Brooke Army Medical Center Research Articles

A Rare Etiology of Bilateral Vocal Fold Paresis: Multinodular Goiter

Otolaryngology–Head and Neck SurgeryVolume 134, Issue 2 p. 340-342 Case Report A Rare Etiology of Bilateral Vocal Fold Paresis: Multinodular Goiter Heath Tennyson MD, CPT, USA, MC, Corresponding Author Heath Tennyson MD, CPT, USA, MC [email protected] Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXReprint requests: Heath Tennyson, MD, CPT, USA, MC, Brooke Army Medical Center, Department of Otolaryngology, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. E-mail address: [email protected].Search for more papers by this authorCraig Fowler DDS, COL, USAF, DC, Craig Fowler DDS, COL, USAF, DC Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXSearch for more papers by this authorJoseph Brennan MD, COL, USAF, MC, Joseph Brennan MD, COL, USAF, MC Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXSearch for more papers by this author Heath Tennyson MD, CPT, USA, MC, Corresponding Author Heath Tennyson MD, CPT, USA, MC [email protected] Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXReprint requests: Heath Tennyson, MD, CPT, USA, MC, Brooke Army Medical Center, Department of Otolaryngology, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. E-mail address: [email protected].Search for more papers by this authorCraig Fowler DDS, COL, USAF, DC, Craig Fowler DDS, COL, USAF, DC Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXSearch for more papers by this authorJoseph Brennan MD, COL, USAF, MC, Joseph Brennan MD, COL, USAF, MC Wilford Hall Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TXSearch for more papers by this author First published: 17 May 2016 https://doi.org/10.1016/j.otohns.2004.12.009 The contents of this manuscript do not reflect the views of the United States Army, United States Air Force, Department of Defense or United States Government. The undersigned authors bear no conflict of interest with the generation or publication of this manuscript. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, New York, NY, September 18–23, 2004. Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume134, Issue2February 2006Pages 340-342 RelatedInformation

Jay Donald Mabrey, MD: A Conversation with the Editor

Jay Mabrey (Figure ​(Figure11) was born in Lawton, Oklahoma, on December 13, 1954. He spent his early years in Norman, Oklahoma, and moved to Warren, Ohio, when he was 13. He graduated from Cornell University cum laude in biological sciences in 1977 and from Cornell University Medical College in 1981. His 2-year general surgery training and 4-year training in orthopaedic surgery were at Duke University Medical Center in Durham, North Carolina. Dr. Mabrey practiced orthopaedic surgery at the Winn Army Community Hospital in Fort Stewart, Georgia, from 1987 until 1990 and then returned to New York City for a fellowship in biomechanics and total joint surgery at the Hospital for Special Surgery. He then moved to San Antonio, Texas, working initially at the Brooke Army Medical Center before working full-time for the University of Texas Health Science Center at San Antonio. During his tenure in San Antonio, he also served as chief of orthopaedics at the Andre L. Murphy Veterans Affairs (VA) Medical Center from 1996 to 2002.

Radiologic-Pathologic Conference of Brooke Army Medical Center

Radiologic-Pathologic Conference of Brooke Army Medical CenterEndometriosis of the Canal of NuckAaron Kirkpatrick1, Christopher M. Reed1, Liem T. Bui-Mansfield1 2, Michael J. Russell3 and Wendy Whitford1Audio Available | Share

Non‐alcoholic fatty liver disease: The unfolding monster?

