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Biomedical subjects

R D Croom

Publications and source records attributed to R D Croom.

At least 19 recordsLinked to original sources
PubMed1991

Case report: splenic infarction and acute splenic sequestration in adults with hemoglobin SC disease.

While acute splenic sequestration and splenic infarction are commonly observed in infants and young children with sickle cell anemia, they are rarely experienced by adult hemoglobin S homozygotes because the recurrent splenic infarction that takes place during childhood is typically followed by scarring, atrophy, and splenic fibrosis. Both acute splenic sequestration and splenic infarction do remain relatively common in adults with the other sickle hemoglobinopathies. These episodes are almost certainly a consequence of the persistently enlarged and distensible spleens that often remain present in these conditions. In this report, the authors describe two adult patients with hemoglobin SC disease: one who developed acute splenic sequestration and one with splenic infarction. In neither case was there a history of recent air travel or exposure to altitude. The clinical course of these two syndromes is presented, and the hematologic, radiologic, and pathologic manifestations are discussed. Because they can sometimes be difficult to distinguish from one another, and because a failure to identify acute splenic sequestration can be catastrophic, these two entities must be included in the differential diagnosis for any hemoglobin SC patient who present with an unexplained fall in hemoglobin, left upper quadrant pain, unexplained fever, or symptomatic splenomegaly.

Acute Disease↗
PubMed1991

Predictive validity of a house-officer selection process at one medical school.

This study explored the rank list generated by a process of evaluating applicants for a surgery residency; the process is a revision of an older process (pre-1982) used for that purpose. The study's aim was to learn whether the new process is more predictive of residents' performances in their first year than was the process it replaced and whether the rough rankings computed directly from ratings of applicants are more predictive than the final rankings determined in a meeting by the department faculty, who modify the rough rankings. The 1982-1986 rankings and performances of 32 first-year residents at the University of North Carolina at Chapel Hill School of Medicine were studied and compared with the rankings and performances of 77 applicants from 1976 and 1978-1979 under the previous system. Correlation analyses revealed that for the applicants studied, the rough rankings in the new and the previous systems were equally predictive of performances as measured by rating scales, but that the new system was more predictive of performances on the surgery in-training examination. However, all correlations were small. Finally, the rough rankings obtained under the new system were more predictive of the residents' later performances than were the faculty's final rankings.

Career Choice↗
PubMed1989

Colonic and esophageal transepithelial potential difference in cystic fibrosis.

To evaluate differences in the expression of cystic fibrosis (CF) transport defects in the gastrointestinal tract of subjects with CF, in vivo measurements of colonic and esophageal transepithelial electrical potential difference (PD) were performed before and during amiloride superfusion in CF and healthy subjects. Esophageal PD before (-16 +/- 2 vs. -16 +/- 3 mV) and after (-14 +/- 2 vs. -15 +/- 0.3 mV) superfusion with amiloride were similar for CF and healthy subjects. Basal rectosigmoid colon PD was also similar (CF: mean -23 +/- 6 and maximal -37 +/- 9 mV; normal: mean -26 +/- 5 and maximal -45 +/- 11 mV) in both groups. However, with amiloride superfusion (10(-4) M) the colonic PD in CF subjects was almost abolished (95% +/- 15% inhibition), whereas the PD in healthy subjects was only partially reduced (42% +/- 6%) (p less than 0.05). The greater inhibition with amiloride in CF, which was evident in absolute terms (26 +/- 4 vs. 16 +/- 3 mV for controls, p less than 0.05) as well as relative terms, could not be ascribed to a difference in mineralocorticoid secretion rates, because 24-h urine excretion of aldosterone and 17 hydroxy and 17 ketosteroids were similar in both groups. Freshly excised colonic epithelia from 1 CF and 3 non-CF subjects were studied in Ussing chambers, and a similar difference in amiloride responsiveness noted: PD and short-circuit current declined 33% +/- 2% and 37% +/- 4%, respectively, in seven tissues from the colons of 3 patients without CF, whereas both PD and short-circuit current were fully inhibited (100%) in all three tissues from the CF patient. As the presence of an amiloride-insensitive component of short-circuit current in non-CF colon is largely due to electrogenic Cl- secretion, the demonstration that this component was absent both in vivo and in vitro in CF colon establishes the presence of a defect in electrolyte transport in CF colon, a defect consistent with recent reports of absent electrogenic Cl- secretion in CF intestine.

