Discussing Medical Errors with Patients

1 Cardiovascular Medicine

Gary L. Schwartz, MD
Mayo Clinic
Sheldon G. Sheps, MD
Mayo Clinic

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When to Use Ambulatory Blood Pressure Monitoring

Cross-sectional studies show that blood pressure (BP) averages from ambulatory BP monitoring (ABPM) correlate better with the presence of target organ injury (especially left ventricular hypertrophy [LVH]) than office BP measurements. Also, prospective studies and population-based observational studies have shown that average BP derived from ABPM predicts additional risk of cardiovascular events after adjustment for clinic or office BP. This is true for both untreated and treated patients.¹ ABPM is the best method to establish the presence of isolated clinic hypertension (so-called white-coat hypertension), which is defined as an elevation in BP that occurs only in the clinic setting, with normal BP in all other settings, in the absence of evidence of target-organ injury.² Screening for white-coat hypertension is currently a reimbursable indication for ABPM by Medicare.³ The possibility of a white-coat effect should be considered in selected patients with resistant hypertension, in elderly patients with significant office systolic hypertension, and in some pregnant women. Other uses for ABPM include assessment of hypotensive symptoms, episodic hypertension, and suspected autonomic dysfunction in patients with postural hypotension.² ABPM is also useful in the evaluation of the occasional patient with hypertensive target-organ injury (LVH, stroke) whose office BP is normal. In addition, it is now recognized that some patients have so-called white-coat normotension, or masked hypertension; in these patients, BP is normal in the office but is elevated outside the office setting.⁴ This important group is often missed in routine practice.

1. Clement DL, De Buyzere ML, De Bacquer DA, et al: Prognostic value of ambulatory blood pressure recordings in patients with treated hypertension. N Engl J Med 348:2407, 2003 [PMID 12802026]

2. Chobanian AV, Bakris GL, Black HR, et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 289:2560, 2003 [PMID 12748199]

3. Coverage and billing of ambulatory blood pressure monitoring (ABPM). Centers for Medicare & Medicaid Services: 2001 http://cms.hhs.gov/manuals/pm_trans/AB01188.pdf

4. Pickering T, Davidson K, Gerin W, et al: Masked hypertension. Hypertension 40:795, 2002 [PMID 12468559]

Should Antihypertensive Drug Therapy Still Start with Diuretics?

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends thiazide diuretics as initial drugs of choice for most hypertensive patients; this recommendation is based on the totality of data from randomized trials, including the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).^1,2 The ALLHAT showed that diuretic-based treatment was equivalent or superior to alpha-blocker-, calcium-antagonist-, or ACE-inhibitor-based treatment in terms of cardiovascular disease outcomes. The alpha-blocker arm of the trial was terminated early because of an almost twofold increased risk of heart failure compared with the diuretic group; consequently, alpha blockers are no longer considered an appropriate initial therapy for hypertension. Compared with the diuretic group, the calcium antagonist group had a higher risk of heart failure, and the ACE inhibitor group had an increased risk of stroke and combined cardiovascular disease. However, much of the increased risk of events was confined to blacks, in whom BP control with the ACE inhibitor was inferior to that with the diuretic.

A subsequent study contradicted the results of ALLHAT and suggested that ACE inhibitors are superior to diuretics in older men.³ In truth, differences in outcomes by drug choice likely reflect differences in achieved BP rather than unique effects of specific agents.⁴ Therefore, achieving the BP goal is more important than the specific agents used to achieve it.

