Biomedical subjects
Publications and source records attributed to V Velanovich.
Gastric vascular ectasias are rare lesions of the gastric antrum that may be the cause of iron deficiency anemia in the elderly. We report a case of proximal gastric vascular ectasias in a young man which caused rapidly fatal hemorrhage. This case is instructive because of the patient's youth, the location of the lesions, and the rapidly fatal hemorrhage.
The increased use of screening mammography has led to increased pressure to differentiate between benign and malignant lesions. Even those lesions considered "suspicious" by qualitative radiologists' interpretations may prove malignant in less than 30% of cases. Fractal analysis is a mathematical technique that quantifies complex shapes. The hypothesis tested is that fractal analysis can quantify the difference between the shapes of benign and malignant lesions as imaged by mammography. Ten mammograms from patients with biopsy-proven invasive ductal carcinoma and 10 mammograms from patients with biopsy-proven benign disease were compared using the box-counting technique of fractal analysis. The fractal dimension of the mediolateral and craniocaudal views were added together to derive the composite fractal dimension. Statistical analysis was done using the Mann-Whitney U test. The median composite fractal dimension for benign lesions was 1.831 (range 1.359-2.009) and for malignant lesions 2.477 (range 2.084-3.158) (P < 0.0001). In addition, all benign lesions had fractal dimensions < or = 2.009, and all malignant lesions had fractal dimensions > or = 2.084. In this sample of 10 mammograms of malignant lesions versus 10 mammograms of benign masses, the composite fractal dimension was perfectly discriminatory. Fractal analysis may be useful to evaluate mammographically discovered breast masses. A blinded, prospective trial will be needed to determine its ultimate usefulness.
Helicobacter pylori has been recognized as a contributing factor in gastrointestinal disease. Yet, questions remain as to its clinical significance. This prospective study was done to determine the prevalence, distribution, clinical significance, and treatment response of H. pylori gastrointestinal infection. A total of 91 patients with upper gastrointestinal symptoms underwent 122 esophagogastroduodenoscopies (EGD). Biopsies were taken for H. pylori from the gastric fundus, body, antrum, prepylorus, and duodenal bulb; 45.3 per cent of patients with abdominal pain, 27.8 per cent with "heartburn," and 55.6 per cent with anemia/GI bleed had H. pylori infections. Pertaining to EGD findings: 54.2 per cent of patients with gastroduodenal ulcer, 56.4 per cent with gastritis/duodenitis, 37.5 per cent with esophagitis/esophageal ulcer, but only 17.6 per cent with normal findings had H. pylori infection. The distribution of H. pylori: fundus (53.3%); body (55.6%); antrum (85.4%); prepylorus (78.4%); duodenum (15.6%). Treatment for H. pylori was amoxicillin, metronidazole, colloid bismuth with an antisecretory drug. H. pylori was eradicated in 78.9 per cent of patients; 93.3 per cent of these patients had symptomatic improvement and/or ulcer healing. Using stepwise logistic regression, H. pylori eradication was an independent predictor of symptomatic improvement.
Recent health care reform proposals have emphasized the need for "generalists" over "specialists." Particularly targeted are the "surgical specialties." If much of this reform comes to pass, this may leave patients for whom the only surgical care may come from the general surgeon. In this setting, opportunities exist for the general surgeon to provide services that now are claimed by surgical specialists. This study reports the outcome experience of one general surgeon providing one such procedure, reduction mammoplasty, to a beneficiary population. Over a 26 month period, 50 reduction mammoplasties were performed. An average of 1527 grams of breast tissue were removed from each patient. There were no episodes of nipple necrosis or other complications requiring reoperation. At 1-26 months follow-up, all patients had relief of presenting symptoms, 90 per cent of patients had normal nipple sensation; all patients were satisfied with the results and would have the operation again by the same surgeon. These results show that a motivated and well-trained general surgeon can provide specialty surgical care to a potentially underserved population. General surgeons should be allowed to develop and practice the full range of skills they will need to take advantage of the opportunities that will be available to the surgical "generalist."
Angiomyxomas are a group of relatively rare mesenchymal myxoid tumors. There are three types: superficial angiomyxoma, aggressive angiomyxoma, and angiomyofibroblastoma. These tumors have a predilection for occurring in the perineum of middle aged females. The youngest reported case was in a 4-year-old female. The youngest male patient was 8 years old. This report presents a case of a 2-year-old male with a groin superficial angiomyxoma mimicking an inguinal hernia. Wide local excision was performed without recurrence at 3-month follow-up. The clinical and pathologic characteristics of this group of tumors are discussed.
