Kevin Grannan

Heparin-induced thrombocytopenia: A prospective study of 142 patients

In a prospective study of 142 patients receiving intravenous heparin of bovine lung origin, thrombocytopenia developed in nine (6%) patients. In the group of 70 patients with a history of prior heparin therapy, seven (10%) had thrombocytopenia. By contrast, only 2 (3%) of 72 patients with no history of previous heparin treatment had thrombocytopenia, a statistically insignificant difference (p less than 0.5). In this group 58 patients received heparin for less than 10 days, and none of them had thrombocytopenia. Of the remaining 14 patients who were given heparin longer than 10 days, two patients (14%) had thrombocytopenia. This difference was statistically significant (p less than 0.01). Monitoring the platelet count detects the disorder early and prompt cessation of heparin prevents serious complications. All patients undergoing heparin therapy should have determination of pretreatment platelet count. In patients with a history of previous heparin therapy, thrombocytopenia may develop even with short duration of heparin treatment, and hence platelet counts should be monitored throughout the duration of treatment. The platelet count of patients who have no history of previous treatment with heparin should be monitored if heparin is continued for more than 7 days.

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

BACKGROUND The purpose of this study was to describe the incidence and clinical/pathologic characteristics of papillary thyroid microcarcinoma (PMC) in a community hospital setting and to evaluate the frequency and characteristics of these lesions when unsuspected preoperatively. METHODS A total of 723 patients underwent a partial or total thyroidectomy. A retrospective review was performed. RESULTS A total of 194 of the 723 patients had a final diagnosis of papillary carcinoma. Ninety-six (49%) of these tumors were PMCs defined as being 1.0 cm or less in diameter. One third (32 of 96) of these lesions were multifocal and 16.7% (16 of 96) were found to have regional lymph node metastases. The majority (58%) of PMCs were found on final pathology and were clinically unsuspected (occult). Multifocality was found in 32.1% (18 of 56) of patients with clinically unsuspected PMC, with nodal metastases in 3.6% (2 of 56). The other 40 patients with PMC had surgeries performed for a clinical reason related to that pathologic lesion. This clinically suspected group was comparably multifocal (35%), but more likely to have cervical lymph node metastasis (35%). Sixty-six percent (37 of 56) diagnosed with a clinically unsuspected PMC underwent a partial thyroidectomy at the initial surgery. CONCLUSIONS The prevalence of clinically unsuspected PMC in our population undergoing thyroidectomy was 7.7% (56 of 723). In our institution, this is more than half of all PMCs. The incidence of cervical lymph node metastasis in clinically unsuspected PMC was only 3.6% compared with 35% in clinically suspected disease, suggesting that the biological behavior (and possibly treatment) may be different. Long-term follow-up evaluation is needed to better evaluate the significance of these differences.

Graduate Medical Education as the Driver for Quality Improvement and Patient Safety: A National Initiative of Independent Academic Medical Centers

ngaging surgical residents in hospital quality-improvement QI) initiatives could be the next important step in the evolving enaissance of surgical education. Your first reaction might be, when are they going to have time for this?” I would suggest that t is really what they do and observe every day in their daily ctivity of patient care that affords them the opportunity to esign QI projects. Partnering in this initiative with faculty is a eans of fostering additional scholarship into the culture of urgical education. It also provides a unique educational expeience in preparation for their life in surgical practice. The Alliance of Independent Academic Medical Centers AIAMC) currently has more than 60 participating instituions. It began in 1989 with a 2-fold purpose. First, it aimed to rovide true benchmarking data for independent academic edical centers, and second, it aimed to increase the represenation of independent academic medical centers in national eadership organizations. These goals were not dissimilar from he vision and mission of the Association of Program Directors n Surgery (APDS) when it began a decade earlier. And alhough the APDS has expanded its vision and mission in the ubsequent 30 years, the basic tenets of its inception were simlar to that of the AIAMC. The initial meetings of the AIAMC provided a forum for esignated institutional officers, chief medical officers, and vice

Impact of Method of Anesthesia on the Accuracy of Needle-Localized Breast Biopsies

Needle-localized breast biopsy (NLBB) is now a commonly performed procedure. We reviewed a series of 260 NLBBs to evaluate the accuracy of the procedure, using specimen radiography as the standard. General anesthesia was used in 114 (44%) procedures and local anesthesia in 146 (56%). The accuracy rate when the patient received general anesthesia was 96.5% compared with 98% when local anesthesia was used (not significant). The cost of this procedure can be reduced substantially by utilizing local anesthesia as opposed to general anesthesia without compromising the accuracy.

Multi-Institutional Study of Self-Reported Attitudes and Behaviors of General Surgery Residents About Ethical Academic Practices in Test Taking

PURPOSE Correlation exists between people who engage in academic dishonesty as students and unethical behavior once in practice. Previously, we assessed the attitudes of general surgery residents and ethical practices in test taking at a single institution. Most residents had not participated in activities they felt were unethical, yet what constituted unethical behavior was unclear. We sought to verify these results in a multi-institutional study. METHODS A scenario-based survey describing potentially unethical activities related to the American Board of Surgery In-training Examination (ABSITE) was administered. Participants were asked about their knowledge of or participation in the activities and whether the activity was unethical. Program directors were surveyed about the use of ABSITE results for resident evaluation and promotion. RESULTS Ten programs participated in the study. The resident response rate was 67% (186/277). Of the respondents, 43% felt that memorizing questions to study for future examinations was unethical and 50% felt that using questions another resident memorized was unethical. Most felt that buying (86%) or selling (79%) questions was unethical. Significantly more senior than junior residents have memorized (30% vs 16%; p = 0.04) or used questions others memorized (33% vs 12%; p = 0.002) to study for future ABSITE examinations and know of other residents who have done so (42% vs 20%; p = 0.004). Most programs used results of the ABSITE in promotion (80%) and set minimum score expectations and consequences (70%). CONCLUSION Similar to our single-institution study, residents had not participated in activities they felt to be unethical; however the definition of what constitutes cheating remains unclear. Differences were identified between senior and junior residents with regard to memorizing questions for study. Cheating and unethical behavior is not always clear to the learner and represents an area for further education.