Asymptomatic carotid endarterectomy. Patient and surgeon selection

PURPOSE: The detection of an infraclinical primary by tonsillectomy in case of cervical lymph node of an epidermoid carcinoma with unknown primary after a radical neck dissection, allows avoiding irradiation of the normal larynx. The aim of this study is to quantify the rate of tonsil primary to justify this procedure. METHODS AND MATERIALS: From 1969 to 1992, 87 patients had a tonsillectomy as part of the workup for cervical nodal metastasis of an epidermoid carcinoma with unknown primary. The mean age was 57 years (range: 39-75 years) and the sex ratio was 8.6. Sixty-seven patients had a single cervical adenopathy (17 N1, 30 N2a, 5 N3, 15 Nx), and 20 patients multiple cervical adenopathies (17 N2b, 3 N2c). The treatments included always an irradiation to the node areas (50 Gy), and to the pharyngolarynx in case of normal tonsil (50 Gy), or to the tonsil if it was the primary (50 Gy with a brachytherapy boost of 20-25 Gy). In this last case, the larynx could be protected. RESULTS: Tonsillectomy never induced specific complication. Out of 87 patients, 26% had a tonsil primary. There was not specific histological differentiation in this group. In the 67 patients with a single cervical adenopathy, 31% had a tonsil primary (6 N1, 7 N2, 1 N3, 7 Nx). It was a subdigastric adenopathy in 38%, a submandibular in 28% and a midjugulocarotidian in 23%. Among the 17 patients N2b, none had a tonsil primary. In the three patients N2c, two presented a tonsil carcinoma (two subdigastric nodes). CONCLUSION: Tonsillectomy allows avoiding irradiation of normal larynx in 26% of patients who have a cervical lymph node with unknown primary. It should be performed in case of a single node of the subdigastric, midjugulocarotidian or submandibular area or bilateral subdigastric adenopathies.     

Off-label dermatologic therapies. Usage, risks, and mechanisms

Off-label refers to the prescribing of Food and Drug Administration-approved drugs for a use not indicated on the package insert. The prescribing of off-label drugs may benefit patients with many dermatologic diseases including angiogenesis-related conditions. We surveyed 55 dermatologists from a single large academic program to assess their use of particular drugs for specific skin conditions, their perception of such use as being for Food and Drug Administration-approved or for off-label indications, and their attitudes towards off-label therapies. The practice of prescribing off-label drugs was common among the respondents, many of whom had misperceptions about which conditions are Food and Drug Administration-approved indications and about the legal ramifications of off-label therapies. We suggest that understanding the principles of off-label prescribing in conjunction with the mechanisms of drug action in diseases may help clinicians exercise their judgment in finding innovative therapies for their patients.     

Biopsy of the skin. Thoughtful selection of technique improves yield

Skin biopsy can serve both diagnostic and therapeutic purposes. Site selection is not of major importance in the many types of lesions suggestive of malignancy but is crucial with diffuse eruptions. The shave technique is appropriate for many neoplastic lesions, while punch or incisional/excisional biopsy is necessary for more deeply invasive lesions. A variety of anesthetics are available to aid in patient comfort, as are a number of techniques for accomplishing the procedure to achieve the best cosmetic result.     

Managed care and the treatment of skin disease, 1995. Continued growth and emerging dominance

OBJECTIVE: To document changes in type of financing for office-based visits for the treatment of common skin conditions and to dermatologists. DESIGN: Data from a national survey of visits to office-based practitioners conducted by the National Center for Health Statistics were used. The stratified sampling technique permits estimation of the total number of office visits with specific characteristics in the United States. SETTING: A national probability sample of visits to office-based practitioners occurring in 1995. SUBJECTS: In 1995, 36,875 visits were sampled. Of these, 2121 were for common skin problems to any physician and 1886 were visits for any reason to dermatologists. MAIN OUTCOME MEASURES: The distribution source of payment and presence of managed care arrangements for office visits for common skin problems and to dermatologists. INTERVENTION: None. RESULTS: In 1995, preferred provider and health maintenance organizations provided payment for 34% of all ambulatory care and 38% of office visits for common skin complaints. CONCLUSION: Managed care is already the dominant mechanism of payment for the treatment of skin disease for many patient groups and in many areas of the country. Preferred provider organizations are much more likely to employ dermatologists to provide care of common skin problems than are health maintenance organizations. If the recent trends continue, by year 2000 most patients seen by dermatologists will be seen under the auspices of managed care systems.     