Adult↗
PubMed1987

Current management of the patient with autonomously functioning nodular goiter.

Autonomously functioning thyroid nodules (AFTNs) are presumably independent of TSH for growth and function and appear "hot" on scintiscan because they selectively concentrate radionuclide to a greater extent than the remaining thyroid gland, which is controlled by the normal TH-TSH feedback mechanism. Such autonomously functioning tissue may occur in "patchy" areas, as a solitary nodule, or as multiple nodules (classic Plummer's disease), with the mass of hyperfunctioning tissue and the related secretion of thyroid hormones determining whether the patient is euthyroid or hyperthyroid. Important diagnostic tests include a 99mTc thyroid scan, T4 RIA, T3 uptake, FTI, TSH RIA, and occasionally T3 RIA ("T3 thyrotoxicosis"). Solitary autonomous nodules in adult patients characteristically progress slowly over many years, with toxicity rarely developing in nodules less than 2.5 cm in diameter and occurring primarily in nodules 3 cm or larger and in older patients. The decision to treat a solitary nodule depends upon the size and degree of function of the nodule and the patient's age. Surgery and radioactive iodine are effective therapies. Hyperfunctioning thyroid nodules in children and adolescents (under age 18) have a more rapidly progressive course than those in adults and should be treated by thyroid lobectomy at the time of diagnosis. Subtotal thyroidectomy is the preferred treatment for most patients with toxic multinodular goiter, because it achieves prompt control of the hyperthyroidism and removes the goiter. Radioiodine therapy and long-term antithyroid drug therapy are alternative forms of treatment for patients who are poor surgical risks or who develop recurrent hyperthyroidism following thyroid surgery.

Adenoma↗
PubMed1987

Autonomously functioning thyroid nodules in childhood and adolescence.

Autonomously functioning thyroid nodules (AFTNs) in children and adolescents (under age 18) are unusual but are not as rare as earlier reports suggested. These lesions have a significantly different biologic potential than similar lesions in older patients. In the younger age group there is a more rapid progression toward toxicity and a higher incidence of thyroid carcinoma. Our experience with 12 patients is combined with those previously reported for identification of a total of 61 children and adolescents with AFTNs, of whom 53 have undergone operation. Hyperthyroidism was present in 15 patients (24.6%), and in six patients (11.3%) the AFTN was due to a well-differentiated thyroid carcinoma. Surgical treatment is advisable for all children and adolescents with AFTNs because of the risks of hyperthyroidism and thyroid carcinoma. Surgical excision (lobectomy is preferred) results in rapid restoration of a euthyroid state for the toxic AFTN and allows histopathologic diagnosis. Therapy with radioiodine is not advisable for treatment of AFTNs in this age group. Thyroid-stimulating hormone suppression should be used for all patients with a diagnosis of thyroid carcinoma.

Adolescent↗
PubMed1986

Oophoropexy and the management of Hodgkin's disease. A reevaluation of the risks and benefits.

Female patients with Hodgkin's disease who undergo staging laparotomy frequently have oophoropexy performed to preserve both fertility and hormone production. Because of recent changes in therapy favoring systemic chemotherapy rather than total nodal irradiation for patients with stage III Hodgkin's disease, the need for oophoropexy may be less than previously described. Thirty-nine women of childbearing age underwent laparotomy at the University of North Carolina, Chapel Hill, from 1970 to 1984. Twenty-seven patients underwent oophoropexy. Only three of these patients would have needed this procedure based on their subsequent therapy. Two patients required additional gynecologic surgery because of complications related to the oophoropexy. The success rate in preservation of menstrual function and fertility is also discussed. We review the previous experience with oophoropexy and suggest an alternative approach to the routine use of this procedure.

Abdominal Muscles↗
PubMed1986

Hirschsprung's disease in young adults.