1. Chobanian AV, Bakris GL, Black HR, et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 289:2560, 2003 [PMID 12748199]

2. Psaty BM, Lumley T, Furberg CD, et al: Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 289:2534, 2003 [PMID 12759325]

3. Wing LM, Reid CM, Ryan P, et al: A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 348:583, 2003 [PMID 12584366]

4. Wang JG, Staessen JA: Benefits of antihypertensive pharmacologic therapy and blood pressure reduction in outcome trials. J Clin Hypertens (Greenwich) 5:66, 2003 [PMID 12556657]

Matching Hypertensive Patients with Antihypertensive Drugs

Randomized clinical trials suggest that the presence of certain comorbid conditions constitutes a so-called compelling indication for selection of specific drugs [see Table]. Other considerations that should influence drug selection include concomitant conditions for which some agents may be beneficial and others contraindicated [see Tables 1 and 2] potential drug-drug interactions, concerns about quality of life, cost (generic formulations are available for diuretics, beta blockers, calcium antagonists, and ACE inhibitors), and, finally, demographics (in general, older patients and blacks respond better to diuretics and calcium antagonists, whereas younger patients and whites respond better to beta blockers, ACE inhibitors, and angiotensin receptor blockers). In general, the drug chosen should have a long half-life (once-daily dosing is preferable). It should be continued only if the patient tolerates it and is comfortable with its cost, because these are important factors in long-term compliance. To achieve currently recommended blood pressure goals, many patients will require more than one drug; this possibility should be discussed at the outset with the patient. Regardless of the agent chosen, blood pressure should be reassessed after 2 to 4 weeks of treatment [see Figure].

The Morbidity and Mortality Conference: The Most Valuable Hour in Surgical Education

Larry R. Kaiser, M.D., F.A.C.S.
University of Pennsylvania School of Medicine

The morbidity and mortality (M&M) conference (also known as the death and complications conference in some regions of the United States) has come to be an accepted part of surgical education, though its importance has declined in recent years. As we continue to intensify our efforts in quality assessment and quality improvement, it is useful to look closely at the contribution of the M&M conference to these efforts. It is my firm belief that the M&M conference, when properly structured, is the most important teaching exercise in a surgery department and is a valuable component of a wide-ranging quality-improvement program. By its very nature, the M&M conference remains the last bastion of medical debate. It is unique in that it provides a forum where both faculty and residents can examine surgical failure and so learn to put in place mechanisms to avoid repeating mistakes. To be effective, the conference must be conducted with a tone that avoids placing blame or creating defensiveness. This has not always been the case—the conference has been used on occasion to entertain the audience at the expense of the presenter. The atmosphere needs to be such as to attract individuals to come together to improve the quality of patient care without fear of incrimination; this applies to any quality-improvement effort. Quality improvement is more difficult to effect when the underlying theme is punitive.

The origins of the modern-day M&M conference are not totally clear but likely trace back to the efforts of Codman at the Massachusetts General Hospital in the early 20th century. He utilized an "end-result card," on which he meticulously kept a record of every case, and particularly every complication. Codman made an effort to establish a reason or explanation for an adverse outcome. He advocated open disclosure of these end results to physicians and the public alike; this was a radical idea for the time, and it elicited intense opposition, as might be expected.

Contemporaneously, the American College of Surgeons, a new organization at that time, encouraged the establishment of standards of care. The Philadelphia County Medical Society established the Anesthesia Mortality Committee in 1935. The purpose of the committee was to facilitate discussion and to share knowledge about fatalities secondary to the use of anesthesia, as well as knowledge about "other interesting anesthetic situations." This group became the Anesthesia Study Commission, and its mandate was expanded to review a variety of topics not related to fatalities. The group, which met monthly, consisted of anesthesiologists, surgeons, and internists who sought to improve anesthesia practice by an open review of cases that probably involved medical error. The style of the meetings was participatory—errors were confronted directly, albeit anonymously. Despite the anonymity, it was impossible to completely avoid the tension between educational goals and fear of incrimination on the part of the participants, a concern that remains relevant today.

Although it had its beginnings among anesthesiologists, today the M&M conference is confined mainly to departments of surgery and is rarely seen in other disciplines. The role of this type of conference is not clearly defined in internal medicine training programs. There is no general consensus as to the structure of the conference, and there are numerous variations. Some institutions have adopted a format in which only selected complications of interest are presented; others attempt to present all complications. Regardless of format, the conference should be the focal point of a department of surgery's quality-improvement efforts.