Medical care as physical injury from the viewpoint of the surgeon

The current criminal law regarding medical malpractice is based on the over 100 years old principle of personal injury, as defined in Section 223 of the criminal code. Attempts to revise this legislation have failed repeatedly in the past. The surgeon's duty of disclosure has gained pivotal importance, often being a handicap for differential surgical treatment. The lack of a specific criminal law regarding medical malpractice in combination with the theoretical construct of a surgical intervention as an authorized personal injury is disadvantageous for both patient and surgeon, since the surgeon is led to deny malpractice and therefore compensation by the liability insurance is not guaranteed. The threat with criminal penal for the surgeon which acted wrong but not gross negligent should be diminished by a definition of a specific criminal law on medical and surgical malpractice.     

E. Amory Codman, surgeon of the 1990s

Ernest Amory Codman is known to orthopaedists primarily for his work in shoulder surgery. But his contributions reached many other fields of medicine, including pathology, radiology, anesthesiology, and most surgical subspecialties. Perhaps his most important work was that on the "end result idea," an early approach to outcome studies that anticipated much of the current health-care climate. This article examines his life and explains his contributions to medicine and surgery and their pertinence to current practice.     

Wound and skin care for the PICU

The consequence of recognition of antigen on antigen-presenting cells that are induced to express major histocompatibility complex (MHC) class II molecules following an inflammatory process is still not clear. In this study, we have investigated the outcome of antigen presentation by epithelial cells and we have used as a model thyroid follicular cells (TFC) that are known to express MHC class II molecules in autoimmune thyroid diseases and acquire the capacity to present autoantigens to T cells infiltrating the thyroid gland. The result show that MHC class II-expressing TFC were unable to stimulate a primary T cell alloresponse, using CD4+ T cells from three HLA-mismatched responders. Phenotypic analysis showed that TFC, after incubation with interferon-gamma, do not express the costimulatory molecules B7-1 (CD80) and -2 (CD86). Addition of murine DAP.3 cells expressing human B7-1 (DAP.3-B7) to cultures containing peripheral blood CD4+ T cells and DR1-expressing TFC led to a proliferative response, suggesting that the failure of TFC to stimulate a primary alloresponse was due to a lack of co-stimulation. Similarly, HLA-DR-restricted, influenza-specific T cell clones dependent on B7 for co-stimulation did not respond to peptide presented by TFC; again the lack of response could be overcome by co-culture of TFC with DAP.3-B7. Furthermore, recognition of antigen on TFC inhibited interleukin-2 (IL-2) production in the B7-dependent T cells. In contrast, in T helper type 0 (Th0) T cells, IL-4 release was not affected by TFC presentation. In addition, antigen presentation by TFC favored IL-4 production relative to IL-2 production by B7-independent Th0 clones. These results suggest that antigen presentation by MHC class II+ TFC may induce tolerance in autoreactive Th1 cells but may simultaneously favors a Th2 response in uncommitted T cells, and thereby support autoantibody production.     

Improving postoperative care: the role of the surgeon in the high dependency unit

A number of attempts have been made to develop measures of severity of illness for patients in the intensive care unit (ICU), but the impact of these indices in a Respiratory Intensive Care Unit (RICU) has not really been studied. At present, outcome can be accurately predicted in approximately 85% of ICU patients, while no data are available for the RICU. These indices will be reviewed in the article. The sophisticated Mortality Probability Model (MPM) II is used to predict the outcome of ICU patients. This technique is based on statistically-derived weights for its variables. The "most popular" indices are the Acute Physiology and Chronic Health Education (APACHE), the Simplified Acute Physiological Score (SAPS) and the Therapeutic Intervention Scoring System (TISS). Overall, the predictive accuracy of the latest APACHE III equation and score is rather good, but there are important limitations concerning its use in the RICU. The SAPS includes 17 variables, and can be considered as a simplified version of APACHE sharing with it the same problems of application. The TISS requires data on approximately 70 treatment variables and assigns each a score ranging 1-4. A high score represents serious intervention, while a low score illness requires much less medical or nursing intervention. The sum of these scores indicates severity of illness because more critical patients are presumed to require higher levels of interventions. The RICU is also characterized by the use of noninvasive mechanical ventilation (NMV) in the treatment of acute respiratory failure. Some indices able to predict the success of NMV, have been developed recently during a brief trial of NMV, and included the level of acidosis and hypercapnia.     

