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PubMed1979

The undescended "parathymus". An occasional cause of failed neck exploration for hyperparathyroidism.

Arrested descent of the inferior parathyroid gland ("parathymus") during embryologic development may leave the gland stranded high in the neck. Adenomas of such undescended glands are a rare cause of primary hyperparathyroidism, but they may not be uncommon among patients who have already had a failed cervical exploration. Unless the surgeon is aware of this entity, he will probably overlook it. If one is to find these tumors, it is necessary to extend the dissection upward above the superior pole of the thyroid gland, sometimes as far as the angle of the jaw. Adenomas of undescended "parathymus" glands were encountered in seven patients during a recent 20 month (May 1975 through December 1976) surgical experience encompassing 414 primary operations and 27 reoperations for hyperparathyroidism. These tumors were found at initial exploration in one patient and at reoperation in six patients. The individual case histories are presented to illustrate the difficulties posed by this anatomic variant.

Adenoma↗

PubMed1981

Impact of choledochoscopy on the management of choledocholithiasis. Experience with 499 common duct explorations at the Massachusetts General Hospital.

This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones.

Endoscopes↗

PubMed1991

Closed mediastinal exploration in patients with persistent hyperparathyroidism.

Described are two patients with persistent hyperparathyroidism after unsuccessful neck explorations. Both had deep mediastinal parathyroid tumors located within the thymus gland. Formerly it had been the practice of the authors to perform a median sternotomy for the removal of such tumors. In the present cases, however, the neck was re-explored through a cervical incision and the entire thymus gland then was removed by the technique of "closed mediastinal thymectomy." An enlarged parathyroid gland was found embedded in the resected parenchyma of the thymus gland in each patient, and both were cured by the operation.

Adolescent↗

PubMed2000

Direct, minimally invasive adenomectomy for primary hyperparathyroidism: An alternative to conventional neck exploration?

OBJECTIVE: To evaluate the feasibility and efficacy of a direct, minimally invasive adenomectomy (MIA) as an alternative to conventional neck exploration (CNE) in patients with primary hyperparathyroidism. SUMMARY BACKGROUND DATA: Because primary hyperparathyroidism is caused by a solitary adenoma in 85% to 90% of patients, a direct adenomectomy through a mini-incision would theoretically suffice whenever an adenoma is correctly localized on preoperative imaging. If effective, a less invasive method could spare the patient an unnecessary bilateral neck exploration, thus saving time and rendering future surgical procedures in the neck less problematic. METHODS: Between October 1994 and October 1998, 110 consecutive patients with biochemically proven primary hyperparathyroidism who were to undergo surgery were enrolled in this study. Ultrasound and spiral CT were routinely performed as standard preoperative imaging modalities in the first series of 65 patients. In the second series of 45 patients, ultrasound was performed as the sole initial modality; it was supplemented by CT only in case of inconclusive test results. If test results were unequivocal (one adenoma), the patient was offered MIA. CNE was performed if the results were equivocal or if multiglandular disease was suspected. RESULTS: Overall, 84 patients were selected for MIA and 26 for CNE. In the first series, 2 MIA procedures (2/51) were converted to CNE because of negative perioperative findings. All 65 procedures resulted in normocalcemia. In the second series, all but five (4/33 MIAs, 1/12 CNEs) resulted in normocalcemia. A reexploration (CNE) was performed in three patients, resulting in normocalcemia after resection of a second or third adenoma. Two patients are still awaiting reexploration. In both series together, 78 of the 110 patients were successfully treated with MIA and spared CNE. CONCLUSION: MIA is a safe and effective alternative to CNE that may replace CNE in approximately two thirds of all patients.

Adenoma↗

PubMedDate not supplied

Qualitative research: exploring new frontiers.

Qualitative research is an excellent strategy for exploring new areas of study. It is particularly appropriate for the field of gastroenterology nursing, a developing nursing specialty. In this article, the authors provide an introduction to qualitative research through a comparison of quantitative and qualitative perspectives, exploration of qualitative research designs, and discussion of qualitative analysis. Examples of qualitative research are used to illustrate the rich, vivid, and practical information gained using four different mehtodological approaches. Qualitative research topics appropriate for gastroenterology nurse researchers are suggested.