There are several key assumptions that need to be articulated when considering any discussion of complications. The word "complication" derives from the Latin complicare, "the action of weaving together an intricate fabric made up of differing elements." These origins tell a story and ring true to anyone who has ever attended an M&M conference. We define complication in the surgical sense as any event that deviates from the anticipated uneventful recovery from an operation. Even an anticipated complication is still a complication by this definition. We must recognize that adverse events and error are an inevitable part of surgery. If we are to minimize the effects of these, ascribing blame should not be part of the process. For real progress to occur, we should focus attention on systems problems, not individual errors. An adverse event—an injury caused by medical management that prolongs hospitalization or produces a disability that is present at the time of discharge—differs from negligence or care that falls below the standard expected of physicians in a given community. (Community here is used in the broadest sense; it refers not just to geographic area but, for example, to the community of colon and rectal surgeons.) Medical error is defined as an adverse event or "near miss" that is preventable in light of the current state of medical knowledge.

Any successful M&M conference depends on the honest and accurate reporting of all adverse events and errors. All complications can be classified as one of the following: the result of an error in judgment; the result of an error in technique; the result of patient disease; unavoidable; or the result of an error in diagnosis. Once the complication is identified and classified, there follows a brief presentation of the case that includes a narrative with pertinent historical details, a review of the relevant studies (ideally, with significant images available for viewing), a review of the surgical procedure, and a chronology and treatment of the complication. Following this, the lead discussant (previously assigned) or the moderator comments and then entertains comments and questions from the audience. The case is then discussed by the presenter in the context of the available literature. This is followed by comments by the surgeon. The discussion should focus on systems improvements, because a complication is rarely an isolated event but rather is the end result of a cascade of events. In the ideal situation, local practice data are collected prospectively and incorporated into the conference so that trends and practice patterns emerge and opportunities for improvement become apparent. Selected reprints are made available after the conference; these may be distributed via e-mail.

The moderator of the conference must maintain the established format and keep the conference on track; it is important to avoid finger-pointing. The individual acting in the role of moderator may be the department chair or the residency program director, or the role may rotate. The caliber of the conference depends to a great extent on the tone set by the moderator, and the importance of the moderator cannot be overestimated.

Attendance at the departmental M&M conference should be mandatory for residents, and the faculty should at least be expected to attend. A sign-in sheet should be available, and the conference should be designated and approved for CME credit. The presence of interested community surgeons adds greatly to the learning environment.

The data generated by the reporting of complications should be maintained in a secure database. The database should be available for individuals with queries concerning practice patterns and trends that are relevant to the quality-improvement effort. Periodically, perhaps quarterly, the data generated should be reviewed at the M&M conference for insights and comments by the attendees. Through these means, practice patterns may change, patient safety may be enhanced, and costs may be reduced.

In conclusion, regardless of format, the conference should be provocative and stimulating, and it should be conducted in an environment in which all would want to attend. As I said at the start, the M&M conference should be the major teaching conference within a department of surgery where residents and faculty alike are on a level playing field and all have the same goal in mind: to improve the way we take care of sick people.

larrykaisermd@webmd.net

William D. Suggs, M.D., F.A.C.S.
Albert Einstein College of Medicine of Yeshiva University
Frank J. Veith, M.D., F.A.C.S.
Albert Einstein College of Medicine of Yeshiva University

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Discusses preoperative evaluation and operative management of lower-extremity ischemia secondary to infrainguinal arteriosclerosis. Operative techniques and outcome evaluation are described for above-the-knee and below-the-knee femoropopliteal bypass, infrapopliteal bypass, and plantar bypass; alternative bypasses using more distal inflow vessels are also described.

