Appendectomy. Improving care through quality improvement.

Objective: To evaluate the practice of appendectomy in Department of Defense hospitals worldwide in a large-scale quality improvement initiative.

Design: Case series study.

Population And Setting: A total of 4950 consecutive nonincidental appendectomies performed in 147 Department of Defense hospitals worldwide during a 12-month period ending January 31, 1993.

Recurrent hyperparathyroidism from benign neoplastic seeding: a review with recommendations for management.

Benign neoplastic seeding represents a rare cause of hyperparathyroidism found at parathyroid reoperations. It consists of pathologically benign neoplastic parathyroid tissue scattered throughout a previous parathyroid surgical site. We describe a case of recurrent and then persistent hyperparathyroidism occurring in a patient during an 18-year period.

Analysis of human TSH receptor gene and RNA transcripts in patients with thyroid disorders.

Human TSH receptor (hTSH-R) gene and RNA transcripts were analyzed by Southern and Northern blots in patients with various thyroid disorders, and in tissue cell lines. A 1.4 Kb cDNA encoding the extracellular human TSH-R domain was used as a probe.

Thyrotropin modulation of epidermal growth factor (EGF) binding to receptors on cultured thyroid cells.

Previous studies had shown that epidermal growth factor (EGF) will stimulate growth of cultured thyroid cells in vitro, and TSH will stimulate total assayable EGF receptor in cultured porcine thyroid cells. In this study, we report the effect of TSH on EGF binding to human thyroid cells. Addition of bTSH (1 mU/mL) in binding buffer during receptor assay stimulated specific EGF binding to cells, with an increase of 44% observed over the control after 1 h incubation at 37 degrees C.

Thyrotropin modulates receptor-mediated processing of the atrial natriuretic peptide receptor in cultured thyroid cells.

In a prior study of atrial natriuretic peptide (ANP) binding to cultured thyroid cells, we reported that at 4 C, more than 95% of bound ANP is recovered on cell membranes, with negligible ANP internalization observed. Since ANP binding was inhibited by TSH, we have further studied TSH effects on postbinding ANP processing to determine whether this phenomenon reflects enhanced endocytosis of the ANP-receptor complex. An ANP chase study was initiated by binding [125I] ANP to thyroid cells at 4 C for 2 h, followed by incubation at 37 C.

Characterization by affinity cross-linking of a receptor for atrial natriuretic peptide in cultured human thyroid cells associated with reductions in both adenosine 3',5'-monophosphate production and thyroglobulin secretion.

We have previously identified specific atriopeptin (ANP) receptors in cultured human thyroid cells and demonstrated that ANP reduced thyroglobulin (Tg) secretion. In this report the relationship of Tg inhibition to cyclic nucleotide intermediate pathways was explored, and the thyroidal ANP receptor was characterized by affinity cross-linking. Concentrations of Tg, cGMP, and cAMP were measured in medium from thyroid cells cocultured with ANP.

Biliary tract melanoma.

A case of melanoma of the upper extremity with a solitary metastasis to the common bile duct is reported. A comprehensive review of melanoma in the biliary tree is presented. Antemortem diagnoses of such cases are rare but are associated with a high percentage of disease clinically confined to the biliary tree.

Effects of epidermal growth factor on thyroglobulin and adenosine 3',5'-monophosphate production by cultured human thyrocytes.

While several workers have identified epidermal growth factor (EGF) receptors on human thyroid membranes, very few reports have described EGF effects on intact human thyroid cells in primary culture, and these were short term studies indicating that EGF effects were primarily inhibitory [reduced iodide uptake and thyroglobulin (Tg), T4, and T3 release]. Paradoxically, in vivo EGF stimulates thyroid growth and increases colloid stores. In this study we examined the effects of EGF on cultured thyroid cells in regard to thymidine incorporation, Tg secretion, and cAMP production during a 12-day period.

[Molecular genetic detection of polyclonal immune response in autoimmune thyroiditis and inflammatory bowel diseases].

Southern blot hybridization techniques were used to analyze the arrangements of the immunoglobulin and the T cell antigen receptor genes in lymphocytes of patients with Graves disease and Hashimoto's thyroiditis as well as in patients with Crohn's disease, chronic ulcerative colitis, and with other gastrointestinal disease. The results indicate that the immune response of autoimmune thyroid disease and inflammatory bowel disease is of polyclonal origin.

Thyrotropin modulates receptors for atrial natriuretic peptide on intact human thyroid cells.

Interest in the mechanism of impaired salt and water metabolism in hypothyroidism has led to growing evidence of an interaction between atrial natriuretic peptide (ANP) and the thyroid, which includes reports of direct effects of thyroid hormone on ANP synthesis and circulating ANP levels, and of the presence of specific ANP receptors in human thyroid tissue, which may act to inhibit thyroglobulin (Tg) secretion. The authors questioned whether or not thyrotropin (TSH) has a role in this interaction. They used 125I-ANP to study the effect of TSH on ANP binding to human thyroid cells in primary culture.

Long-term followup of penetrating abdominal aortic injuries after 15 years.

Eleven of 14 survivors who sustained trauma to the abdominal aorta have been evaluated 16 to 18 years after injury through personal interview, physical examination, and abdominal contrast computerized tomography (CCT). The average age of survivors was 39 years (range, 37-47). All patients had minimal debridement of the aortic injury with lateral arteriorrhaphy.

Immunoglobulin and T cell antigen receptor gene arrangements indicate that the immune response in autoimmune thyroid disease is polyclonal.