Data Collection↗

PubMed1991

Effects of mammillary body and mediodorsal thalamic lesions on elevated plus maze exploration.

This study investigates the effects of lesioning the mamillary bodies (MB) or the dorsomedian nucleus (MD) of the thalamus on exploration of an elevated plus maze in mice. Exploration of 'open' and 'enclosed' arms of the maze has been used to evaluate anxiety in rodents. Normal rodents visit the enclosed arms more often than the open ones (innate agoraphobia). As operationally defined, the less the activity in the open arms, the more anxious is the subject. MB-lesioned mice entered the open alleys more often, and spent more time in them, than did controls, whereas the opposite was observed in MD-damaged subjects. It is suggested that, in mice given this task, MB lesions decrease anxiety and that MD lesions increase anxiety.

Animals↗

PubMed2004

Exploring the gap between knowledge and behavior: a qualitative study of clinician action following an educational intervention.

PURPOSE: Many medical education interventions improve clinicians' knowledge but fail to change behavior. The authors exposed this knowledge-behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors. METHOD: A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001-02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants' relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge-behavior discrepancy were then explored using semistructured interviews, which were audiotaped, transcribed, and analyzed using grounded theory methods. RESULTS: Half of participants demonstrated varying degrees of knowledge-behavior gap. Eight main rationalizations (relationships, patient agenda, knowledge deficit, clinical style, means to an end, ideals, autism stigma, and systems barriers) were used to justify choices of clinical behavior, and the same rationalizations were used to justify opposite choices of behavior. Two conditions that promote clinical action based on knowledge (level of certainty and sense of urgency) were identified. CONCLUSION: The knowledge-behavior gap was exposed and factors reported to influence clinicians' decisions about whether to implement new knowledge were elicited. That identical rationalizations were used to justify opposite behaviors implies these factors may not be behavioral determinants. Sense of urgency and level of certainty promote clinical action based on knowledge; focusing on these may increase the impact of education on practice.

Attitude of Health Personnel↗

PubMed2005

Viewpoint: exploring the human interior: the roles of cadaver dissection and radiologic imaging in teaching anatomy.

For a variety of reasons, new radiological imaging techniques are supplanting traditional cadaver dissection in the teaching of human anatomy. The authors briefly review the historical forces behind this transition, and then explore the advantages and drawbacks of each approach. Cadaver dissection offers an active, hands-on exploration of human structure, provides deep insights into the meaning of human embodiment and mortality, and represents a profound rite of passage into the medical profession. Radiological imaging permits in vivo visualization, offers physiologic as well as anatomic insights, and represents the context in which contemporary practicing physicians most frequently encounter their patients' otherwise hidden internal anatomy. Despite its important strengths, radiology cannot simply substitute for cadaver dissection, and the best models for teaching gross anatomy will incorporate both cadaver dissection and radiological imaging.

Anatomy↗

PubMed2000

Radiation exposure for human Mars exploration.

One major obstacle to human space exploration is the possible limitations imposed by the adverse effects of long-term exposure to the space environment. Even before human space flight began, the potentially brief exposure of astronauts to the very intense random solar energetic particle events was of great concern. A new challenge appears in deep-space exploration from exposure to the low-intensity heavy-ion flux of the galactic cosmic rays since the missions are of long duration, and accumulated exposures can be high. Because cancer induction rates increase behind low to moderate thicknesses of aluminum shielding, according to available biological data on mammalian exposures to galactic cosmic ray-like ions, aluminum shield requirements for a Mars mission may be prohibitively expensive in terms of mission launch costs. Alternative materials for vehicle construction are under investigation to provide lightweight habitat structures with enhanced shielding properties. In the present paper, updated estimates for astronaut exposures on a Mars mission are presented and shielding properties of alternative materials are compared with aluminum.

Cosmic Radiation↗

PubMed1985

Exploration of the biliary system in recurrent acute pancreatitis of undetermined etiology despite normal cholecystography.

