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Metastatic Tumors To The Lung

The cancers that are most commonly metastatic to the lung are:

1. Colon
2. Breast
3. Renal (kidney)

In many cases, these tumors can be resected (surgically removed) if the following criteria are met:

1. There is no other metastatic disease in the body.
2. The amount of lung resection leaves adequate pulmonary reserve.
3. The primary tumor is adequately controlled.

Electrocardiogram Findings in Pericarditis

Pericarditis (inflammation of the sac around the heart) is associated with several ECG findings:

1. Low voltage (i.e., "small") QRS complexes.
2. Electrical alternans.
3. ST segment elevations with a "concave up" morphology more common.
4. Depression of the PR wave.
5. T wave inversion, but usually only after the ST segment has normalized

Killip Classification

This classification predicts risk of mortality after a ST-segment elevation myocardial infarction (STEMI.)

Class 1 - absence of congestive heart failure - 6% risk of mortality.
Class 2 - presence of an S3 murmur and/or bibasilar rales - 17% risk of mortality.
Class 3 - presence of pulmonary edema - 30-40% risk of mortality.
Class 4 - presence of cardiogenic shock - 60-80% risk of mortality.

Sgarbossa Criteria

The presence of a left bundle branch block (LBBB) makes it difficult to determine if there are ischemic changes on an electrocardiogram (ECG.)

The Sgarbossa scoring system can determine with a 90% specificity if cardiac ischemia is present on an ECG in the setting of a LBBB if the score equals 3 or greater.

The criteria are:

1. Elevation of the ST segment of 1 mm or greater that is concordant as the QRS in any lead - 5 points.

2. Depression of the ST segment of 1 mm or greater in any lead from V1 to V3 - 3 points.

3. Elevation of the ST segment of 5 mm or greater that was discordant with the QRS complex - 2 points.

Use of Transdermal Fentanyl

Fentanyl patches that deliver the narcotic transdermally are often used to treat patients with chronic pain from metastatic cancer and other conditions. Some factors to be considered when considering this drug via this route:

1. Fentanyl patches come in doses of 25, 50, 75, and 100 mcg/hr.

2. Fentanyl patches are relatively expensive when compared to other narcotics.

3. Fentanyl patches are should be changed every three days for most patients. About 20% of patients require patches to be changed after 48 hours.

4. Fentanyl patches should never be used in patients who are beginning opioid therapy.

5. An increase in body or ambient temperature increases Fentanyl drug effect.

6. Coverage with an oral or intravenous opioid should be initiated for the first 15-20 hours until the patch "kicks in."

7. A short-acting opioid should be prescribed for rescue doses for breakthrough pain.

Eligibility for Medicare Paid Hospice

Medicare Part A covers hospice care for eligible patients. To be eligible, the following criteria must be met:

1. The patient must be expected to live less than 6 months if the disease follows the expected course.

2. The patient must be certified as terminally ill by the attending physician and the director of the local hospice center within 48 hours of entering the hospice care program.

3. The patient must actively choose the hospice care option, which prohibits them from seeking regular Medicare reimbursement for curative treatment.

Amaurosis Fugax

Amaurosis fugax is a classic sign (more often described than actually seen) for an acute embolus to the ophthalmic artery, a branch of the internal carotid artery

It presents as an acute descending blindness in one eye, as if a shade is being pulled down over the eyelid. It is considered an indication for carotid endarectomy (surgical removal of atheromatous plaque in the carotid artery.)


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Treatment of Kidney Stones

The development of kidney stones (aka urinary calculi) is a common condition seen by family practice doctors, emergency room physicians, and urologists. There are several considerations when treating kidney stones:

1. Most small calculi (< 4mm) pass spontaneously on their own without intervention.
2. Treatment of stones < 4mm consists of pain medication, vigorous hydration, and straining of the urine.
3. Stones larger than 4 mm but less than 2.5 cm are treated by extracorporeal shock-wave lithotripsy (ESWL).
4. Stones larger than 2.5 cm require percutaneous nephrolithotomy (PCNL).
5. Staghorn calculi require PCNL.
6. Stones that do not pass spontaneously typically obstruct the urinary system at three points: the ureteropelvic junction, the area where the ureter crosses the iliac vessels, and the ureterovesical junction.


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Caloric Yield of Basic Nutrients

Adequate surgical nutrition is critically important in recovering from injury or illness. When calculating the energy yield from nutritional substances, the following caloric determinants are used:

Fat - 9 kcal/gm
Protein - 4 kcal/gm
Carbohydrate - 3.4 kcal/gm

The goal in any nutritional therapy is to provide sufficient calories in fat and carbohydrate to prevent protein breakdown.


