Preservation of the kidney by carbon monoxide: a black swan phenomenon

Nakao and colleagues demonstrate that carbon monoxide added to organ preservation solution reduces donor-kidney injury that occurs after cold storage and transplantation and improves the survival of the recipient. These findings are important because they highlight the role of the cytochrome P450 system in the pathogenesis of donor-kidney injury and they suggest a strategy for preserving the donor kidney, namely, the addition of carbon monoxide to organ preservation solution.     

Measuring medical students' experience with surgical problems and procedures.

BACKGROUND: Measuring medical students' experience on their surgical clerkship rotations to assess the adequacy of the breadth of exposure is essential for producing generalist clinicians. METHODS: A Surgical Clinical Checklist was developed by surveying the surgical faculty for those surgical problems and procedures that every generalist physician should experience. The checklist was then distributed to 48 consecutive third-year medical students for completion during their core clerkship in surgery. RESULTS: Students reported encounters with surgical procedures more frequently than with surgical problems (64.3% of procedures versus 21.9% of problems were encountered by 80% of respondents). Students actively participated as often as they reported passive observation alone. Students assigned to two different teaching sites encountered similar numbers of items at each site although the distribution of individual items was different. CONCLUSIONS: The Surgical Clinical Checklist provides a valuable measurement tool to assess student experiences on their surgical clerkship and can be used to direct future teaching initiatives.     

Septic shock: surgical and medical problems in the elderly

The sepsis is a bacterial invasion of the organism producing many manifestations which are able to amplify themselves. In the United States of America there are 100,000 death per year and the incidence is among 300,000-500,000 cases. The major surgery in the elder (especially if it is in emergency) has a great percental of risk because the preoperative study isn't often complete. Fever, agitation, panting, bullation, abdominal splinting, enteroplegia, are signals of evolving inflammatory situation. Moreover there are disorders of biochemical values: leukocytosis, thrombocytopenia, increased levels of VES, PCR, amylase and biliribinaemia. The more common radiological examinations are the straight radiography of abdomen and horax, abdomen ultrasonography, CT or MRI. In the last years pro-calcitonin, interleukin-6 , C-reactive protein, and nitric oxide from endothelial and muscularis cells have been evaluated as prognostic factors in the septic shock.     

Emerging trends in the outsourcing of medical and surgical care

As total health care expenditures are expected to constitute an increasing portion of the US gross domestic product during the coming years, the US health care system is anticipating a historic spike in the need for care. Outsourcing medical and surgical care to other nations has expanded rapidly, and several ethical, legal, and financial considerations require careful evaluation. Ultimately, the balance between cost savings, quality, and patient satisfaction will be the key determinant in the future of medical outsourcing.     

Conjoined twins: medical, surgical and ethical challenges.

Four sets of conjoined twins were reviewed. One set was of the omphalopagus type with no associated abnormalities and were successfully separated at 12 days of age. The other three were of the thoracoomphalopagus type with major cardiac and other abnormalities, they were not amenable to surgery and did not survive. Conjoined twins require precise clinical and radiological evaluation. Many factors contribute to the management of such twins and ethical issues must be considered before surgical separation is undertaken.     

Gestational macromastia: a medical and surgical challenge

Gestational macromastia is a rare and complex disorder. Establishing an optimal medical and surgical management regimen has been challenging. Medical regimens have included tamoxifen, progesterone, bromocriptine, and testosterone. Surgical therapies have included reduction mammaplasty and mastectomy. This report will highlight the successful medical and surgical management in a woman with severe gestational macromastia.     

Peyronie's disease: etiology, medical, and surgical therapy

Peyronie's disease remains an enigma. With the recent introduction of an animal model for Peyronie's disease, the entry of a number of double-blind placebo-controlled clinical trials, and the application of new molecular diagnostic methods, the investigation of this wound-healing disorder of the penile tunica albuginea should illuminate many of the unknowns. Investigators need to be open to innovations in other fields of medicine involving idiopathic fibrosing conditions in other organ systems, eg, Dupuytren's contracture, keloids, hypertrophic scarring, etc. Applications from these other disciplines will undoubtedly widen our scope about Peyronie's disease. While a minority of patients respond with observation alone, most authorities recommend at least a trial of medical therapy with a safe, inexpensive, and well-tolerated agent, as early-stage disease is reputedly more likely to respond better than patients with established, longstanding Peyronie's plaques. The reintroduction of intralesional therapies (verapamil and interferon alpha-2b) provides the clinician with an alternative minimally invasive intervention that has promising possibilities. In severe fibrotic or calcified plaques or with major structural abnormalities, the judicious use of surgery with or without grafting materials and a penile prosthesis can restore many men back to their previous level of high esteem and provide both partners an excellent quality of life.     

Necrotizing fasciitis: a medical and surgical emergency. Apropos of a case]

We report about a 66-years-old obese and diabetic female patient, treated with anti-inflammatories for osteoarthritis of the hip and operated for varices of the lower limbs by a bilateral stripping of the internal saphenous veins, who presented with a mortal necrotizing fasciitis during the postoperative period. Necrotizing fasciitis is a severe, infrequent disease jeopardizing the vital prognosis, in which an appropriate and early treatment (medical, using antibiotics, and surgical by extensive debridement) can prevent a fatal outcome. The most often involved germs are streptococci (45%). The association of anaerobic and aerobic germs sometimes causes mixed cellulitis. The vital prognosis is always threatened by postoperative fasciitis. The mortality rate ranges from 50 to 75%, the main causes of death being a septic shock or pulmonary embolism. The functional prognosis of the surviving patients depends on the extent and quality of surgery.     