Exposure of the Femoral Artery in Above-the-Knee Femoropopliteal Bypass

Femoropopliteal bypass: above knee: exposure of femoral artery

A slightly curved skin incision, with the concavity facing the medial aspect, is made starting at a point slightly above the inguinal crease and extended distally for 10 to 12.5 cm [see Figure, part a]. The incision should be slightly lateral to the pulsation of the femoral artery so as to avoid the lymphatics as much as possible. Any minor bleeding or divided lymphatic vessels should be controlled with electrocoagulation or fine ligatures. Self-retaining retractors are placed both proximally and distally in the wound, and the lymphoadipose tissue is gently retracted medially [see Figure, part b].

The deep fascia is opened along the femoral artery [see Figure, part c], and the sheath of the artery is opened along its axis [see Figure, part d]. The common and superficial femoral arteries are mobilized, and Silastic loops are placed around them [see Figure, part e]. These vessels are then elevated slightly, and the origin of the common femoral artery comes into view lateral and posterior to the superficial femoral artery. Dissection of the origin of the deep femoral artery must be done carefully so as not to injure the collateral vessels coming off the artery at that level and the one or two branches of the satellite veins that cross the anterior portion of its initial segment. If mobilization of the deep femoral artery proves difficult, the satellite vein branches can be divided and ligated.

Endoscopic Vein Harvesting Reduces Complications

Femoropopliteal bypasses performed with segments of the greater saphenous vein are associated with 4-year primary patency rates ranging from 68% to 80% and limb salvage rates ranging from 75% to 80%. Femoropopliteal bypasses performed with polytetrafluorethylene grafts yield comparable patency and limb salvage rates above the knee but are significantly less successful below the knee.

Newer vein-harvesting technique may help improve outcome further. The use of endoscopic vein-harvesting methods has been shown to reduce the incidence of wound complications associated with femoropopliteal bypass. This approach allows above-the-knee bypasses to be performed through two incisions.

When Femoropopliteal Bypass Is Contraindicated, Consider Infrapopliteal Bypass

Bypasses to the small arteries beyond the popliteal artery are performed only when femoropopliteal bypass is contraindicated according to accepted criteria. Infrapopliteal bypasses are performed to the posterior tibial artery, the anterior tibial artery, or the peroneal artery, in that order of preference. As a rule, a tibial artery is used only if its lumen runs without obstruction into the foot, though bypasses to isolated tibial artery segments and other disadvantaged outflow tracts have been performed and have remained patent for more than 4 years. Generally, the peroneal artery is used only if it is continuous with one or two of its femoral branches, which communicate with foot arteries. Neither the absence of a plantar arch nor vascular calcification is considered a contraindication to a reconstruction. With both femoropopliteal and infrapopliteal bypasses, stenosis of less than 50% of the diameter of the vessel is acceptable at or distal to the site chosen for the distal anastomosis.

Exposure of posterior tibial artery

The very proximal portion of the posterior tibial artery is approached via a below-the-knee popliteal incision. The deep fascia is incised, and the popliteal space is entered. The gastrocnemius muscle is retracted posteriorly, and the soleus muscle is separated from the posterior surface of the tibia. The distal portion of the posterior tibial artery is approached via a medial incision along the posterior edge of the tibia; deepening this incision along the posterior tibialis muscle and the posterior surface of the tibia allows exposure of the posterior tibial artery. The tunnel from the popliteal fossa to the distal posterior tibial artery is made just below the muscle fascia, ideally with a long, gently curved clamp.

Close Follow-up and Surveillance Improve Secondary Patency Rates in Infrapopliteal Bypass

Infrapopliteal bypasses should have 5-year primary patency rates ranging from 60% to 67% and limb salvage rates ranging from 70% to 75% whether they are done with the reversed-vein technique or with the in situ technique. For all such grafts, close patient follow-up and graft surveillance improve secondary patency rates. Reduced complications and decreased length of stay have been reported for patients undergoing distal in situ bypasses using either the endoscopic or the coil occlusion approach.