Non-alcoholic fatty liver disease is now recognized as a common clinical condition that includes a spectrum of liver damage, ranging from simple, bland steatosis, which is usually associated with a benign prognosis, to NASH, which is believed to possess the potential to progress to cirrhosis and its inherent complications of liver failure and liver cancer. 4‐7 The scenario is quite similar to the Helicobacter pylori story. When the possibility that the organism H. pylori could produce peptic ulcer was first mooted in the 1980s, the idea was greeted with much skepticism: was it something of any import or was it a mere toy for researchers to fool around with and embellish their curriculum vitae? The attention that the ugly duckling, that is, NAFLD is now getting is obvious if one conducts a search of publications relating to NAFLD in PUBMED. While there was only one paper or two for the whole year a decade ago, the number of papers published on NAFLD in recent years is skyrocketing; last year, the figure almost reached 100. Every hepatologist worth their salt has jumped into the fray. What then is this entity? Is the hype justified? What are the facts? With the available information is it possible to separate the wheat from the chaff? Is there any basis to justify the claims that the disease is not the benign little thing that everyone thought it to be, that it could actually, over the years, progress to cirrhosis of the liver or even liver cancer? Is the evidence incriminating NAFLD foolproof? Let us take a look at the information available regarding the outcome or natural history of this disease. In 1990, Elizabeth Powell et al. from Australia published their experience on the natural history of 42 patients with NASH. 8 In their study, serial liver biopsy specimens revealed minimal or no apparent progression of the disorder in most of the patients, in keeping with their benign clinical course. Only one patient with minimal baseline fibrosis showed progression from fibrosis to cirrhosis during the 5-year observation period. However, in two patients who had extensive fibrosis at the outset, the liver disease evolved from one of active inflammation to one of inactive cirrhosis without fat or inflammation, and one of the patients with cirrhosis later died of hepatocellular carcinoma. This work has been widely acclaimed, and is considered a landmark paper in showing how two of their patients with fatty liver disease could progress to cirrhosis of the liver without any trace of fat, leading to the hypothesis that NASH could be a prime candidate for a significant proportion of cryptogenic cirrhosis. Notwithstanding, one needs to take this with a pinch of salt. That study involved a very small number of patients, and cirrhosis developed in only three patients, all of whom had fibrosis in the beginning itself; in fact two of these patients had extensive fibrosis at the outset. Also, this cohort had a disproportionate number of patients with significant fibrosis. When Harrison et al . at the Brooke Army Medical Center in Texas, USA decided to study the natural history of NASH, and reviewed liver biopsy slides from non-alcoholic fatty liver patients who underwent more than one liver biopsy during the period from 1985 to 2001, they could lay their hands on the slides of 22 patients only. 9 Of these, 10 patients (45%) had fibrosis stage 1 or 2, and two patients (9%) had bridging fibrosis or cirrhosis (stage 3 or 4) on first biopsy. Seven (32%) had increases in fibrosis score. Four patients (18%) had decreases in fibrosis score. The percentage of patients with stage 3 or 4 increased from 9% to 18%. In two patients the disease progressed rapidly, and three patients progressed from steatosis to steatohepatitis with fibrosis. The authors concluded that one-third of patients have fibrosis progression, and one-third of these have rapid progression to advanced fibrosis, and that steatosis alone may progress to NASH with fibrosis. A close look, however, reveals that these numbers were too small, only 22 during a 16-year period. These patients underwent repeated biopsies because they had qualified for same during therapeutic trial. It is obvious that these patients were the sicker ones, and that data pertaining to them should not be extrapolated to the average NAFLD patients. Another attempt by Fassio et al . in Argentina to elucidate the natural history also involved an identical figure of 22. 10

The treatment of burns. By Curtis P. Artz, M.D., F.A.C.S., Lt. Col., M.C., U.S.A. (Rtd.). Late Director, Surgical Research Unit, Brooke Army Medical Center, Fort Sam, Houston, Texas; and Eric Reiss, M.D., Instructor in Medicine, Washington University School of Medicine, St. Louis, Missouri. 10 × 6 1/2 in. Pp. 250 + xii, with 105 illustrations. 1957. Philadelphia and London: W.

Journal Article The treatment of burns. By Curtis P. Artz, M.D., F.A.C.S., Lt. Col., M.C., U.S.A. (Rtd.). Late Director, Surgical Research Unit, Brooke Army Medical Center, Fort Sam, Houston, Texas; and Eric Reiss, M.D., Instructor in Medicine, Washington University School of Medicine, St. Louis, Missouri. 10 × 6 1/2 in. Pp. 250 + xii, with 105 illustrations. 1957. Philadelphia and London: W. B. Saunders. 52s. 6d Get access The treatment of burns. By Curtis P Artz, M.D., F.A.C.S., Lt. Col., M.C., U.S.A. (Rtd.). Late Director, Surgical Research Unit, Brooke Army Medical Center, Fort Sam, Houston, Texas; and Eric Reiss, M.D., Instructor in Medicine, Washington University School of Medicine, St. Louis, Missouri. 10 × 6 1/2 in. Pp. 250 + xii, with 105 illustrations. 1957. Philadelphia and London: W. B. Saunders. 52s. 6d British Journal of Surgery, Volume 45, Issue 190, September 1957, Pages 207–208, https://doi.org/10.1002/bjs.18004519038 Published: 06 December 2005

