maximal glucose infusion rates in parenteral formulas
should not exceed 5 mg/kg/min. - Refeeding syndrome occurs in moderately to severely
malnourished patients (e.g., chronic alcoholism or anorexia nervosa)
who, upon presentation with a large nutrient load, develop clinically
significant decreases in serum phosphorus, potassium, calcium, and
magnesium levels. Hyperglycemia is common secondary to blunted insulin
secretion. ATP production is mitigated, and the classic presentation is
respiratory failure. - Glutamine is the most common amino acid found in muscle and
plasma. Levels decrease after surgery and physiologic stress. Glutamine
serves as a substrate for rapidly replicating cells (interestingly, it
is also the number one metabolic substrate for neoplastic cells),
maintains the integrity and function of the intestinal barrier, and
protects against free radical damage by maintaing GSH levels. Glutamine
is unstable in IV form unless linked as a dipeptide. - Fever is caused by activated macrophages that release
interleukin-1, tumor necrosis factor, and interferon in response to
bacteria and endotoxin. The result is a resetting of the hypothalamic
thermoregulatory center. - Cardiac output = heart rate x stroke volume; normal CO is
5-6 L/min. - SVR = [(MAP - CVP)/CO] x 80; normal SVR is 800-1200
dyne.sec/cm-5. - Hypovolemic shock: low CVP and PCWP, low CO and SVO2,
high SVR. - Cardiogenic shock: high CVP and PCWP, low CO and SVO2,
variable SVR. - Septic shock: low or normal CVP and PCWP, high CO
initially, high SVO2, low SVR. - Kehr’s sign is concurrent LUQ and left shoulder pain,
indicating diaphragmatic irritation from a ruptured spleen or
subdiaphragmatic abscess. Anatomically, the diaphragm and the back of
the left shoulder enjoy parallel innervation. - Rebound tenderness implies peritoneal inflammation and
irritation not simply abdominal tenderness. - The 5 Ws of post-operative fever are wound
(infection), water (UTI), wind (atelectasis,
pneumonia), walking (thrombophlebitis), and wonder
drugs (drug fevers). - Cricothyroidotomy should not be performed in
patients < 12 years old or any patient with suspected direct
laryngeal trauma or tracheal disruption. - The radial (wrist) pulse estimates SBP > 80 mmHg;
femoral (groin) pulse estimates SBP > 70 mmHg; and carotid (neck)
pulse estimates SBP > 60 mmHg. - A general rule for crystalloid infusion to replace blood
loss is a 3:1 ratio of isotonic crystalloid to blood. - Raccoon eyes (periorbital ecchymosis) and Battle’s sign
(mastoid ecchymosis) are clinical indicators of basilar skull fracture. - CPP = MAP – ICP. Some debate exists on the minimum
allowable CPP, but consensus indicates that a cerebral perfusion
pressure of 50-70 mmHg is necessary. - Violation of the platysma defines a penetrating neck wound.
- Tension pneumothorax is air accumulation in the pleural
space eliciting increased intrathoracic pressure and resulting in a
kinking of the SVC and IVC that compromises venous return to heart. - The most common site of thoracic aortic injury in blunt
trauma is just distal to the take-off of the left subclavian artery. - The most common manifestation of blunt myocardial injury is
arrhythmia. - Indications for thoracotomy in a stable patient with
hemothorax include an immediate tube thoracostomy output of > 1500
mL and ongoing bleeding of 250 mL/h for 4 consective hours. - Beck’s triad is hypotension, distended neck veins, and
muffled heart sounds. - The hepatic artery supplies approximately 30% of blood flow
to the liver while the portal vein supplies the remaining 70%. The
oxygen delivery, however, is similar for both at 50%. - The Pringle maneuver is a manual occlusion of the
hepatoduodenal ligament to interrupt blood flow to the liver. - Splenectomy significantly decreases IgM levels.