Popliteal Artery or Superficial Femoral Artery as an Inflow Source

Traditionally, the femoral artery has been the inflow site of choice for infrainguinal bypasses. Since the early 1980s, the superficial femoral, deep femoral, popliteal, and tibial arteries have all been used as inflow sources when these vessels were relatively disease free or when the amount of autologous vein available was limited. Currently, the superficial femoral artery and the popliteal artery are preferentially used for primary bypasses when they are free of disease.

The strategy of utilizing more distal inflow sources is particularly applicable to inframalleolar bypasses, in which very long vein segments would be required to reach the dorsalis pedis or other pedal arteries from the usual more proximal inflow sites. In a review of our own experience with popliteal-distal vein graft bypasses,¹ we reported a patency rate of 65% at 4 years—a figure comparable to rates reported for femorodistal bypasses with reversed or in situ vein grafts (67% and 69%, respectively). Given these results, surgeons should not hesitate to employ either the popliteal artery or the superficial femoral artery as an inflow source. Use of these more distal inflow sites results in shorter grafts and allows portions of saphenous vein to be preserved for other purposes.

1. Wengerter KR, Yang PM, Veith FJ, et al: A twelve-year experience with the popliteal-to-distal artery bypass: the significance and management of proximal disease. J Vasc Surg 15:143, 1992 [PMID 1728672]

Robert G. Sawyer, M.D.
University of Virginia School of Medicine
Jeffrey S. Barkun, M.D., F.A.C.S.
McGill University Faculty of Medicine
Robert Smith, M.D.
University of Virginia School of Medicine
Tae Chong, M.D.
University of Virginia School of Medicine
George Tzimas, M.D.
McGill University Faculty of Medicine

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Discusses the evaluation of and intervention options for upper and lower abdominal infections; controversies and special cases are considered.

Tests to Differentiate Acute Cholecystitis, Acute Cholangitis, and Acute Pancreatitis

Biliary tract and pancreatic infections present as a systemic septic response or as infections localized in the upper abdomen. Typical findings include abdominal pain, a tender upper abdominal mass, fever and leukocytosis, and jaundice. Various combinations of these symptoms may occur, but it is convenient to consider three common clinical presentations. In each of the presentations, one or two symptoms dominate: (1) upper abdominal pain and fever, (2) fever and jaundice, and (3) an upper abdominal mass and fever. These clinical findings signal the need for a battery of screening tests, including a complete blood count; routine blood tests of liver function; determination of serum amylase level, prothrombin time, and partial thromboplastin time; blood culture; chest and abdominal x-rays; and abdominal ultrasonography. When considered together, the clinical findings and the test results allow early differentiation of the three most common disease entities: acute cholecystitis, acute cholangitis, and acute pancreatitis.

Differentiating acute pancreatitis from acute cholecystitis may be difficult. The serum amylase level lacks specificity, but if the clinical findings suggest acute pancreatitis, an elevated serum amylase level clinches the diagnosis; in fact, a serum amylase concentration above 1,000 U/L strongly suggests a biliary origin of the pancreatitis. In addition, determination of serum lipase levels has been shown to be more specific than, as well as at least as sensitive as, determination of amylase levels for the detection of acute pancreatitis.¹ Unless clinical findings and the results of biochemical tests and ultrasonography are unequivocal, a contrast-enhanced spiral abdominal CT scan is usually performed to establish the diagnosis and to stage acute pancreatitis. It has been suggested, however, that CT scanning should be reserved for patients with clinically suspected severe acute gallstone pancreatitis, on the grounds that the results would not change the recommended course of action in other patients. Occasionally, a very mild pancreatitis may give rise to no findings on a CT scan; a normal technetium-99m—labeled hepatic immunodiacetic acid (HIDA) scan may help differentiate this condition from acute cholecystitis.

1. Yadav D, Agarwal N, Pitchumoni CS: A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol 97:1309, 2002 [PMID 12094843]

When Is Severe Pancreatitis an Indication for ERCP?