Melan-A/MART-1 Positive ???Pseudonests??? in Lichenoid Inflammatory Lesions: An Uncommon Phenomenon

To the Editor: Maize et al1 recently called attention to the phenomenon of Melan-A-positive pseudonests in the setting of lichenoid inflammation. Although the histologic features in their patient suggested partially regressed melanoma in-situ, this interpretation was at odds with the clinical information, and the pseudonests did not stain for S100 protein or a “melanoma cocktail” of tyrosinase and HMB-45. The authors proposed that the pseudonests represented degenerated melanocytic debris engulfed by macrophages or keratinocytes damaged by the lichenoid tissue reaction. The unexpected staining pattern raised appropriate concern about the diagnostic utility of Melan-A in the setting of a lichenoid tissue reaction. The findings were of particular interest to us, as we have previously studied lichenoid tissue reaction in melanomas.2 We used MART-1, rather than Melan-A, as our primary immunoperoxidase stain for melanocyte lineage. Melan-A and MART-1 antibodies generally give similar staining patterns.3-6 In our study, we found MART-1 helpful in highlighting melanocytic nests in the setting of lichenoid regression of melanoma.2 The potential for non-specific staining of pseudonests is of concern, in that it could result in a spurious diagnosis of regressing melanoma. We designed a study to evaluate the frequency of pseudonest staining with Melan-A or MART-1 in the setting of proven lichenoid inflammatory lesions. A total of 132 biopsies of lichen planus were retrieved from the surgical pathology files of Brooke Army Medical Center, Wilford Hall Medical Center and Geisinger Medical Center. The 80 cases from BAMC and WHMC were stained with Melan-A, while 52 cases from Geisinger Medical Center were stained with both Melan-A and MART-1. Formalin-fixed, paraffin-embedded tissue sections were used for immunohistochemical analysis. We used the Dako Melan-A antibody with a 1:30 dilution and microwave heating retrieval in Citrate Buffer at pH 6.0. The sections were rinsed in water and placed in Tris Buffered Saline. MART-1 antibody from Biocare Medical was used at a dilution of 1:100, with the retrieval method of the “Borg Decloaker” at ph 9.5 that involved preheating the tissue sections in a 96°C water bath. The sections were left in hot decloaker and a water bath for 20 minutes, then removed and allowed to cool for 20 minutes. The sections were then washed in tap water and placed in Tris Buffered Saline. Finally, slides were placed on the Dako Autostainer and detected and visualized with Dako's Envision Plus detection system. Slides were examined to determine the presence or absence of pseudonests staining positive for Melan-A and/or MART-1. In these 132 cases of cutaneous lichen planus, we found no Melan-A/MART-1 positive pseudonests. The staining intensity and number of junctional melanocytes in each case was identical between the two stains. Our study provides some reassurance that non-specific pseudonest staining by Melan-A/MART-1 in lesions with lichenoid inflammation is an uncommon occurrence. Despite this reassurance, we agree with the recommendation made by Maize et al to exercise caution when interpreting a single immunoperoxidase stain and to correlate histologic findings with the clinical history. Captain Steven D. DeMartini USAF, MC* MAJ Scott R. Dalton, MC, USA† Tammie Ferringer, MD‡ Dirk M. Elston, MD‡ *Department of Pathology, Wilford Hall Medical Center and Brooke Army Medical Center San Antonio, TX; †Department of Pathology, Bassett Army Hospital, Fort Wainwright, AK; ‡Department of Dermatology, Geisinger Medical Center, Danville, PA