Patient education by the surgeon. Judicial aspects, ethical aspects, deontologic aspects

AIM OF THE STUDY: The surgeon must inform his patient about eventual risks before any investigation with diagnosis purpose and before any therapeutic intervention. According to the decree of the first Civil chamber of the "Court of Cassation", the surgeon must be able to prove that this information has been given as required by the article 1315 of the civil code. This decree has created in France an important change in the relationship between surgeon and patient. The French Academy of Surgery has organized a special session to study this problem in terms of legal, ethical and deontological aspects. CONCLUSIONS OF THE ACADEMY: The Academy confirms the necessity to give information to the patients and suggests that the modalities of the information be prepared by the medical societies, the "Conseil National de l'Ordre des Médecins", eventually by ethical committees and legal organizations concerned with medical questions, in view of a common use in all French juridictions. According to the Academy, it is necessary to determine the limits of the information to be given to the patient concerning the most common risks and those with the most serious consequences, in order not to disturb him psychologically. The Academy wishes that necessary and sufficient means be indicated in order for the surgeon to be able to prove that the information has really been given.     

Use of autologous fibrin glue in dermatologic surgery: application of skin graft and second intention healing

OBJECTIVE: To evaluate the efficiency of biological sealant, an autologous fibrin glue, in dermatological surgery. DESIGN: Randomized clinical trial. SETTING: The Dermatology Service of Hospital das Clinicas, Universidade de Campinas (UNICAMP), referral center. PATIENTS: 14 patients with malign epithelial cutaneous tumors participated in the evaluation, each having two tumors, generally facial and symmetrical, in order to perform a comparative evaluation on the same individual. PROCEDURES: The glue was prepared beforehand with a sample of autologous blood. Surgical extirpation of the tumor was followed by grafts or second intention healing. OUTCOMES: The efficiency of the sealant was then evaluated in relation to hemostasis, adhesion, surgical time and evolution of the granulation tissue, clinically and histologically. RESULTS: Immediate hemostasis and graft adhesion, with a significant reduction of surgical time, and in the open wounds there was immediate hemostasis and a clinical increase in granulation tissue, but with no histological differences among the groups on the 7th day. CONCLUSION: It is an adjuvant resource in skin cancer surgery.     

Fluorescence with Wood's light. Current applications in dermatologic diagnosis, therapy follow-up and prevention

The invisible long-wave ultraviolet radiation (340-450 nm, max.365 nm) produced by a Wood lamp can help to diagnose dermatoses with a characteristic fluorescence (tinea capitis, erythrasma, tinea versicolor, Pseudomonas infections, porphyrians, and pigmentary alterations). It is also used in the detection of medications that are taken systemically (tetracycline) or that are applied to the skin. Recently, a fluorescence technique with Wood light has been used as a preventive measure to monitor and quantify skin protection at the workplace and to teach workers in high-risk occupations the proper use of protective creams.     

The ABC's of black hair and skin care

This paper identifies the physiological basis for hair and skin care of African-American children and adults. Culturally specific terms are included to assist readers from other cultures to understand and communicate with African-American clients. In addition to describing various hair styles used by African-Americans, products that can assist with caring for black hair and skin are also discussed. Black and African-American are used interchangeably.     

Personality measurement, faking, and employment selection.

Real job applicants completed a 5-factor model personality measure as part of the job application process. They were rejected; 6 months later they (n = 5,266) reapplied for the same job and completed the same personality measure. Results indicated that 5.2% or fewer improved their scores on any scale on the 2nd occasion; moreover, scale scores were as likely to change in the negative direction as the positive. Only 3 applicants changed scores on all 5 scales beyond a 95% confidence threshold. Construct validity of the personality scales remained intact across the 2 administrations, and the same structural model provided an acceptable fit to the scale score matrix on both occasions. For the small number of applicants whose scores changed beyond the standard error of measurement, the authors found the changes were systematic and predictable using measures of social skill, social desirability, and integrity. Results suggest that faking on personality measures is not a significant problem in real-world selection settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attributional style, task selection, and achievement.

In a study of causal attributions for achievement and their effects on task selection, it was found that 743 5th–12th graders who attributed their own success on achievement tasks to ability, effort, or luck preferred tasks that were compatible with such beliefs. Thus, students who generally attributed their achievement to ability were likely to prefer tasks in which competence was a requisite to outcome. Conversely, students who believed that success was largely a function of luck were likely to avoid ability tasks and prefer games of chance. This tendency was relatively unaffected by an immediate experience of success or failure at a task and generalized across age, sex, and urban–rural groups. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)