Patients with three or more Ranson signs are at particular risk for pancreatic sepsis. Repeated clinical and radiologic evaluation is required in these patients to ensure early detection of complications, because the outcome of an episode of pancreatitis depends on whether sepsis supervenes. When infection occurs, operative debridement and drainage are required. Some surgeons have attempted to alter the course of severe disease by early operation; however, urgent operation is associated with a high mortality in patients with more than three Ranson signs. To avoid the mortality associated with early operative intervention, some clinicians advocate early diagnosis by endoscopic retrograde cholangiopancreatography (ERCP) followed by biliary decompression by means of endoscopic sphincterotomy and stone extraction. It appears that ERCP is warranted mainly in cases of acute pancreatitis complicated by cholangitis and biliary sepsis.^1,2

1. Chang L, Lo S, Stabile BE, et al: Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial. Ann Surg 231:82, 2000 [PMID 10636106]

2. Nitsche R, Folsch UR, Ludtke R, et al: Urgent ERCP in all cases of acute biliary pancreatitis? A prospective randomized multicenter study. Eur J Med Res 1:127, 1995

Diagnosing Acute Cholecystitis

Acute cholecystitis is the most common diagnosis in patients presenting with upper abdominal pain and fever. It is characterized by the clinical finding of a midinspiratory arrest on palpation of the right upper quadrant (Murphy sign). With the widespread availability of ultrasonography, acute cholecystitis can usually be diagnosed rapidly on the basis of the findings of gallbladder wall thickening, pericholecystic fluid, and stones. Occasionally, more complex cases must be evaluated with nuclear medicine scanning to look for cystic duct obstruction. Concurrent acute obstructive cholangitis must also be considered in all patients with acute cholecystitis. Supportive laboratory data include a high serum bilirubin level and an increased alkaline phosphatase level. Positive blood cultures and dilated biliary ducts on abdominal ultrasonography usually confirm the diagnosis.

Emphysematous cholecystitis

An uncommon and insidious variant of acute cholecystitis, emphysematous cholecystitis is characterized by gas in the gallbladder lumen or wall or in the pericholecystic soft tissue and biliary ducts secondary to gas-forming bacteria. The key to the diagnosis is the presence of air on abdominal x-ray or ultrasound examination. Three stages of emphysematous cholecystitis have been defined: (1) gas is seen only in the lumen of the gallbladder, (2) a ring of gas is identified in the wall of the gallbladder, and (3) gas is seen in the tissues adjacent to the wall. Compared with ordinary acute cholecystitis, emphysematous cholecystitis is associated with a fivefold increase in the risk of gallbladder perforation, as well as a 10-fold increase in mortality in patients younger than 60 years.

Fever and Jaundice Should Suggest Cholangitis

An alternative presentation of upper abdominal infection includes patients whose predominant symptoms are fever and jaundice, with pain a less marked component. Jaundice is almost always associated with obstruction of the biliary tree, either intrahepatic or extrahepatic. The combination of fever with jaundice always suggests acute cholangitis, a condition that can have a fulminant and fatal course if not treated promptly. If a patient presents with a temperature higher than 38.5° C (101.3° F) in conjunction with jaundice, the possibility of acute cholangitis should always be investigated. If cholangitis is present, laboratory studies will reveal leukocytosis, and blood cultures will often be positive. A finding of gallstones and dilated biliary ducts on abdominal ultrasound examination supports the diagnosis. Reynolds pentad is present in the full-blown syndrome. This syndrome includes upper abdominal pain, fever and chills, jaundice, hypotension, and mental-status changes. Acute cholangitis is usually related to choledocholithiasis, recent biliary manipulation, or biliary stenting for chronic obstruction.