Subungual Squamous Cell Carcinoma of the Finger

5Department of Surgery, Orthopedic Service, Brooke Army Medical Center, San Antonio, TX 78234. 53-year-old woman presented to a dermatologist with a subungual mass in the right index finger. Radiographs revealed a subungual soft-tissue mass that had eroded into the distal phalanx of the index finger. The dermatologist performed a biopsy, revealing the diagnosis of squamous cell carcinoma. The index finger was amputated. The differential diagnosis of an erosive lesion in the distal phalanx includes implantation dermoid cyst, subungual fibroma, glomus tumor, giant cell tumor of tendon sheath, subungual squamous cell carcinoma, subungual keratoacanthoma, and mucous cyst [1]. Radiologically, subungual squamous cell carcinoma is almost indistinguishable from subungual keratoacanthoma. Keratoacanthoma is a localized endoexophytic growth of squamous epithelium with a characteristic central keratin-filled crater. Keratoacanthomas may be locally destructive and sometimes are associated with transformation to squamous cell carcinoma with subsequent invasion. Some authors consider keratoacanthoma a subset of squamous cell carcinoma [2]; however, keratoacanthomas more frequently undergo spontaneous involution, and the larger consensus is that they are separate lesions with distinctive behavior. The treatment of subungual keratoacanthoma is conservative, while that of subungual squamous cell carcinoma is amputation. Both subungual keratoacanthoma and squamous cell carcinoma may present with pain, localized swelling, and inflammation. Patients with subungual squamous cell carcinoma tend to be older (seventh decade peak) than those with keratoacanthoma (fifth decade peak) [1–4]. Squamous cell carcinoma grows slowly and often is mistaken for chronic inflammation. In contrast, subungual keratoacanthoma grows rapidly, proliferating to an obvious 1to 2-cm mass within several weeks to months; then generally stabilizes and later spontaneously involutes, leaving a small pitted scar [1]. Eighty-four percent of subungual squamous cell carcinomas occur in the fingers, the remaining in the toes. The majority of subungual squamous cell carcinoma in the fingers occurs in the thumb (44%); and those in the toes affect the great toe predominately (64%) [3, 4]. Predisposing factors for subungual squamous cell carcinoma include chronic paronychia, trauma, congenital ectodermal dysplasia, radiation exposure, and previous human papillomavirus (HPV) infection [3, 4]. In A

Cost and time benefits of dual implantation of inflatable penile and artificial urinary sphincter prosthetics by single incision

Objectives To evaluate the efficiency, safety, and cost-effectiveness of synchronous prosthetic treatment of male urinary incontinence and impotence using a single transverse scrotal incision. Methods A total of 92 inflatable penile prostheses (IPPs), 21 artificial urinary sphincters (AUSs), and 15 combined IPPs/AUSs were implanted in 128 men at Brooke Army Medical Center and the University of Texas Health Science Center at San Antonio. The operative times and outcomes were compared among three groups (group 1, IPP; group 2, AUS; and group 3, dual IPP/AUS). We performed cost estimates of synchronous versus two-stage implant procedures. Results Dual implantation in a single-stage procedure significantly reduced (24.7%) the operative time ( P <0.05, mean 113 minutes) compared with the total time for the individual procedures (IPP, average of 78 minutes; AUS, average of 72 minutes; total 150 minutes). No prosthetic infections or erosions occurred in this series. Dual implantation was associated with approximately a $7000 cost savings compared with individual procedures. Conclusions The results of our study have shown that dual prosthetic implantation through a single incision is safe, efficient, and cost-effective.

Review of Subacute Stent Thrombosis Following Percutaneous Coronary Intervention at a Low‐Volume Catheterization Laboratory

The frequency of coronary stent subacute thrombosis (SAT) following percutaneous coronary intervention (PCI) with uncoated stents in recent studies is 0.5%-0.9%. Prior studies have indicated that complication rates are significantly higher when performed in low-volume centers. We sought to determine the incidence and outcomes of SAT following PCI with stent placement at a low-volume catheterization laboratory. We reviewed the Brooke Army Medical Center Interventional Database for all consecutive PCIs with stent implantation performed from January 1998 to December 2002. Clinical outcomes were obtained primarily through hospitalization records and clinic follow-up visits. There were 789 interventions with stenting on 750 patients over the specified time period, for an average of 158 procedures on 150 patients per year. There were seven cases of SAT, representing a rate of 0.89%. There was no difference in the clinical characteristics, procedural technique, or postprocedural antithrombotic therapy of the subjects with and without SAT. Of those with SAT, there were no subjects requiring surgical revascularization during index hospitalization, and all survived to index hospital discharge. Six of these seven subjects with SAT (85.7%) were alive at one year, with the single death noncardiovascular related. The incidence of thrombosis occurring within 30 days of intracoronary stent implantation is similar in low- and high-volume catheterization laboratories. In our low-volume laboratory experience, these events were not associated with significantly increased adverse outcomes.

