Biomedical subjects
Publications and source records attributed to R Zeppa.
We have described the rare case of a woman with no recognized predisposing factors for hepatocellular carcinoma in whom a second hepatic neoplasm was successfully resected nine years after a presumed "curative" partial hepatectomy. The importance of long-term measurements of available tumor markers as well as aggressive surgical management is emphasized.
The purpose was to see if students changed their attitudes about medical care during the surgical clerkship and whether those who selected surgery as a career differed from other students at the end of the clerkship and time of entrance into a residency. Students were assessed before and after the clerkship in regard to confidence about handling problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive aspects of care. In general, the class changed positively in dealing with patients, had more concerns about future practice, and were more negative about preventive aspects of care. Potential surgeons had concerns about future practices similar to those of other students but differed from the rest of the class by having more confidence in dealing with patients and more positive attitudes about preventive aspects of care. When they entered the clerkship, would-be surgeons had more favorable ratings than did other students on ego strength and acceptance of people. The study suggests that attention may need to be given to the experiences of students in the clerkship that lead to their increased concerns about future practice and, for those not selecting surgery as a career, their increased negative attitudes about preventive care.
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Hepatic insulinase activity was studied in cirrhosis in an attempt to explain the hyperinsulinemia known to occur in this disease. Liver tissue was obtained during laparotomy in seven patients with cirrhosis of the liver and five patients without liver disease. Insulin degradation was significantly decreased in the cirrhotic liver at each time interval measured (p less than 0.05). Insulinase inhibitor activity was measured in the plasma of 12 patients with cirrhosis of the liver and six controls. There was no significant difference between the two groups. Decreased insulinase activity in cirrhosis may account, in part, for the hyperinsulinemia seen in this disease.
The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.
This article examines perceptions of stress and career choice. One hundred sixty-nine junior students specified what they thought were the two most and two least stressful careers, as well as their own career preferences before and after a 12-week surgical clerkship. The class was divided for analysis into three groups: those who selected careers that they said were A) most stressful (42%), B) least stressful (10%), and C) neither most nor least stressful (48%). Surgery was cited as one of the two most stressful choices by 99% of the class before and 93% after the clerkship. The next most stressful career was internal medicine, cited by 43% before and 35% after the clerkship. The two least stressful careers were dermatology and radiology, cited by approximately 50% of the class before and after the clerkship. Those who chose careers that they said were most stressful had significantly higher self-esteem (p less than 0.05), experienced less unfavorable stress themselves as measured by a 31-item stress scale before and after the clerkship (p less than 0.01), and experienced more favorable (in their view) stress (p less than 0.05) than did the other two groups. Reanalysis of data comparing those who selected surgery with those who did not confirmed findings similar to that of the matched high-stress career group. The study suggests that some students may be able to tolerate stress better and in fact, tend to thrive in an environment that they perceive as stressful, and that such students are more likely to go into a surgical career, which they foresee as one of the most stressful that they can enter.
The biliary penetration of cefamandole was studied in six patients with total biliary obstruction before and after placement of a transhepatic bile drainage catheter. Biliary levels of cefamandole remained depressed even when the drug was administered as late as 7 days after decompression of the biliary tract.
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A prospective, randomized study was conducted on 219 surgical patients with biliary tract disease. There were 100 patients undergoing elective biliary surgery, and 119 others with suspected biliary sepsis who were assigned to Prophylactic or Therapeutic clinical categories, then randomized into ampicillin or cefamandole treatment groups. Organisms resistant to the antibiotics given were found less often among patients in the cefamandole groups than among those in the ampicillin groups. No postoperative wound or intra-abdominal sepsis (IAS) occurred in the Prophylactic category. In the Therapeutic category there were two cases (3.2%) of wound and IAS in the ampicillin group and one case (1.8%) of wound infection in the cefamandole group. Overall, cefamandole showed superior coverage in vitro against the biliary flora, but both drugs were equally effective in maintaining a low incidence of postoperative sepsis as well as a minimal number of febrile or total hospital days. The authors suggest that the choice of antimicrobials may not be as critical as effective surgical management in the prevention of septic complications following biliary tract surgery.
The purpose of the authors in the study reported here was to compare perceived stress in junior medical students (n = 169) before and after a clinical clerkship and to determine the relationship of unfavorable and favorable stress to personality and performance. Degree of stress and whether the stress was considered favorable or unfavorable were determined by the students' ratings on a stress scale administered before and after their surgical clerkship. Locus of control and self-esteem scales were used as measures of personality. It was determined that students likely to experience more unfavorable stress were more external in control and lower in self-esteem as compared with the other students. The students' cognitive performance was evaluated by two written and two oral examinations; their attitudes and skills were assessed by a behavioral scale completed by faculty members and residents. The major finding was that unfavorable stress was associated with poor performance. Since stress predictably will increase in the residency and in the practice years, students should be exposed to stress management techniques to help prevent the known high consequences of stress, such as substance abuse and suicide, among practicing physicians.
An adolescent with stunted growth was treated for 6 months with a synthetic anabolic androgen. During his evaluation for right upper quadrant pain an abnormal liver scan demonstrated what proved to be a hypervascular hepatic lesion. At surgery, the diagnosis of focal nodular hyperplasia was established. Herein we document the unusual association of focal nodular hyperplasia with use of a synthetic anabolic androgen.
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A technique for biliary and duodenal bypass in patients with metastatic or locally nonresectable pancreatic carcinoma was used in 18 patients. Biliary tract decompression was achieved with a Roux-en-Y cholecystojejunostomy and duodenal bypass with a gastrojejunostomy using an automated stapling device. Although all patients eventually die of this disease, there was no operative mortality and no evidence of anastomotic leak, bleed, or stricture formation in the present series. This procedure reduces the operative time required to perform these anastomoses in poor-risk cases.
We investigated the values and attitudes of junior medical students in relation to career preference (particularly surgery), ward behavior, and cognitive performance in the surgical clerkship. Students choosing specialty surgery were more cynical and authoritarian than those selecting general surgery. Those choosing general surgery had more self-esteem, and along with those who selected specialty surgery, more intolerance for ambiguity than other students. None of the values or attitudes were associated with grades, but several were related to ward behavior as judged by faculty and house staff. Students who valued academic achievement more and independence and intellectualism less and those with more submissive authoritarian views and more ego strength were considered better ward performers. This raises the question of whether such values and attitudes should be reinforced in ward performance or whether such students are rated higher simply because they are less disruptive to busy ward routines.
Insulin acts as a regulator of lipid metabolism by inhibiting the rate of lipolysis. Hyperinsulinemia, produced by the peripheral infusion of glucose, therefore, causes a lowering of plasma free fatty acids (FFA) by decreasing the mobilization of fats from peripheral deposits. Based on previous studies, it was postulated that a lowering of plasma FFA could be produced, in the absence of hyperinsulinemia, by the infusion of glucose directly into the liver. This study was undertaken to investigate the existence of endogenous factors other than insulin, which inhibit lipolysis. It was determined that glucose at a dosage of 0.125 gm/kg/hr could be infused into the portal vein of dogs without increasing plasma insulin levels. This dosage significantly lowered plasma FFA levels when injected into the portal vein but had no effect on plasma FFA when infused peripherally. There were significant decreases in FFA turnover following portal glucose administration, with no changes in fractional turnover. This indicated that the lowered plasma FFA concentrations found following portal infusions of glucose, were due to reduced lipid mobilization from adipose tissue, rather than increased tissue uptake of FFA. These results suggested the existence of an hepatic factor, stimulated by portal glucose infusion, which lowered FFA mobilization from adipose tissue.
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