The incidence of pancreatitis associated with biliary tract disease is high in certain parts of the world, including Israel. Sometimes, pancreatitis is the first or only manifestation of gallstone disease. However, this may be accompanied by a normal oral or intravenous cholangiogram. Between 1968 and 1980, 173 patients with acute pancreatitis were treated at the Hadassah University Medical Center in Jerusalem. One hundred and two patients (59%) suffered from proven biliary tract disease. In 36 of these 102 patients, repeat preoperative oral and intravenous cholecystograms failed to demonstrate disease in the biliary system. All were referred to surgery on the basis of a high index of suspicion only. At surgery, acute or chronic cholecystitis were found in all cases; gallstones were found in 32 and some degree of pancreatitis in 32. Operative cholangiography demonstrated a common entrance of the ductus choledochus and the pancreatic duct with reflux of contrast material into the pancreatic duct in at least 52.8% of the cases. In 14 patients (38.9%), palpation and cholangiography did not reveal stones and only bile aspiration and filtration through gauze demonstrated many tiny stones. All patients underwent cholecystectomy, and 11 additionally had a common duct exploration. The follow-up period ranged from 2 to 12 years (mean 7 years) with no signs or symptoms of recurrent pancreatitis or biliary tract disease. It has become our practice to attempt proving gallbladder disease radiographically in all cases of recurrent pancreatitis with no other known etiologic background. Failing this, surgical exploration of the biliary system is undertaken.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed2002

Nursing exploration summer camp: improving the image of nursing.

Improving the image of nursing and finding ways to encourage young people to enter the nursing field are two areas that need attention from nurse executives. That concept was turned into reality with Inova Nursing Exploration Summer Camp 2001, a camp for seventh and eighth graders who are exploring their interest in nursing careers. The camp was a unique partnership among a county public school system, a local university, and an integrated healthcare system. The program, developed by the system nurses in consultation with middle school educators, introduced students to the nursing profession via demonstrations, site visits at multiple hospitals, role-playing, discussions, and a trip to the local nursing school to experience life as a nursing student. The authors discuss the planning, implementation, and outcome of this unique summer camp.

Adolescent↗

PubMed1979

Exploration of low-velocity gunshot wounds of the neck.

Review of 68 consecutive patients seen between 1966 and 1976 with low-velocity gunshot wounds of the neck is reported. Treatment and results are compared. Comparison of preoperative evaluation and operative findings shows that the initial evaluation may miss serious injuries. Associated severe injuries are common. Morbidity following exploration is low. Exploration of all low-velocity gunshot wounds to the neck is recommended.

Adult↗

PubMed1997

Exploring the relationship between inpatient facility and physician services.

OBJECTIVES: Medicare hospitalizations involve both facility and physician services. Although several studies analyze hospital-level variations in Medicare inpatient facility and inpatient physician services per admission, few studies directly explore the relationship between these services. Theoretically, inpatient facility and physician services may be complements or substitutes. That is, an increase in facility services may lead to an increase or decrease in physician services and vice versa. This article contributes to the existing literature by exploring directly the relationship between facility and physician services. METHODS: Medicare physician claims were linked to inpatient hospital stays using data from the Medicare hospital cost reports, the Medicare Patient Analysis and Review file, and the Medicare National Claims History System. RESULTS: In multivariate regression analyses, the (partial) correlations between facility and physician services were positive, which is consistent with complementarity. Standardized regression coefficients indicate that physician services are the single most important determinant of facility services; however, facility services are a less important determinant of physician services. A 10% increase in physician services is associated with at least a 3.0% increase in facility services. CONCLUSIONS: Proposals that reduce inpatient physician expenditures also would reduce facility expenditures in the long-run.

Aged↗

PubMedDate not supplied

Wellness motivation theory: an exploration of theoretical relevance.

Data were collected from 14 older, rural African American men and women to explore how individual motivation affects the initiation and maintenance of health-related behavior. The research consisted of an inductive exploration designed to examine the validity and cultural relevance of an existing theoretical framework for wellness motivation in health behavior change. Through the technique of constant comparative analysis, the basic social process of empowering potential was substantiated as a process of individual growth and goal-directed behavior that facilitated the initiation and maintenance of positive health patterns. The process of empowering potential consisted of three stages: appraising readiness, changing, and integrating change. Two categories provided a cultural context for the process: health value orientation and network affiliation. The data validated and expanded a developing theoretical framework for wellness motivation in health behavior change.