Fertility in Men After Treatment for Stage 1 and 2A Seminoma

The purpose of this article is to assess the long-term fertility and attitudes towards fecundity in men after radical inguinal orchiectomy and radiation therapy (RT) for seminoma, and also to assess how often sperm cryopreservation is being offered to patients with seminoma prior to treatment. A retrospective review was conducted at 3 institutions (Wilford Hall Air Force Medical Center, Brooke Army Medical Center, and Fitzsimmons Army Medical Center) to identify patients who had undergone treatment of stage 1 or 2A seminoma during the period from 1975 to 1997. Seventy-three of 212 (34%) patients meeting the selection criteria of stage 1 or 2A seminoma provided information for this analysis. This was thought to be a good response rate, given that many of the patients had changed duty stations or had separated from the military by the time this study started. We performed a review of RT and tumor board records of 73 patients who were treated for testicular seminoma at selected treatment facilities from 1975 to 1997. Patients completed questionnaires and phone interviews that focused on prior fertility, the desire to father (more) children, other fertility-affecting factors (varicocele, cryptorchidism, infection, and erectile dysfunction), and incidence of physician counseling with regard to cryopreservation. All patients were asked to obtain a current semen analysis (SA). Eleven (15%) patients reported that they had tried to father children since completion of their RT. Seven of 11 (64%) successfully achieved pregnancy within a mean time of 3.5 years since RT (range: 1 month to 5 years). Of the 4 couples that were not successful, 1 had severe female factor infertility problems and a second had organic erectile dysfunction. A third had a past surgical history remarkable for vasectomy with subsequent vasectomy reversal. Nine patients provided SA. Mean sperm count and motility were 24.2 Mil/mL (range: 5-81 Mil/mL) and 63.1% (range: 30-90%), respectively (normal SA values: count = 20-250 Mil/mL, motility >50%, and volume = 1.5-5.0 mL). No patients were azoospermic. Overall mean time interval from radiation therapy was 7.9 years. Radiation dose and time since RT did not correlate with either SA results or conception. Only 16 of 73 (22%) men had been offered pretreatment sperm cryopreservation by their counseling physician. It is concluded that (1) patients who are treated for early stage seminoma by orchiectomy and RT have greater than a 50% chance of regaining normal semen parameters, and all regain at least some spermatogenesis; 2) recovery of spermatogenesis is not related to therapeutic radiation dose with the use of modern shielding and RT portals; (3) the majority of treated patients who desire children can conceive; and (4) sperm cryopreservation remains an underutilized option for seminoma patients.

Using a Distance-Learning Program to Educate Staff on the Joint Commission National Patient Safety Goals

A motion picture expert group (MPEG) distance-learning program was created in 2003 at Brooke Army Medical Center (BAMC; San Antonio, Texas) on the Joint Commission National Patient Safety Goals. The 34 2-4-minute scripted video productions addressed the 7 goals and 13 recommendations for 2003 and 2004. For each goal, three MPEGs respectively describe sentinel events pertaining to that goal, root causes and risk-reduction strategies, and Army Medical Department and BAMC recommendations and policies. The program entailed creating the scripts, narrating video, editing the tapes, and compressing the videos into the MPEG format. A featured MPEG was emailed weekly to over 3,000 hospital staff with a scripted endorsement and photograph of a key BAMC leader and a link to the MPEG. In addition, the MPEGs were placed on the hospital's intranet site. As the National Patient Safety Goal MPEG distance-learning program gained more recognition, different branches of the Army used the program to educate their staff on the Joint Commission National Patient Safety Goals. The next step is to update the distance-learning program with new MPEGs that will provide guidance on the current National Patient Safety Goals.

Guidelines for appropriate in-hospital emergency team time management: the Brooke Army Medical Center approach.

Successful outcome following cardiac arrest have been reported in the range of 13-59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention. Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards. The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67-91, 85-95, 67-71 and 93-86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017). Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge.

Wechsler Adult Intelligence Scale-Third Edition Characteristics of a Military Traumatic Brain Injury Sample

This article describes the postinjury cognitive functioning of a sample of active duty, retired, and military beneficiaries who received traumatic brain injuries. Patients were seen in the neuropsychology clinic at Brooke Army Medical Center for a detailed cognitive and personality assessment. The scores on a major component of this evaluation, the Wechsler Adult Intelligence Scale, third edition, are summarized. The results are compared with those reported in the Wechsler Adult Intelligence Scale, third edition technical manual for a smaller, less diverse sample. The findings are consistent with the formulation that stable verbal skills are most resistant to brain injury, followed by nonverbal reasoning and visuospatial ability, and then working memory with speed of information processing being the most vulnerable to the effects of brain injury.