- 90% of trauma fatalities due to pelvic fractures are due to
venous bleeding and bone oozing; only 10% of fatal pelvic bleeding from
blunt trauma is arterial (most common site is superior gluteal artery). - Intraperitoneal bladder rupture from blunt trauma:
operative management; extraperitoneal rupture: observant management. - Pseudoaneurysm is a disruption of the arterial wall leading
to a pulsatile hematoma contained by fibrous connective tissue (but not
all three arterial wall layers, which defines a true aneurysm). - The earliest sign of lower extremity compartment syndrome
is neurologic in the distribution of the peroneal nerve with numbness
in the first dorsal webspace and weak dorsiflexion. - Posterior knee dislocations are associated with popliteal
artery injuries and are an indication for angiography. - Management of suspected navicular fracture despite negative
radiography is short-arm cast and repeat x-ray in 2 weeks; at high risk
for avascular necrosis. - Parkland formula: lactated Ringer’s at 4 mL/kg x %TBSA
(second- and third-degree only) of burn. Infuse 50% of volume in first
8 hours and the remaining 50% over the subsequent 16 hours. - The metabolic rate peaks at 2.5 times the basal metabolic
rate in severe burns > 50% TBSA. - Gallstones and alcohol abuse are the two main causes of
acute pancreatitis. - Alcohol abuse accounts for 75% of cases of chronic
pancreatitis. - Isolated gastric varices and hypersplenism indicate splenic
vein thrombosis and are an indication for splenectomy. - The treatment for gallstone pancreatitis is cholecystectomy
and intraoperative cholangiogram during the same hospital stay once the
pancreatitis has subsided. - Proton pump inhibitors irreversibly inhibit the parietal
cell hydrogen ion pump. - Definitive treatment of alkaline reflux gastritis after a
Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm
efferent jejunal limb. - Cushing’s ulcer is a stress ulcer found in critically ill
patients with central nervous system injury. It is typically single and
deep, with a tendency to perforate. - Curling’s ulcer is a stress ulcer found in critically ill
patients with burn injuries. - Marginal ulcer is an ulcer found near the margin of
gastroenteric anastomosis, usually on the small bowel side. - The most common cause of small bowel obstructions is
adhesive disease; the second most common cause is hernias.
Prostate Cancer
97 PROSTATE CANCER
Brett B. Abernathy M.D.
1. How common is prostate cancer?
Show answer
It is the most common malignancy diagnosed in men in the United States; almost 200,000 new cases were diagnosed in 2001.
Read more
Incoming search terms
polascik urology 1998 51:884-890,Dissecting Aortic Aneurysm. Controversies
CONTROVERSIES
13. Which is preferred: surgical or medical management of descending dissections?
Show answer
* Initial surgical managementApproximately 25% of patients initially treated medically need an operation eventually.
* Operative mortality is much lower today (20%) than in the past.
* Medical management has the same in-hospital mortality (20%).
* Initial medical managementThis avoids unnecessary operation and its attendant cost and complication rate.
Read more
What Is Cancer. Controversy
CONTROVERSY
24. Is axillary lymph node treatment for breast cancer of therapeutic value, or does it merely help select patients who should receive chemotherapy?
Inflammatory Bowel Disease
50 INFLAMMATORY BOWEL DISEASE
Anthony J. LaPorta M.D., Gilbert Hermann M.D.
1. What two clinical entities encompass the diagnosis of inflammatory bowel disease?
Show answer
Crohn’s disease and ulcerative colitis (acute or chronic).
2. Although the two diseases often overlap, they usually can be distinguished by clinical criteria. What are the major clinical differences?
Show answer
Rectal bleeding is unusual in Crohn’s disease but common in chronic ulcerative colitis. An abdominal mass and anal complications (fissure, fistula) are more common in Crohn’s disease.
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Coronary Artery Disease. Controversies
CONTROVERSIES
15. Is there an advantage to surgical revascularization with all arterial conduits?
Show answer
The logical extension of the observation that an internal mammary artery has superior patency to a saphenous vein has sparked an interest in total arterial revascularization. Instead of using saphenous veins as bypass conduits, some surgeons also use the right internal mammary artery, the gastroepiploic artery, and the radial artery as bypass conduits instead of vein. Convincing data suggest a survival benefit as well as freedom from angina when the LIM artery is used as a conduit. The data supporting total arterial revascularization are much less clear.
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MITRAL REGURGITATION
76 MITRAL REGURGITATION
David A. Fullerton M.D., Glenn J.R. Whitman M.D.
1. List the causes of mitral regurgitation.
Show answer
* Rheumatic fever
* Endocarditis
* Ruptured chordae tendineae
* Senile mitral annular calcification
* Papillary muscle dysfunction from ischemia
* Annular dilatation from left ventricular dilation
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Parental Nutrition. Cotroversies
CONTROVERSIES
20. Does preoperative TPN enhance surgical outcome?
Show answer
It is well documented that malnourished patients are at an increased risk for septic complications, problems with wound healing, longer hospital stays, and increased mortality. However, nutritional status may be a reflection of the severity of disease. Results of studies evaluating preoperative TPN and outcome are variable. Preoperative TPN may decrease the rate of postoperative complications, but not mortality, in moderately malnourished patients with GI cancers. When malnourished GI cancer patients were fed high-kilocalorie TPN only after surgery, complication rates increased. Perioperative enteral nutrition may lower postoperative complications in patients with a variety of cancers. Provision of immune-enhancing diets, when adequately tolerated, may decrease complications and reduce length of hospital stays after surgical resection of upper GI cancer. In elderly, underweight women with hip fractures, supplemental enteral feedings increase functional status, reduce complications, and decrease length of stay. After major abdominal surgery, early enteral nutrition reduces complications, especially wound infection. Further research is needed in homogenous patient populations using current level of feeding practice and glycemic control in order to determine the impact on outcome of perioperative nutritional support.
Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