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Criteria For Referring Patients To A Burn Center

Burn wounds are distressingly common and can be dangerous for the patient and difficult to treat. It is generally acknowledged that the following criteria are indications for referral to a burn center:

Inhalation Injury
Burns to the face, feet, hands, or perineum
Electrical burns
Chemical burns
Burns involving more than 10% of total body surface area
Burns in patients with co-morbidities (ex. HIV)


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Although none of the editors of InsideSurgery.com have participated in his care, we have noted the news reports that entertainer Michael Jackson has died of sudden cardiac arrest. He was 50.

Jackson, who became a controversial figure over the last 18 years of his life, had no previously reported cardiac disease.

Although invariably shocking to bystanders who witness a sudden cardiac death, the condition is distressingly common, comprisingly more than 50% of all cardiac deaths. Approximately 300,000 patients each year in the United States die of sudden cardiac arrest (aka heart attack, myocardial infarction and MI).

Causes

The formal definition of sudden cardiac arrest is an instantaneous collapse of the cardiovascular system within one hour of onset of symptoms. It is usually caused by a malignant arrhythmia such as ventricular fibrillation (VF), which is the unsynchronized quivering of the two heart ventricles with absence of a meaningful volume of blood being pumped to the brain.

V-fib, if left untreated, almost universally leads to cardiac asystole, which is complete absence of cardiac contractility.

Approximately 80% of patients who suffer sudden cardiac death (SCD) have underlying coronary artery disease. About 15% have valvular disease, dilated cardiomyopathy (enlarged heart), or left ventricular hypertrophy (enlarged left ventricle.)

Risks factors include male sex (70% of sudden cardiac deaths occur in men) and vigorous activity, which increases the risk approximately 17 fold over normal daily activities. Additional factors include race (more prevalent in African Americans) and diabetes mellitus, as well as hypertension, tobacco use, and high serum cholesterol.

Many sudden cardiac arrest investigators also believe that certain medications such as amphetamines, cocaine, tricyclic antidepressants, antihistamines, diuretics, and angiotension converting enzyme inhibitors can precipitate sudden cardiac death.

The incidence of sudden cardiac death has dropped in recent years, likely due to the decrease in the incidence of coronary atherosclerotic disease.

The onset of sudden cardiac death occurs in a diurnal pattern, peaking in the hours between 7 AM and 10 AM and then in the late afternoon between the hours of 4 PM and 7PM. It is more prevalent in the colder, winter months that have fewer hours of daylight.

In addition, some investigators have hypothesized that there is a stress component in the onset of sudden cardiac death, perhaps explaining a spike in incidence in the post holiday period of January.

Prognosis

Despite the recent emphasis of having readily available defibrillators in many public places, the mortality of sudden cardiac arrest is high. Patients who suffer out-of-hospital sudden cardiac arrest have a 4 to 40% chance of surviving to hospital discharge.

Of those patients who do survive sudden cardiac arrest, 90% have emerged from their acute event and have good mental functioning by day three post-arrest; those who remain in a coma after 72 hours have a dismal prognosis.

The risk of a recurrent sudden cardiac arrest after survival of an initial event is 10 to 30%, even with aggressive therapy such as the initiation of beta-blockers, valvular repair, and coronary artery bypass.

Treatment

The most important factor by far in determining overall survival after a sudden cardiac arrest is time to defibrillation, which can be administered by trained lay persons who have access to an AED or by medical professionals.

For every minute that passes from a witnessed sudden cardiac arrest to defibrillation, the chance of survival decreases by 7-10% if no cardiopulmonary resuscitation is given and 3-4% if CPR is administered.

What is little understood by the public is that defibrillation does not actually "restart" the heart but rather stuns the heart in an attempt to allow the normal pacemaker mechanism to function.

In all situations, cardiopulmonary resuscitation (CPR) must be undertaken immediately (without checking for a pulse) for a minimum of several minutes after a patient with sudden cardiac arrest is defibrillated.

This provides delivery of oxygenated blood to the brain and other organs during the interval that the heart is attempting to return to organized electrical activity.

Correctly performed CPR consists of chest compressions to a depth of 1.5 to 2 inches for thirty compressions, with two rescue breaths given at the end. Emergent transfer to a hospital is mandatory.

Meaningful chance of recovery diminishes very rapidly if a rhythm and discernable pulse is not established within 15-20minutes. Most professionals suspend resuscitative efforts if there are no correctable abnormalities and the patient is warm after about 25-30minutes from onset of resuscitation.


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Study Shows Highly Promising New Class Of Anti-Cancer Drugs

The New England Journal of Medicine has published a study today that shows stunning results of a new class of anti-cancer drugs known as PARP inhibitors. Scientists think this the class of drugs might be effective against breast, ovarian, and prostate cancers among others.


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Doctor Trapped In Antarctica With Breast Cancer In 1999 Has Died

Dr. Jerri Nielsen, the emergency room physician who diagnosed and treated herself with chemotherapy for five months until rescuers could reach her after the winter season ended, has died. She was 57.

Surgeon Who Operated On Steve Jobs Gives Press Conference

Transplant surgeon Dr. James Eason of Methodist University Hospital in Memphis, Tennessee discusses the steps Steve Jobs took to receive his recent transplant.