CT Scanning Useful for Evaluating Enteric Perforations

Although enteric perforations, like pancreatitis and cholecystitis, present most commonly with pain and fever, their diagnosis differs from that of upper abdominal infections of the solid organs. The pain associated with enteric perforation is frequently not well localized; consequently, CT scanning is used more frequently than ultrasonography because it is superior for evaluating the entire abdomen. Moreover, a perforated viscus may present more acutely than other forms of infection do, and it is a common indication for emergency exploration. Thus, in the setting of a possible lower abdominal infection, the diagnostic emphasis is on confirming or ruling out the presence of an acute condition necessitating operation, rather than on fine localization of a more chronic illness.

Palmer Q. Bessey, M.D., F.A.C.S.
Weill Medical College of Cornell University

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Discusses metabolic responses in critically ill surgical patients and the clinical factors that lead to debility; metabolic responses discussed include the hyperdynamic or hypermetabolic state, muscle wasting, glucose intolerance, altered temperature regulation, altered protein metabolism, altered carbohydrate metabolism, and systemic mediators; the roles of the gut and central nervous system are described, and endotoxins, bacteria, inflammation, and organ failure are addressed; methods of manipulating the response to critical illness are described.

Protracted Critical Illness Affects Anterior Pituitary Hormone Levels

Endocrine changes (1) mobilize amino acids and fuel substrates to support wound healing, resolution of inflammation, and tissue repair and (2) turn down anabolism and growth in the rest of the body. This response to acute illness would seem to be an adaptive one: wounds heal and patients recover, despite a transient loss of lean tissue. However, patients with protracted critical illnesses, who have been maintained for weeks or months in the ICU, may present a different clinical picture. Despite closure of the wound, drainage of pus, provision of nutrients, and treatment of infection, they remain catabolic and are extremely slow or unable to recover. Current evidence suggests that this syndrome may reflect a different endocrine pattern. Many of the anterior pituitary hormones (e.g., adrenocorticotropic hormone, thyroid-stimulating hormone, and growth hormone) are present in reduced concentrations, or the pattern of their secretion is altered. These alterations may reflect a change in hypothalamic function; infusion of various releasing factors can restore normal hormone responsiveness in the thyrotropic, somatotropic, and gonadotropic axes.¹

1. Van den Berghe G, Baxter RC, Weekers F, et al: The combined administration of GH-releasing peptide-2 (GHRP-2), TRH and GnRH to men with prolonged critical illness evokes superior endocrine and metabolic effects compared to treatment with GHRP-2 alone. Clin Endocrinol 56:655, 2002 [PMID 12030918]

Oxandrolone Beneficial in Critically Ill Patients

An anabolic steroid, oxandrolone, has a good margin of safety and may play a beneficial role in critical illness by promoting nitrogen retention and accelerating recovery. Combined with a high-protein diet (2 mg/kg/day), oxandrolone promoted weight gain and functional improvement in a randomized study of burn patients who had recovered sufficiently to enter a rehabilitation program.¹ Hart and associates demonstrated improved efficiency of protein synthesis in nutritionally depleted burned children who received oxandrolone.² They observed the same benefit in patients who had received appropriate nutritional support from the time of injury.³ In this group, oxandrolone was also associated with an improvement in lean body mass and increased expression of genes for several functional muscle proteins.

1. Demling RH, DeSanti L: Oxandrolone, an anabolic steroid, significantly increases the rate of weight gain in the recovery phase after major burns. J Trauma 43:47, 1997 [PMID 9253907]

2. Hart DW, Wolf SE, Ramzy PI, et al: Anabolic effects of oxandrolone after severe burn. Ann Surg 233:556, 2001 [PMID 11303139]

3. Wolf SE, Thomas SJ, Dasu MR, et al: Improved net protein balance, lean mass, and gene expression changes with oxandrolone treatment in the severely burned. Ann Surg 237:801, 2003 [PMID 12796576]

Romano Delcore, M.D., F.A.C.S.
University of Kansas School of Medicine
Laurence Y. Cheung, M.D., F.A.C.S.
University of Kansas School of Medicine

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Discusses the assessment of the patient with acute abdominal pain, the differential diagnosis, investigative studies, the working diagnosis, the suspected surgical abdomen, and the suspected nonsurgical abdomen.