Balanitis xerotica obliterans: epidemiologic distribution in an equal access health care system.

We analyzed the incidence of balanitis xerotica obliterans (BXO) by both age and ethnicity at an equal-access health care facility. We retrospectively reviewed discharge records from 1997 to 1999 at Brooke Army Medical Center to determine ethnicity and age of patients with BXO. Of 153,432 male patients, 108 (0.070%) had a diagnosis of BXO. The age distribution was similar over a range from 2 to 90 years, with the exception of the third decade, when the incidence almost doubled. Black and Hispanic patients had twice the incidence found in white patients (10.59, 10.67 and 5.07 per 10,000 patients, respectively). At our equal-access health care facility, the incidence of BXO in black and Hispanic patients was double that in whites. This unexpected finding, in concert with the greater incidence in the third decade, may result from greater access to medical attention for these patients in the military setting. Nevertheless, further research into the origin of the disease is warranted.

The Usefulness Of A Preoperative Pregnancy Questionnaire In Determining The Need For Pregnancy Testing Prior To Anesthesia

Background: Many physicians require pregnancy testing before anesthesia despite no evidence that anesthetics in clinical concentrations are teratogenic. This approach is costly and does not follow current recommendations. The authors designed a preoperative pregnancy questionnaire to determine the likelihood of pregnancy. The goal was to determine if an assessment based on history would help decrease needless preoperative tests. Methods: Patients (n=216) 13-56 yrs completed the questionnaire and underwent urine pregnancy testing prior to surgery. The questionnaires were reviewed to determine if pregnancy testing was indicated. Results: Twenty-one patients needed pregnancy testing based on their histories. The testing yielded one positive result that was predicted based on history. Conclusions: A questionnaire is useful for the anesthesiologist when determining the need for preoperative pregnancy testing. A history is the backbone of medicine, and should guide preoperative testing. This would streamline the preoperative process, while maintaining vigilance. Funding from: Anesthesia and Operative Service, Brooke Army Medical Center.

Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department

Cardiovascular textbooks1–3 report that alleviation of chest discomfort with nitroglycerin is a diagnostic clue to myocardial ischemia as the underlying cause. The Diamond and Forrester criteria4 for establishing a likelihood of obstructive coronary artery disease uses pain relief with rest or nitroglycerin as 1 of 3 symptoms to define typical angina pectoris. In the acute care setting, underlying cardiac disease is frequently invoked to explain chest pain symptoms that respond to nitrate therapy. Despite this, the scientific literature has little published research that merits nitroglycerin’s use in this manner. We sought to evaluate the diagnostic value of the nitroglycerin response and whether such response in the emergency department predicts the subsequent diagnosis of a cardiac etiology of chest discomfort. A retrospective review was conducted of the records of all patients who presented with ongoing chest pain to the emergency department at Brooke Army Medical Center, San Antonio, Texas, from January 2000 to May 2000. Patients were included who presented to the emergency department with ongoing chest pain, who received sublingual nitroglycerin, who did not receive medications (other than aspirin, 325 mg) within 10 minutes of nitroglycerin, whose response was charted in the nursing records, and whose follow-up data were available.

Computer Simulation: A Methodology to Improve the Efficiency in the Brooke Army Medical Center Family Care Clinic

Computer Simulation: A Methodology to Improve the Efficiency in the Brooke Army Medical Center Family Care Clinic

Auscultation versus echocardiography in a healthy population with precordial murmur