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BACKGROUND: Treatment of uncomplicated gastroesophageal reflux disease (GERD) is primarily to improve the symptoms of the patient. However, measurement of symptomatic outcome is difficult because it is as the patient perceives it to be and not "objective." This creates a need to develop a simple and understandable instrument to measure symptomatic outcome. STUDY DESIGN: All patients referred for evaluation of GERD were eligible for this prospective study. During the initial visit, patients were asked to complete the Gastroesophageal Reflux Data Sheet. This ten-item questionnaire included an overall assessment of satisfaction; the best possible score was 0, and the worst was 45. The evaluation included history, physical examination, and additional studies, including upper gastrointestinal series, esophagogastroduodenoscopy, esophageal manometry, and 24-hour esophageal pH monitoring as indicated. Initial treatment was medical with histamine2-blockers, omeprazole, cisapride, or both. If a patient was dissatisfied with medical treatment and had both a hypotensive lower esophageal sphincter and abnormal results of the 24-hour pH monitoring, then operative treatment with either laparoscopic or open Nissen or Toupet fundoplication was offered. After approximately three months of medical treatment or one month after operative treatment, patients were asked to complete the questionnaire again. Data were analyzed using nonparametric tests and linear regression analysis. RESULTS: A total of 72 patients were assessed, and 100 percent of them completed the questionnaire. Patients who were satisfied with their condition had a median health-related quality of life (HRQL) score of five, and those who were dissatisfied had a median score of 26 (p < 0.000001). Patients who ultimately chose surgical therapy had a median preoperative score of 28, compared with 15 for patients who chose to continue medical therapy (p = 0.0001). The change in HRQL score from before treatment to after treatment for surgical patients was 27 compared with 11 for medically treated patients (p < 0.002). Items 1 through 6 of the questionnaire were individually sensitive to the effects of treatment. However, there was no correlation between HRQL and the composite pH score or with the lower esophageal sphincter pressure. CONCLUSIONS: This HRQL score has advantages over standard health status instruments for GERD including simplicity for patients (and therefore a high compliance rate), ease of understanding for physicians, and sensitivity to the effects of treatment. In addition, it may help determine, early in the course of treatment, patients who may ultimately require surgical therapy, thereby avoiding prolonged, but futile, medical therapy.
Helicobacter pylori has been recognized as a contributing factor in gastrointestinal disease. A prospective study was done to evaluate the treatment response of H. pylori nonulcer dyspepsia versus H. pylori-associated gastroduodenal ulcer. Eighty patients were prospectively studied with esophagogastroduodenoscopy. The presence of H. pylori was determined by biopsy. Treatment for H. pylori was amoxicillin, metronidazole, and colloid bismuth with an anti-secretory drug. H. pylori was eradicated in 78.9% of patients. Eighty percent of patients with nonulcer dyspepsia symptomatically improved, compared to 100% of ulcer patients (p = 0.037). Using stepwise logistic regression, H. pylori eradication was an independent predictor of symptomatic improvement. Therefore, this antibiotic regimen was less likely to lead to improvement in patients with nonulcer dyspepsia; however, patients in whom the organism could be eradicated were more likely to benefit.
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BACKGROUND: The increased usage of screening mammography has led to an increase in the number of needle localized breast biopsies. The perceived low yield of the biopsies has caused concern about the costs and effectiveness of this procedure. Arguments have centered on what is the appropriate true-positive rate for screening mammography, and which abnormal findings may be observed rather than tested immediately. METHODS: A decision analysis was done to help answer these questions. Factors evaluated included age of patient at discovery of abnormal finding, the rate of follow-up mammograms eventually requiring biopsy, the potential effects of tumor-doubling time on increasing the stage of disease, quality-of-life issues, and costs. RESULTS: For an average 50-year-old woman the quality-adjusted life expectancy (QALE) was longer for immediate biopsy by 0 to 3 years, depending on the assumptions on tumor-doubling time; however, immediate biopsy increased the cost per patient from $700 to $900. The QALE was also superior for immediate biopsy if more than 30% of follow-up mammograms required biopsy, and immediate biopsy was more cost effective if more than 36% of follow-up mammograms required biopsy. Patient age did not affect the superiority of immediate biopsy over observation, although quality-of-life issues did. CONCLUSIONS: Those lesions with a greater than 20% to 30% probability of being malignant, or lesions with potentially short doubling times, should undergo immediate biopsy. Lesions judged to be at lower risk may be observed for 6 months. Either of these recommendations should be adjusted depending on an individual patient's quality-of-life concerns.
