Faculty Bibliography

Concomitant adenocarcinoma and non-Hodgkin's lymphoma, both located in the intestinal tract, are unusual. We report a unique case of moderately differentiated of the cecum and a simultaneous follicular lymphoma, Grade 1, of the terminal ileum and regional lymph nodes in a 55-yr-old man. One lymph node was involved by both adenocarcinoma and follicular lymphoma. To our knowledge, this is the fifteenth reported case of concurrent adenocarcinoma and non-Hodgkin's lymphoma of the intestine, but this is the first case with involvement of follicular lymphoma and adenocarcinoma within the same lymph node.

Work rounds have received little attention in the medical education literature. At the outset of the second post graduate year, medical residents are expected to function, without much guidance, as both team leaders and teacher. New York State health code regulation 405 restrict house staff work hours and may influence the manner and content of work rounds. The goals of work rounds were identified through a literature review and our own experiences. A 36-item questionnaire utilizing the identified goals was used in this cross-sectional descriptive study. The participants were the Program Directors of New York State Internal Medicine residency programs. Each of the fourteen goals identified reflects one of three resident behaviors: patient care, teaching, and evaluation. The goals that received the highest importance scores were patient management and updating team leader of events. Ninety percent (90%) or more of the participants indicated that patient management, teaching clinical reasoning and problem solving, verifying important chart data, and verifying physical examination should be performed "often" or "almost always." Most programs employed verbal instructions but only few held conference or provided literature on the expectations and conduct of work rounds. New York State Internal Medicine program directors perceive work rounds as primarily a patient care task, and many rely on verbal instructions to convey the objectives to the house staff. While previous research has demonstrated that work rounds are an important setting for house staff education, this study reveals that in most New York State programs this opportunity may be missed.

BACKGROUND:Although peptic ulcer disease (PUD) is common in adults, the risk of bleeding from an active ulcer after nonulcer surgery is poorly defined in the literature. The objectives of this study were to define the risk of postoperative upper gastrointestinal (UGI) tract hemorrhage in patients with active PUD and to identify risk factors that predict bleeding. METHODS:This case-control study was conducted at a suburban community teaching hospital. Sixty patients with active PUD at the time of nonulcer surgery were identified and compared with a control group of 120 patients without PUD. All charts were reviewed for the presence of coagulopathy, antiplatelet and anticoagulant drug use, preoperative and postoperative UGI tract bleeding, and perioperative medical therapy for PUD. RESULTS:Cases and controls were similar in age, length of stay, number of procedures, type of surgery, anticoagulant use, and presence of coagulopathy. Most patients had general surgery; none had neurosurgery, and few had cardiac surgery. Patients with PUD had a greater number of major diagnoses (P < .02), rate of preoperative UGI tract bleeding (P < .001), and use of perioperative antiulcer medications (P < .02). There was no difference in the rate of postoperative UGI tract bleeding between the two groups (P = .63; odds ratio, 1.3; 95% confidence interval, 1.21 to 1.41). There were no patient characteristics that predicted postoperative UGI tract bleeding. While 10% of patients with PUD experienced postoperative UGI tract bleeding, only one required blood transfusion; in the majority, the bleeding was clinically unimportant. CONCLUSION/CONCLUSIONS:For patients with PUD similar to this study group, nonulcer surgery need not be deferred to allow for peptic ulcer healing.

Primary care physicians play a major role in the risk stratification of patients with coronary artery disease (CAD) preparing for noncardiac surgery. Preoperative risk assessment takes into account the type and urgency of surgery and the extent of underlying CAD. With this approach, patients can be categorized as being at high, intermediate, or low risk for postoperative cardiac complications. Judicious use of preoperative noninvasive cardiac testing may help identify those patients at particularly high risk for such complications.

With effective communication, optimal use of perioperative therapeutic techniques, and postoperative follow-up, the medical, surgical, and anesthetic teams can prevent or minimize cardiac complications that occur during the postoperative period. Up to 50% of postoperative myocardial infarctions may be silent, or they may present as congestive heart failure, hypotension, or arrhythmia. Dyspnea is a common finding. All high-risk patients should be monitored in the intensive care unit during the first 7 days after surgery, when adverse cardiac events are most common.

The primary care physician can play a major role in preoperative consultation in terms of assisting the surgical team to reduce the risk of thromboembolism. A preoperative risk assessment takes into account the type and duration of surgery as well as the existence of risk factors such as age and underlying medical conditions. With careful communication, the consulting physician and surgical team can together select a method of preventing thromboembolism that will prove both safe and effective.