P murmurs are common in young asymptomatic adults, occurring in 5% to 52% of screened populations.1 Frequent cardiac consultation is requested for evaluation of murmurs detected during routine physical examinations. Echocardiograms are often requested by referring and consulting physicians. However, screening echocardiography is not indicated for 2 principle reasons: first, the cost is not trivial, and second, the current resolution of echocardiography can reveal details of cardiac function that may be physiologic but interpreted as pathologic, resulting in unnecessary testing or therapy. Murmur examination before echocardiography is recommended by the 1997 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Clinical Application of Echocardiography.2 In these guidelines, innocent murmurs are defined as short systolic ejection murmurs that occur at the left sternal border, that are soft in intensity (grades 1 to 2/4), that are associated with a normal second heart sound, and do not have other cardiac examination abnormalities. This is based on clinical research showing that these features, when assessed together with normal electrocardiography and plain chest x-rays, seem to be associated with the absence of cardiac pathology.3–6 However, the only blinded study in nonpregnant adults utilizing the above murmur criteria showed only a 62% sensitivity for predicting normal echocardiography (38% of those with “innocent murmurs” had abnormalities on echocardiography).7 We sought to evaluate the ACC/ AHA echocardiographic guidelines for murmur evaluation in a young, healthy population. • • • We prospectively enrolled the cohort of all military patients referred to the cardiology clinic for an abnormal precordial murmur. Patients were excluded if they had previously documented echocardiographic abnormalities or were being referred for evaluation of other cardiac complaints. All patients received a standardized questionnaire, which included questions on cardiovascular and valvular disease risk factors, as well as any previous cardiovascular symptoms. All patients underwent a detailed cardiovascular examination performed by a staff cardiologist or senior cardiology fellow. This included standardized auscultation, determining the presence, location, timing, duration, quality, and intensity of the murmur. Further, the character of S1 and S2 and the presence of gallops or extra heart sounds were noted. Examiners were blinded to the results of echocardiography. Innocent murmurs were defined using the ACC/AHA echocardiographic guidelines.2 All other murmurs were considered abnormal murmurs. All patients underwent electrocardiography and echocardiography. Trained technologists performed a complete 2-dimensional Doppler echocardiogram, utilizing Hewlett-Packard Sonos (Palo Alto, California) 1500 and 2500 commercial ultrasound units in standard imaging planes and recorded on SuperVHS videotape. The studies were read in a standardized format by cardiologists blinded to the physical examination results. Abnormal echocardiograms were defined as requiring bacterial endocarditis prophylaxis (AHA guidelines8), medical therapy, surgery, other invasive procedure, or any medical follow-up. All others were considered normal. Normal echocardiograms included some patients with mild amounts of mitral or tricuspid regurgitation and structurally normal valves. Consent was obtained for the use of the patient’s data in the study. The institutional review board approved the study protocol. The statistical analyses performed were determined before study inception. The primary analysis evaluated the test characteristics and predictive value of the physical examination, using echocardiography as the gold standard. A total of 72 patients were referred; 31 were activeduty military personnel and 41 were Reserve Officer Training Corps cadets. Significantly, the 41 cadets with murmurs represented 1% of all cadets screened in a one-time physical examination. Mean age was 25 6 5.7 years. There were 28 women and 44 men. Although not referred for other complaints, 11 patients had 14 complaints on detailed cardiovascular history: 8 had experienced palpitations, 3 had shortness of breath, and 3 had prior syncope. All patients were without symptoms at the time of examination. Six patients had chronic medical conditions: 4 had hypertension, 1 had Graves’ disease, and 1 had Ehlers-Danlos syndrome. Detailed cardiovascular physical examinations were normal in all patients except for the precordial murmurs and blood pressures. Of the 72 patients, 30 patients did not meet the ACC/AHA criteria for an innocent murmur, and were thus defined as having an abnormal murmur. Murmur examination findings are listed in Table 1. Twenty-nine patients had innocent murmurs. Thirteen patients had transient murmurs (murmurs that prompted the referral but were not present at the time of evaluation). Four patients were found to be hypertensive. Nine patients (13%) had abnormal echocardioFrom the Cardiology Division, Brooke Army Medical Center, San Antonio, Texas; Pike’s Peak Cardiology Group, Colorado Springs, Colorado; and Cardiology Division, Walter Reed Army Medical Center, Washington, DC. Dr. Shry’s address is: Cardiology Service, 3851 Roger Brooke Drive, Bldg. 3600, Brooke Army Medical Center, San Antonio, Texas 78234-6200. E-mail: Eric.Shry@CEN. AMEDD.ARMY.MIL. Manuscript received September 8, 2000; revised manuscript received and accepted January 9, 2001.