Breast pathology may be found during preoperative mammagraphy prior to reduction mammaplasty. When nonpalpable lesions are found, a decision must be made: to proceed with the reduction or to biopsy the lesions prior to the reduction. We describe a patient with bilateral breast lesions who underwent bilateral needle-localized biopsies during reduction mammaplasty. Good communication between the radiologist and surgeon is essential for success. The suspicious lesion must be divided from the remaining breast specimen for adequate specimen mammagraphy. The advantage is that both procedures can be done during one anesthetic dose.
This article will review the embryology, clinical presentation, diagnosis, treatment, and clinical significance of ectopic breast tissue, supernumerary breasts, and supernumerary nipples. These structures most commonly develop along the embryonic "milk line." Supernumerary nipples can be identified at birth, whereas ectopic breast tissue becomes noticeable only after hormonal stimulation, usually during puberty, pregnancy, or lactation. Axillary ectopic breast tissue may provide a diagnostic challenge, as other benign and malignant lesions occur in this area. Fine needle aspiration is a useful tool. Ectopic breast tissue is subject to the same pathologic events that occur in normally positioned breasts. Excision may be required for diagnosis, treatment of symptoms, or cosmesis. Supernumerary nipples do not themselves pose diagnostic or symptomatic problems, but evidence suggests that they are markers for associated conditions, most notably urologic malformations or urogenital malignancies.
OBJECTIVE: To evaluate factors which influence surgeons in their decision to treat blunt splenic injuries in adults by observation, splenorrhaphy or splenectomy. DESIGN: Decision analysis. SETTING: Army hospital, USA. MATERIAL: 56 Selected papers on the treatment of splenic trauma published between 1983 and 1993. INTERVENTION: Variables evaluated included the incidence of transfusion, postsplenectomy sepsis, posttransfusion hepatitis, chronic active hepatitis, cirrhosis, and rebleeding. MAIN OUTCOME MEASURES: Quality adjusted life expectancies (QALE) after each procedure. RESULTS: QALEs when the mean incidence of each variable was used in the decision analysis were 39.68 years for observation, 39.56 years for splenorrhaphy, and 38.94 years for splenectomy. Sensitivity analysis showed that when the incidence of transfusion was controlled, splenorrhaphy was superior, and both splenorrhaphy and observation were superior to splenectomy. Once a patient had been given blood products the advantages of non-operative management were lost. CONCLUSIONS: Only patients with minor splenic injuries who did not require blood transfusion should be treated by observation. Patients who require blood transfusion should be explored with the object of salvaging the spleen. Some patients with severe, devitalising injuries will require splenectomy despite the best attempts to salvage the organ.
Ectopic breast tissue presents as solitary or multiple masses in young women along the milk line. The most common site is in the axilla. This may present a diagnostic problem as lymphadenopathy, either primary or secondary, or other soft tissue tumors that may present in a similar way. Six patients with eight axillary masses suspicious for ectopic breast tissue were evaluated with fine needle aspiration (FNA) cytology. Five aspirates revealed epithelial cells consistent with breast tissue; one showed adipose tissue; and two were non-diagnostic. This information helped prevent surgery in one pregnant and one lactating woman. Therefore, FNA examination is helpful in the diagnosis of management of ectopic breast tissue.
Gastric diverticula are relatively rare findings. Although usually asymptomatic, they may cause vague epigastric pain. These lesions may be confused radiologically for gastric ulcers or cancers. Endoscopically, they may be confused for paraesophageal hernias. This report discusses the appearance and evaluation of gastric diverticula.
Caplan has argued that the philosophy of medicine does not exist. Although I will not deny the points he makes, I will argue that the philosophy of medicine has characteristics of a developing field with the potential to meet all of Caplan's criteria. The argument is based on Dewey's established views on logical development for a field of inquiry, as well as pointing out how other criteria Caplan imposes can be fulfilled.
Glomus tumors are uncommon, benign soft tissue tumors that can occur in a familial or sporadic pattern. Only 15 pedigrees have been reported to date. We report a family with three generations developing multiple glomus tumors of the skin. Although controversy exists over pattern of inheritance, review of the published pedigrees plus this additional one suggests an autosomal dominant inheritance with incomplete penetrance and variable expressivity.
A diagnosis is made by a process in which the physician gathers evidence. The physician uses this evidence to put the patient in a class of patients with a disease. Bayes' theorem quantifies the effects of the evidence in increasing the probability that the patient has the disease. This article will discuss the potential of Bayesian analysis for medical diagnosis. Applications of Bayesian analysis to the diagnostic process could improve the efficiency of this process.