William Adamas-Rappaport

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Books

• Adamas-Rappaport, W., Quesada, O., SantaMaria, M., & Verlade, B. (2008). Problem Based Medical Spanish. Philadelphia, PA: Saunders.
• Adamas-Rappaport, W. (2005). Crash Course in Surgery. Philadelphia, PA: Mosby.

Journals/Publications

• Amini, R., Adamas-Rappaport, W., Situ-Lacasse, E., Bates, J., Tegethoff, A. M., Kelley, R., Johnstone, C., Ratesic, A., Viscusi, R. K., & Fisher, J. (2018). Clinical Skills Temporal Degradation Assessment in Undergraduate Medical Education. Journal of Advances in Medical Education & Professionalism, 6(1), 1-5.
• Ellis, M. S., Nelson, J. T., Kartchner, J. Z., Yousef, K. A., Adamas-Rappaport, W. J., & Amini, R. (2017). Cadaver-based abscess model for medical training. Advances in medical education and practice, 8, 85-88.
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  Ultrasound imaging is a rapid and noninvasive tool ideal for the imaging of soft tissue infections and is associated with a change of clinician management plans in 50% of cases. We developed a realistic skin abscess diagnostic and therapeutic training model using fresh frozen cadavers and common, affordable materials. Details for construction of the model and suggested variations are presented. This cadaver-based abscess model produces high-quality sonographic images with internal echogenicity similar to a true clinical abscess, and is ideal for teaching sonographic diagnostic skills in addition to the technical skills of incision and drainage or needle aspiration.
• McCrary, H. C., Faucett, E. A., Hurbon, A. N., Milinic, T., Cervantes, J. A., Kent, S. L., & Adamas-Rappaport, W. J. (2017). A Fresh Cadaver Model for the Instruction of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 157(1), 30-35.
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  Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)-guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students' ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar's test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment ( P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure ( P = .001), but not for indications or complications ( P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.
• Mohty, K. M., Cravens, M. G., Adamas-Rappaport, W. J., Amini-Shervin, B., Irving, S. C., Stea, N., Adhikari, S., & Amini, R. (2017). Cadaver-based Necrotizing Fasciitis Model for Medical Training. Cureus, 9(4), e1168.
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  Necrotizing fasciitis is a devastating infectious disease process that is characterized by extensive soft tissue necrosis along deep fascial planes, systemic toxicity, and high mortality. Ultrasound imaging is a rapid and non-invasive tool that can be used to help make the diagnosis of necrotizing fasciitis by identifying several distinctive sonographic findings. The purpose of this study is to describe the construction of a realistic diagnostic training model for necrotizing fasciitis using fresh frozen cadavers and common, affordable materials. Presently, fresh non-embalmed cadavers have been used at medical institutions for various educational sessions including cadaver-based ultrasound training sessions. Details for the preparation and construction of a necrotizing fasciitis cadaver model are presented here. This paper shows that the images obtained from the cadaver model closely imitate the ultrasound appearance of fluid and gas seen in actual clinical cases of necrotizing fasciitis. Therefore, it can be concluded that this cadaver-based model produces high-quality sonographic images that simulate those found in true cases of necrotizing fasciitis and is ideal for demonstrating the sonographic findings of necrotizing fasciitis.
• Hoyer, R., Means, R., Robertson, J., Rappaport, D., Schmier, C., Jones, T., Stolz, L. A., Kaplan, S. J., Adamas-Rappaport, W. J., & Amini, R. (2016). Ultrasound-guided procedures in medical education: a fresh look at cadavers. Internal and emergency medicine, 11(3), 431-6.