Hirschsprung's disease is rarely seen in the young adult, and presents unique problems in management because of the massive dilatation and hypertrophy that occur proximal to the aganglionic rectum or the rectosigmoid colon. The diagnosis, which may be suspected by barium enema, is confirmed by suction or full-thickness biopsy of the rectum that may be complemented by anal manometry. Based on our experience with eight patients, a two-stage surgical reconstruction is recommended, with a preliminary sigmoid colostomy through the normally innervated colon and an associated defunctionalized stoma constituting the initial operation. The distal colonic stoma permits cleansing of the caudal colon while the normally innervated proximal colon reverts to near normal caliber, usually within 2 to 6 months. This approach is in accord with the recommendation of Fairgrieve. Reconstruction using a Duhamel or Soave procedure has given good results. The Duhamel procedure seems preferable when a considerable discrepancy remains between the ganglionic and aganglionic segments of rectum.

Adolescent↗
PubMed1986

Hereditary spherocytosis. Recent experience and current concepts of pathophysiology.

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. A deficiency of spectrin, the largest and most abundant structural protein of the erythrocyte membrane skeleton, results in the formation of spherocytes which lack the strength, durability, and flexibility to withstand the stresses of the circulation. Clinical manifestations of the disease are primarily dependent on the severity of hemolysis, which additionally results in an increased incidence of pigment gallstones. The likelihood of cholelithiasis is directly related to patient age and is uncommon before 10 years of age. Splenectomy is indicated in virtually every patient. When the disease is diagnosed in early childhood, the risk of overwhelming postsplenectomy sepsis makes it advisable to delay splenectomy until after 6 years of age if possible. At the time of splenectomy, it is important to identify and remove any accessory spleens. If gallstones are present, cholecystectomy should be performed. Although spherocytosis persists following splenectomy, hemolysis is alleviated and clinical cure of the anemia is achieved for most patients. Patients with recessively inherited spherocytosis are exceptions. Although they are significantly benefited by splenectomy, their anemia is not completely corrected. Splenectomy reduces hemolysis in all patients and thereby decreases the risk for development of pigment gallstones. Excision of an enlarged spleen removes the danger of traumatic rupture.

Adolescent↗
PubMed1986

Cholelithiasis in sickle cell anemia: surgical considerations.

Gallstones are frequently found in patients with sickle cell anemia. The differentiation between acute calculous biliary tract disease and sickle cell crisis can be difficult and should be based on the clinical presentation, comparison with previous episodes of abdominal pain, and judicious use of hepatobiliary radionuclide scanning. Emergency cholecystectomy is associated with a high morbidity and should be avoided if possible. Elective cholecystectomy is associated with a lower but still significant risk of complications. We believe patients with sickle cell anemia and symptomatic cholelithiasis should have elective cholecystectomy. Careful management is essential to minimize the danger of postoperative complications.

Acute Disease↗
PubMed1985

Neonatal intestinal obstruction from omphalomesenteric duct remnants.

Three cases of omphalomesenteric band obstruction in early infancy with various radiographic presentations, including intermittent obstruction in one, are reported. Small-bowel volvulus was found in all three patients at surgery. One case progressed to bowel necrosis with portal venous gas. A survey of the mode of presentation, surgical findings, and pathology of 135 published cases of intestinal obstruction in children demonstrates that a closed loop, with or without volvulus, is the most common complication of remnant bands.

Female↗
PubMed1984

Intestinal endometriosis.

Endometriosis involving the intestine usually takes the form of asymptomatic, small, superficial serosal implants on segments of bowel lying in the pelvis in proximity to the genital organs. Deeper and more extensive intestinal wall involvement may result in obstruction and occasionally bleeding and requires distinction from a neoplasm or other inflammatory bowel process. Intestinal endometriosis should be considered in the differential diagnosis of recurring lower abdominal pain and other episodic bowel symptoms in women of child-bearing age. The diagnosis may be suspected based on the patient's history and frequently associated gynecologic symptoms. Due to the extramucosal location of the endometrioma, preoperative evaluation is unlikely to establish the diagnosis with certainty. Intestinal involvement by endometriosis, to the degree that it produces symptoms, almost always requires excision. Asymptomatic serosal lesions found incidentally at celiotomy for other disease should be biopsied and the diagnosis confirmed by frozen section. Symptomatic disease should be treated by resection of the involved intestine or by local excision, if the latter is feasible, and primary colon carcinoma can be excluded with confidence. Decisions regarding concurrent treatment for the underlying endometriosis should be made after consultation with an experienced gynecologist and must be based on the patient's menstrual status, age, and desire for future pregnancy.