Adaptation, Psychological↗

PubMedDate not supplied

An exploration of recurrent injury prevention in patients with trauma.

INTRODUCTION/PURPOSE: Individuals who have sustained an injury are also at an increased risk for recurrent injury. The purposes of this study were to explore perceptions of recurrent injury risk and prevention, factors associated with the initiation of behavioral and environmental injury prevention strategies, and barriers to injury prevention. The Health Belief Model provided the theoretical framework for this study. METHODS: In this descriptive cross-sectional study, subjects completed a semi-structured interview. Questions were designed to explore subjects' perceptions and behaviors regarding strategies to prevent recurrent injury and any injury prevention information they may have received since their injury event. SAMPLE: Thirty adults who had sustained a nonviolent unintentional injury, mean age 43, mean time since injury 4 months. RESULTS: The majority of subjects reported high levels of perceived susceptibility to injury, and a large degree of perceived control in injury prevention. Factors associated with initiation of environmental strategies included injury to a lower extremity, lower physical function scores, use of an assistive device, and higher perceived injury severity. Few barriers to injury prevention were identified. DISCUSSION/CLINICAL IMPLICATIONS: Previously injured individuals made a variety of environmental and behavioral changes to prevent recurrent injury. However, subjects' perceived susceptibility for recurrent injury and lack of injury prevention information support the need for nursing interventions designed to decrease the risk of recurrent injury.

Adolescent↗

PubMed1991

Correlation of radiologic assessment of lumbar spine fusions with surgical exploration.

Although inspection of posterolateral lumbar fusion is the best method of determining its solidity, routine exploration of the fusion is somewhat impractical because of the morbidity and expense involved. Removal of internal fixation devices or implantable batteries or reoperation for failed back surgery enabled the exploration and assessment of lumbar spine fusions in 214 operations on 175 patients. The preoperative radiologic assessment (plain roentgenographs, polytomography, bending films, and computed tomographic scans) were correlated with surgical findings. This study indicated a significant percentage of inaccuracy of all radiologic modalities used. Noncorrelations were present in 36% of plain roentgenographs, 41% of polytomograms, 38% of bending films, and 43% of computed tomographic scans. Radiologic inaccuracy was manifest on both the positive and negative sides. Computed tomographic scanning presented the lowest percentage of inaccuracy (22%) and bending films the highest percentage (27%). Based on these findings, there exists the need for more accurate noninvasive methods to determine the solidity of spine fusions.

Adult↗

PubMed1995

Measurement of vertebral cortical integrity during pedicle exploration for intrapedicular fixation.

STUDY DESIGN: This study determined the predictive ability of electrical impedance measurement in detecting cortical perforation in a porcine model of pedicular exploration. OBJECTIVE: This study tested the hypothesis that a large decrease in electrical impedance would occur as a result of perforation of the vertebral cortex by the pedicle probe. SUMMARY OF BACKGROUND DATA: The resistivity of cortical bone has been reported to be 25 to 100 times greater than that of soft tissues. METHODS: A total of 42 pedicles of the lumbar spines of six swine were explored using the instrumented pedicle probes. RESULTS: Using a 1 microAmp 30-Hz current source, measurement of electrical impedance predicted cortical rupture with a sensitivity, specificity, and accuracy of 95%. Maximum applied voltages of 2.8 mV did not result in myogenic stimulus. CONCLUSIONS: Electrical impedance measurement provides an accurate real-time measurement of cortical perforation. This technique is adapted readily for use with pedicular screws and screw tape. Further investigation to determine the clinical use of this technique is recommended.

Animals↗

PubMed2000

Exploration of physicians' recommendations for activities in chronic low back pain.

STUDY DESIGN: A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients. OBJECTIVES: To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations. SUMMARY OF BACKGROUND DATA: Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations. METHODS: Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders. RESULTS: Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms. CONCLUSIONS: Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.

Activities of Daily Living↗