TREATMENT OF GRADE 4 RENAL STAB WOUNDS WITH ABSORBABLE FIBRIN ADHESIVE BANDAGE IN A PORCINE MODEL

In a porcine model we evaluated the efficacy of the absorbable fibrin adhesive bandage and other novel fibrin products for treating major renal stab wounds. In commercial swine we produced an almost lethal, grade 4 renal stab wound via a 3.5 cm. sagittal, centrally located, through-and-through laceration. Each pig then received treatment in random fashion, including conventional oversewing of capsular defects with absorbable gelatin sponge and horizontal mattress sutures in 6, external absorbable fibrin adhesive bandage that was pressure held for 60 seconds in 6, external and internal absorbable fibrin adhesive bandage that was applied externally, inserted into the renal defect and pressure held for 60 seconds in 6, liquid fibrin sealant that was placed in the laceration and held for 60 seconds in 8, fibrin foam that was applied in the same manner as liquid fibrin in 5 and closing of the peritoneum over the lacerated kidney without further treatment in 6. Blood loss and time to hemostasis were recorded. Animals were sacrificed at 6 weeks to evaluate the injured renal unit. Compared with conventional therapy the absorbable fibrin adhesive bandage applied externally alone or externally and internally resulted in significantly less bleeding and significantly less time to hemostasis (p <0.001). Liquid fibrin and fibrin foam did not reliably achieve hemostasis. Postoperatively computerized tomography and histological sectioning suggested that the absorbable fibrin adhesive bandage results in a stable, durable clot and healing is at least as successful as with conventional treatment. The absorbable fibrin adhesive bandage appears to be a safe, rapid means of renal salvage after injury.

6969 Outcome of rescreening patients referred for open access flexible fiberoptic sigmoidoscopy.

Backround: Open access flexible fiberoptic sigmoidoscopy (FFS) has been in place for one year at Brooke Army Medical Center. This service is available for routine colorectal cancer screening and thus performed on average risk asymptomatic patients. To ensure that these patients are appropriate candidates a health care provider must answer a series of questions to ensure that these patients are at average risk. After these screening questions have been answered, the patient is enrolled into the open access FFS clinic. The patients are not interviewed further and a FFS is completed. Methods: Three hundred and thirty seven patients, who were enrolled in the open access FFS program by the primary care providers, were contacted by telephone and rescreened by a member of the gastroenterology clinic for appropriateness of the FFS.Those who did not meet criteria for screening FFS were referred back to the primary care provider to obtain a full gastroenterology appointment. Results: There were two hundred and eighty three or 83.9% who fulfilled the criteria for screening FFS. The remaining 16.1% were either not average risk for colorectal cancer or needed a total colonic exam rather than a screening flexible sigmoidoscopy. Twentyfour (7.1%) patients had a family history of colon cancer, 15 (4.5%) patients had a personnel history of colonic polyps, 12 (3.6%) patients had recent history of hematochezia, and 3 (.9%) patients had a personnel history of colon cancer. Conclusion: Routine screening FFS is an appropriate screening strategy in approximately 3/4 of patients in an open access FFS program. Further questioning will result in a total colonic exam as being a more appropriate test in about 1/4 of patients. Backround: Open access flexible fiberoptic sigmoidoscopy (FFS) has been in place for one year at Brooke Army Medical Center. This service is available for routine colorectal cancer screening and thus performed on average risk asymptomatic patients. To ensure that these patients are appropriate candidates a health care provider must answer a series of questions to ensure that these patients are at average risk. After these screening questions have been answered, the patient is enrolled into the open access FFS clinic. The patients are not interviewed further and a FFS is completed. Methods: Three hundred and thirty seven patients, who were enrolled in the open access FFS program by the primary care providers, were contacted by telephone and rescreened by a member of the gastroenterology clinic for appropriateness of the FFS.Those who did not meet criteria for screening FFS were referred back to the primary care provider to obtain a full gastroenterology appointment. Results: There were two hundred and eighty three or 83.9% who fulfilled the criteria for screening FFS. The remaining 16.1% were either not average risk for colorectal cancer or needed a total colonic exam rather than a screening flexible sigmoidoscopy. Twentyfour (7.1%) patients had a family history of colon cancer, 15 (4.5%) patients had a personnel history of colonic polyps, 12 (3.6%) patients had recent history of hematochezia, and 3 (.9%) patients had a personnel history of colon cancer. Conclusion: Routine screening FFS is an appropriate screening strategy in approximately 3/4 of patients in an open access FFS program. Further questioning will result in a total colonic exam as being a more appropriate test in about 1/4 of patients.