To further define the degree of heterogeneity of the antibody and cellular immune responses in autoimmune thyroid disease, we used Southern blot hybridization techniques to analyze the arrangements of immunoglobulin and T cell antigen receptor genes in circulating lymphocytes and in those infiltrating the thyroid gland in nine patients with thyrotoxicosis due to Graves' disease and five patients with Hashimoto's thyroiditis. The sensitivity of these techniques was sufficient to detect a monoclonal population when there was as little as 1% clonal involvement in a mixed cell population. In the patients studied, DNA from non-T peripheral blood cells and non-T intrathyroid lymphocytes had only a germline gene pattern and no clonal nongermline rearrangements of immunoglobulin genes, as assessed using an immunoglobulin joining heavy chain (IgJH) gene probe.

Intrinsic abnormality of thyroid cells from a patient with a Brobdingnagian goiter.

Thyrocytes from normal and goitrous portions of the thyroid gland from a patient with an enormous (635 gm) goiter were cultured in media, and their relative abilities to uptake thymidine, synthesize DNA, and secrete Tg and T4 were assessed. Tg, T4 and the ratio Tg/T4 in media at 72 h were 120 micrograms/dl, 1.6 micrograms/dl and 75 for normal cells, and 410 micrograms/dl and 273 for goitrous cells.

c-myc expression in the thyroid. II: Thyrocytes and peripheral and intrathyroidal lymphocytes from patients with autoimmune thyroid disease.

Enhanced oncogene expression observed in lymphocytes from patients with systemic lupus erythematosus has suggested the importance of studying oncogene expression and regulation in the cellular events of autoimmune thyroid diseases (AITD). The present study examines oncogene expression in peripheral and intrathyroidal lymphocytes from patients with Hashimoto's disease (HD) and Graves' disease (GD). Intrathyroidal lymphocytes from a patient with primary thyroid lymphoma were also examined.

c-myc expression in the thyroid. I: Normal, adenomatous, and cancerous thyroid tissue.

Recent investigations have suggested that myc oncogene expression may be important in the development or progression of thyroid tumors. The purposes of the present study were to assess cellular (c)-myc expression in thyroid adenomas (n = 5), as well as in thyroid cancer (n = 4) and in normal thyrocytes (n = 7). Total RNA was prepared by extraction with guanididium thiocyanate and ultracentrifugation through a CsCl2 cushion.

Adult duodenal web associated with reflux esophagitis.

Duodenal webs are the third leading cause of alimentary tract obstruction in infants. They rarely present in adulthood, with 47 cases reported in the literature. These seems to be an association with peptic ulcer disease.

Massive abdominal wall desmoid tumor. Treatment by resection and abdominal wall reconstruction.

The management of a massive abdominal wall desmoid tumor in a young woman with Gardner's syndrome is discussed. Treatment options included primary radiation, subtotal excision with radiation, primary chemotherapy, or radical resection with abdominal wall reconstruction. The advantages and disadvantages of the various treatment options are discussed, and the technique of resection and reconstruction is explained.

Spindle cell carcinoma of the breast: case report and review.

Spindle cell carcinoma is a distinct, but unusual, variant of squamous cell carcinoma. It is seen most frequently in the upper aerodigestive tract and esophagus. The natural history seems to be similar to that of the more typical squamous cell carcinoma.

Estrogen receptor protein in bone and soft tissue tumors.

Thirty-three histologically diverse bone and soft tissue tumors were analyzed biochemically for the presence of estrogen receptor protein (ERP) and progesterone receptor by means of a conventional, commercially available, steroid-binding assay (dextran-coated charcoal method) on fresh frozen tissue. These results were compared with analysis of ERP by using a specific monoclonal antibody both in an enzyme immunoassay and on frozen tissue sections by using immunohistochemical procedures. Frozen tissue sections were also examined for the presence of estrogen and progesterone receptors using fluorescein-labeled steroids.

Mycobacterium avium infection in a silicone-injected breast.

A case of atypical mycobacterial infection (M. avium intracellulare) in a silicone-injection augmented breast is described. The silicone injection may have been a contributing factor to the development of this unusual infection.

Heterotopic brain presenting as a cystic neck mass with mandibular deformity.

A congenital cystic neck mass causing respiratory distress and hypoplasia of the mandible was excised from a 3-month-old infant. The lesion was subsequently diagnosed as heterotopic brain, a rare, benign condition that should be considered in the differential diagnosis of the neonatal head and neck mass.

Removal of gastrinomas for control of Zollinger-Ellison syndrome.

There are two distinct problems in patients with Zollinger-Ellison Syndrome (ZES): peptic ulcer diathesis and malignant tumors. Antisecretory drugs have allowed us to control the ulcer symptoms and acid output in 45 patients with ZES. We report here the initial seven patients selected for surgical exploration with the goal of removing their gastrinomas.

Paraduodenal hernia: diagnosis and surgical management.

Paraduodenal hernia is an unusual cause of intestinal obstruction, but one with which all surgeons should be familiar. We reviewed the anatomy, pathophysiology, initial symptoms, radiographic criteria for diagnosis, and subsequent therapy of five patients treated for paraduodenal hernia at Walter Reed Army Medical Center. Contrast radiography of the small intestine remains the mainstay of preoperative diagnosis.

Surgical management of small-bowel radiation enteritis.

We treated 17 patients with severe small-bowel radiation enteritis surgically. Fourteen patients were female. Gynecologic malignant lesions (cervical, ovarian, and endometrial) were the most frequent sites of the primary tumors for which radiation was given.

Intramuscular hemangioma.

In two cases of intramuscular hemangioma of the paraspinous muscles, the tumors were treated with arteriographic embolization followed by immediate local excision. We found that this technique creates a hypovascular surgical field and facilitates the dissection. We believe this approach will decrease morbidity and potential mortality.