Coronary artery spasm. medical management, surgical denervation, and autotransplantation.

Coronary artery spasm was induced by intravascular administration of ergonovine maleate (Ergotrate) during cardiac catheterization. In 78 patients suspected to have Prinzmetal's angina, no morbidity or death has resulted despite complete occlusive spasm in two and three coronary arteries. Typical EKG changes and akinesia of the myocardium in the distribution of the occluded vessels documented functional myocardial ischemia during spasm. The occlusive spasm is readily reversed by sublingual or intravascular nitroglycerin, and ventricular contractility returns to normal following relief of spasm. Occlusive spasm has been demonstrated in 15 patients with clinical evidence of Prinzmetal's angina. Symptoms have been effectively relieved by coronary vasodilators in 10 patients. Of the 5 patients in whom medical therapy failed, 4 were treated surgically. These 4 patients were in the intensive care unit with protracted, prolonged pain, subendocardial infarctions, and persistent failure of coronary vasodilators. Aorta-coronary bypass grafts have been combined with total cardiac denervation by autotransplantation (one patient) and total cardiac denervation by stripping of the great vessels (3 patients). Two of the patients treated by cardiac denervation died in the early postoperative period. The patient treated by autotransplantation has total relief of symptoms but persistent spasm on angiography. The angiographic demonstration of occlusive coronary spasm remains a valuable diagnostic tool to document definitively the presence of spasm. The surgical results question the value of surgical intervention in this disease.     

Ischemic cardiomyopathy: medical versus surgical treatment.

The natural history of patients with ischemic heart disease and depressed left ventricular function is dismal, and medical therapy has failed to alter its course. To assess the results of aorta-coronary bypass grafting in patients with coronary artery disease and decreased left ventricular ejection fraction (LVEF less than or equal to 0.3), we compared 70 medically treated patients to 46 patients having aorta-coronary bypass grafting. The duration of follow-up was 6 to 72 months (mean 19 months). All patients had angina pectoris. Congestive heart failure was present in 56 percent (39/70) of the medical and 43 percent (20/46) of the surgical group. The medical group had a mean LVEF of 0.20 and a mean left ventricular end-diastolic pressure (LVEDP) of 29 mm. Hg. The surgical group had a mean LVEF of 0.21 and a mean LVEDP of 24 mm. Hg. Three vessel disease was found in 60 percent (42/70) of the medical group and 83 percent (38/46) of the surgical group. The operative mortality rate in the surgical group was 4 percent (2/46). There were four late deaths. The 2 year actuarial survival rate for medical and surgical groups was 47 percent and 83 percent, respectively. Significant improvement in angina pectoris and/or congestive heart failure was found in 16 percent (11/70) of medically treated patients and 95 percent (38/40) of the surgically treated patients. Aorta-coronary bypass grafting can be performed in patients with poor left ventricular function with a low operative mortality rate, relief of angina pectoris, and improvement in symptoms of congestive heart failure.     

Recurrent rupture of a mycotic ascending aortic aneurysm: a surgical and medical challenge.

Infection in the vascular tree remains one of the greatest challenges for vascular surgeons. Despite technical advances and newer antibiotics, the morbidity and mortality remain high. The following case report underlines the complex factors encountered in a 62-year-old alcoholic patient presenting with a "classical" history of mycotic aneurysmal disease who suffered from recurrent rupture of the aneurysm of the ascending aorta. In situ reconstruction of the ascending aorta was performed with patch of xenopericardium. As demonstrated in this case, aggressive surgical management and long-term triple antibiotic therapy can salvage patients even with multiple complications in the early postoperative period.     

Robert R. Shaw, MD: thoracic surgical hero, Afghanistan medical pioneer, champion for the patient, never a surgical society president

Dr Robert R. Shaw arrived in Dallas to practice Thoracic Surgery in 1937, as John Alexander's 7th Thoracic Surgical Resident from Michigan University Medical Center. Dr Shaw's modus operandi was, "You can accomplish almost anything, if you don't care who gets the credit." He was a remarkable individual who cared the most about the patient and very little about getting credit for himself. From 1937 to 1970, Dr Shaw established one of the largest lung cancer surgical centers in the world in Dallas, Texas. It was larger than M.D. Anderson and Memorial Sloan-Kettering Hospitals put together regarding the surgical treatment of lung cancer patients. To accomplish this, he had the help of Dr Donald L. Paulson, who trained at the Mayo Clinic and served as Chief of Thoracic Surgery at Brook Army Hospital during the Second World War. Following the War, because of his love for Texas, he ended up as a partner of Dr Shaw in Dallas. Together, they pursued the development of this very large surgical lung cancer center. Dr Shaw and his wife Ruth went to Afghanistan with Medico multiple times to teach men modern cardiac and thoracic surgery. They also served as consultants on Medico's Ship of Hope in Africa. Dr Shaw initiated multiple new operations including: 1) resection of Pancoast's cancer of the lung after preoperative irradiation; 2) upper lobe of the lung bronchoplasty, reattaching (and saving) the lower lobe to prevent the "disabling" pneumonectomy; and 3) resections of pulmonary mucoid impaction of the lung in asthmatics. Because of his humility and giving "the credit to others," Dr Shaw was never President of a major medical or surgical association.