Adult↗
PubMed1984

Primary hyperparathyroidism during pregnancy.

Primary hyperparathyroidism during pregnancy is associated with significant risk of fetal loss and neonatal and maternal morbidity. Neonatal hypocalcemia probably results from transient hypoparathyroidism consequent to abnormal suppression by fetal hypercalcemia. Loss of the protective effect provided by the placental calcium transport mechanism produces significant maternal risk for development of acute hypercalcemia and possible crisis immediately postpartum. Management of maternal primary hyperparathyroidism diagnosed during pregnancy should be based on the patient's symptoms, severity of the disease, and gestational age of the fetus. Patients without symptoms and those with mild hypercalcemia may be managed effectively and safely for a short time with oral phosphate therapy, postponing operation until after delivery. More severe disease characterized by progressive symptoms and inadequately controlled hypercalcemia should be treated surgically after control of hypercalcemia has been achieved with diuretic and/or other medical therapy. Maternal operative morbidity is low and risk to the fetus is slight once organogenesis has been completed. Maternal parathyroidectomy should be performed preferably after the first trimester and should not be deferred unless delivery is imminent.

Adult↗
PubMed1976

Aneurysms of the hepatic artery.

Aneurysms of the hepatic artery are rare and, when symptomatic, they may present a triad of upper abdominal pain, gastrointestinal bleeding, and obstructive jaundice. Asymptomatic and unsuspected aneurysms are demonstrated occasionally by abdominal arteriography or are encountered infrequently during abdominal operation for an unrelated disease. Hepatic artery aneurysms have great potential for rupture with bleeding into the peritioneal cavity, the common bile duct, or an adjacent hollow viscus. Morbidity and mortality with a ruptured aneurysm are high, and aggressive and imaginative operative therapy is required. Patients with an asymptomatic aneurysm should have operation to prevent subsequent rupture and hemorrhage.

Abdomen↗
PubMed1976

Acute jejunogastric intussusception.

Our patient represents an example of acute retrograde jejunograstric intussusception with the additional finding of a bleeding jejunal ulcer in the intussusception. The ulcer may have been etiological in precipitating the intussusception, or a consequence of mucosal sloughing in the hemorrhagic intussusception. Early diagnosis and immediate surgical therapy resulted in an uneventful recovery.

Acute Disease↗
PubMed1975

Diagnosis of an enteric duplication with pertechnetate 99mTc scanning.

A case of enteric duplication is reported in which preoperative pertechnetate (99m)Tc scanning demonstrated localized uptake in the region of the anatomic abnormality. This test is recommended for use in the evaluation of lower gastrointestinal bleeding in infants and children.

Barium Sulfate↗
PubMed1975

Tumors of the small intestine.

An analysis of 80 cases of malignant and benign tumors of the small intestine is presented, and major clinical features of various histologic lesions are discussed. Tumors of the small intestine are rare, and the small bowel may have intrinsic protective systems against the development of neoplasms. Gastrointestinal bleeding and symptoms of intermittent obstruction are prominent findings in patients with symptomatic benign tumors, although many benign tumors are incidental findings at operation for an unrelated disease. Benign lesions should be removed by local excision. Virtually all malignant tumors are symptomatic with abdominal pain, nausea and vomiting, anorexia and weight loss, and gastrointestinal bleeding being common findings. Earlier diagnosis is essential if the prognosis for patients with small intestinal malignancies is to be improved. A high degree of suspicion must be aroused with any vague, nonspecific gastrointestinal complaints in patients over 40 years of age. Exploratory celiotomy should be performed in symptomatic patients even though no abnormality may be detected on roentgenographic examination.

Adenocarcinoma↗