Cross-Sectional Imaging Has Revolutionized Evaluation of Abdominal Pain

The widespread availability of improved cross-sectional imaging technology (e.g., portable ultrasonography and helical, or spiral, CT) has revolutionized the evaluation of patients presenting with acute abdominal pain.¹ A 1999 prospective study suggested that ultrasonography should be part of the routine surgical investigation of acute abdominal pain and that it should be mastered and used by surgeons themselves for this purpose.² Two prospective, randomized trials from 2002 demonstrated that routine early use of CT in the evaluation of acute abdominal pain can identify unforeseen conditions and reduce length of hospital stay and overall mortality in patients with acute abdominal pain of known etiology.^3,4

1. Sucher JF, MacFadyen BV: Imaging modalities for acute abdominal pain. Semin Laparosc Surg 9:3, 2002 [PMID 11979405]

2. Allemann F, Cassina P, Rothlin M, et al: Ultrasound scans done by surgeons for patients with acute abdominal pain: a prospective study. Eur J Surg 165:966, 1999 [PMID 10574106]

3. Tsushima Y, Yamada S, Aoki J, et al: Effect of contrast-enhanced computed tomography on diagnosis and management of acute abdomen in adults. Clin Radiol 57:507, 2002 [PMID 12069469]

4. Ng CS, Watson CJ, Palmer CR: Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomised study. BMJ 325:1387, 2002 [PMID 12480851]

Constant Reevaluation Is Needed

Ideally, the tentative differential diagnosis list generated after the clinical history was obtained should be narrowed down to a working diagnosis by the physical examination and the information provided by the basic laboratory and radiologic studies. Once this working diagnosis has been established, subsequent management depends on the accepted treatment for the particular condition believed to be present. It must be emphasized that the patient needs to be constantly reevaluated (preferably by the same examiner) even after the working diagnosis has been established. If the patient does not respond to treatment as expected, the working diagnosis must be reassessed and the possibility that another condition exists must be immediately entertained and investigated by returning to the differential diagnosis list.

Approach to Human Immunodeficiency Syndrome

Approach to Human Immunodeficiency Virus Infection

[See Algorithm].

• Recommendations for the management of special populations: renal disease in diabetes (Am J Hypertens - DGReview)
• Management of women who test positive for high-risk types of human papillomavirus: the HART study (Lancet - DGReview)
• Attributes of long-term heavy cannabis users: a case-control study (Psychol Med - DGReview)
• Aplastic anemia following administration of a tumor necrosis factor-alpha inhibitor (E J Haematol - DGReview)
• Homocysteine levels are associated with the severity of peripheral arterial disease in Type 2 diabetic patients (J Thromb Haemost - DGReview)
• Levetiracetam in the treatment of neuropathic pain: three case studies (Clin J Pain - DGReview)
• FDA Approves Symbyax (Olanzapine and Fluoxetine), First Medication for Bipolar Depression (DGNews)
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• Investigation of generalized osteoarthritis by combining X-ray grading of the knee, spine and hand using biochemical markers for arthritis in patients with knee osteoarthritis (Clin Rheumatol - DGReview)
• Trimetazidine improves left ventricular function in diabetic patients with ischemic cardiomyopathy (Cardiovasc Diabetol - DGReview)

• New evidence on the importance of the renin-angiotensin system in the treatment of higher-risk patients with hypertension (J Hypertens - DGReview)
• Nonhormonal therapy for hot flashes (US Pharmacist - DGReview)
• Therapy with statins in patients with refractory rheumatic diseases: a preliminary study (Lupus - DGReview)
• Randomized double-blind study comparing 3- and 6-day regimens of azithromycin with a 10-day amoxicillin-clavulanate regimen for treatment of acute bacterial sinusitis (Antimicrob Agents Chemother - DGReview)
• Short-course antimicrobial therapy of respiratory tract infections (Drugs - DGReview