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New Treatment For Liver Melanoma Looks Promising

Researchers at the Greenebaum Cancer Center at the University of Maryland are testing a new procedure called percutaneous hepatic transfusion (PHP) in patients who have melanoma that is metastatic to the liver. According to oncologist Dr. Richard Alexander, PHP delivers a chemotherapy dose directly to the liver that is ten times what is normally given.

Surgical Trainees At Massachusetts General Hospital Violate Work Rules

Surgical residents at Massachusetts General Hospital are violating the work rules and thus possibly endangering patients, according the Accreditation Council for Graduate Medical Education. But, according to surgical trainees Drs. Parsia Vagefi and Emily Christison-Lagay, the restriction on the number of hours that a surgical resident can work may actually be harming, not helping, patients.


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Although none of the editors of InsideSurgery.com are participating in his care, we have noted reports that Apple Founder and Chairman Steve Jobs received a liver transplant earlier this spring.

Fortune magazine is reporting that he received the transplant in Tennessee and is said to be recovering well. Jobs began a well-publicized job leave earlier this year for medical issues that were later deemed "more complex" than originally believed.

Jobs received surgical treatment in 1994 for an insulinoma of the pancreas.

Liver transplantation is a highly complex surgical procedure and management that is done by surgeons who commonly make this procedure the focus of their careers. Patients undergoing liver transplantation go through three phases of treatment.

Pre-transplantation and Listing

Liver transplantation in the United States is performed under a hybrid "public/private" arrangement between the United Network for Organ Sharing (UNOS) and individual transplant centers. UNOS is the agency that has been awarded exclusive jurisdiction by the federal government in deciding which patients on the transplant waiting lists receive available organs and tissue.

Liver transplant programs require considerable hospital financial and personnel resources. It is generally acknowledged that these operations are best performed by centers who perform large volumes of the procedure by professionals who devote themselves largely to this procedure and patient population.

Individual centers have broad leeway in deciding which patients to place on the waiting list for transplantation. Each center has their own exclusion criteria and protocols for evaluating prospective patients.

Most patients who receive a liver transplant are classified as having either chronic or fulminant (i.e., rapid) liver failure. A small percentage of patients receive a liver transplant to remove a liver containing a malignancy or to correct an underlying physiological defect when they are not in frank liver failure.

Generally, patient evaluation for liver transplant include a detailed history and physical, a financial means test, and an evaluation of likely compliance with the lifelong regimen needed to maintain the viability of the graft.

It is important to determine that the patient has enough physiological reserve to withstand the rigors of the operation and following regimen of immunosuppression.

A diligent search for the reason for liver failure and remaining liver reserve is made. Lab tests commonly drawn include serologies for hepatitis and HIV, blood type, liver function tests, Ebstein Barr virus (EBV), cytomegavirus (CMV), complete blood count, albumin, ammonia, serum electolytes, and urine and blood drug tests.

Other tests performed include computed tomography of the abdomen and pelvis, magnetic resonance imaging, electrocardiogram, and cardiac stress tests.

The most common etiologies in the United States include alcohol and substance abuse and infection with the hepatitis C virus. In cases of substance abuse, many (but not all) centers require a period of abstinence before the patient is entered onto the waiting list.

After a patient is deemed acceptable for transplantation a MELD score is calculated for them and is used as an indicator of severity of liver disease. The variables used in determining the MELD score are age, serum bilirubin, serum creatinine, and INR (internationation normalized ratio, a measure of coagulopathy or "thinned blood".)

The Liver Transplant Surgical Procedure

Immunosuppression and Post-transplant Period






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Academic Hall Of Fame Nominee Recalls Football Glory Days

Orthopedic Surgeon and CoSIDA Academic All-America Hall of Fame nominee Dr. Pat Tyrance reminisces about his days as a linebacker for the Nebraska Cornhuskers.


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British Surgeon Spreading Use Of Single Port "Scar Free" Surgery

Surgeon Paraskevas Paraskeva of the Imperial College NHS Trust is teaching his colleagues the techniques for single port laparoscopic surgery performed through the umbilicus (aka navel or belly button.)


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Neurosurgeon Named To Head Troubled Program At North Shore-Long Island Jewish Health System

Dr. Raj Narayan has been named the new head of Neurosurgery at North Shore-LIJ Health system. He replaces Dr. Thomas Milhorat, who earlier this year abruptly resigned after being suspended by the hospital for allegedly abandoning a patient.


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Patient Desribes Operation To Release Trapped Ulnar Nerve

Patient Tony Njeim explains how Srinath Kamineni released his trapped left ulnar nerve by drilling a hole in the "funny bone" of this left arm.

There are four drugs that are commonly given in initial treatment for acute coronary syndrome, if no contraindications exist. These include:

Morphine, Oxygen, Aspirin, Nitroglycerin

MOAN

Patients having myocardial infarctions moan in pain.