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  Demand for bedside ultrasound in medicine has created a need for earlier exposure to ultrasound education during the clinical years of undergraduate medical education. Although bedside ultrasound is often used for invasive medical procedures, there is no standardized educational model for procedural skills that can provide the learner a real-life simulated experience. The objective of our study was to describe a unique fresh cadaver preparation model, and to determine the impact of a procedure-focused ultrasound training session. This study was a cross-sectional study at an urban academic medical center. A sixteen-item questionnaire was administered at the beginning and end of the session. Fifty-five third year medical students participated in this 1-day event during their surgical clerkship. Students were trained to perform the following ultrasound-guided procedures: internal jugular vein cannulation, femoral vein cannulation femoral artery cannulation and pericardiocentesis. Preparation of the fresh cadaver is easily replicated and requires minor manipulation of cadaver vessels and pericardial space. Fifty-five medical students in their third year participated in this study. All of the medical students agreed that US could help increase their confidence in performing procedures in the future. Eighty percent (95 % CI 70-91 %) of students felt that there was a benefit of learning ultrasound-based anatomy in addition to traditional methods. Student confidence was self-rated on a five-point Likert scale. Student confidence increased with statistical significance in all of the skills taught. The most dramatic increase was noted in central venous line placement, which improved from 1.95 (SD = 0.11) to 4.2 (SD = 0.09) (p < 0.001). The use of fresh cadavers for procedure-focused US education is a realistic method that improves the confidence of third year medical students in performing complex but critical procedures.
• Kay, R. D., Manoharan, A., Nematollahi, S., Nelson, J., Cummings, S. H., Rappaport, W. J., & Amini, R. (2016). A novel fresh cadaver model for education and assessment of joint aspiration. Journal of orthopaedics, 13(4), 419-24.
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  The objective of this study was to describe a novel cadaver model and to determine the utility of this model for teaching and assessing students in performing knee, elbow, and wrist arthrocentesis.
• McCrary, H., J, K., MH, T., Savilo, C., Ho, H., Adamas-Rappaport, W. J., & Viscusi, R. K. (2016). Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students. The American Journal of Surgery, 1-6.
• Miller, R., Ho, H., Ng, V., Melissa, T., Rappaport, D., Adamas-Rappaport, W., Dandorf, S. J., Dunleavy, J., Viscusi, R. K., & Amini, R. (2016). Introducing a fresh cadaver model for ultrasound-guided central venous access training in undergraduate medical education.. Western Journal of Emergency Medicine, 17(3), 362-6.
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  Approximately 2.5 hours spent on project for 2015
• Miller, R., Ho, H., Ng, V., Yeaton, J., Rappaport, D., Adamas-Rappaport, W., Jack, H., Brandis, D., Nematollahi, S., Viscusi, R. K., Alvarado, J., & Amini, R. (2016). Introduction of a fresh cadaver model for ultrasound-guided central venous access training: Maximizing use of the willed-body for educational training. Western Journal of Emergency Medicine.
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  Approximately 2.5 hours spent on project for 2015
• Stoneking, L. R., Waterbrook, A. L., Garst Orozco, J., Johnston, D., Bellafiore, A., Davies, C., Nuno, T., Fatas, J. M., Beita, O., Ng, V., Grall, K., & Adamas-Rappaport, W. (2016). Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?. Advances in Medical Education and Practice, 7, 467-473.
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  Approximately 1 hours spent on project for 2015
• McCrary, H. C., Krate, J., Savilo, C., Ho, H., Ley, M. L., Adamas-Rappaport, W., & Viscusi, R. K. (2015). Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students.. Journal of the American College of Surgeons, 221(2), S50.
• Miller, R., Ho, H., Ng, V., Melissa, T., Rappaport, D., Adamas-Rappaport, W., Dandorf, S. J., Dunleavy, J., Viscusi, R. K., & Amini, R. (2014). Introducing a fresh cadaver model for ultrasound-guided central venous access training in undergraduate medical education.. Western Journal of Emergency Medicine, 17(3), 362-6.
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  Approximately 2.5 hours spent on project for 2015
• Nematollahi, S., Kaplan, S. J., Knapp, C. M., Ho, H., Alvarado, J., Viscusi, R., & Adamas-Rappaport, W. (2015). Introduction of a fresh cadaver laboratory during the surgery clerkship improves emergency technical skills. American Journal of Surgery, 210(2), 401-403.
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  Student acquisition of technical skills during the clinical years of medical school has been steadily declining. To address this issue, the authors instituted a fresh cadaver-based Emergency Surgical Skills Laboratory (ESSL).
• Nematollahi, S., Nematollahi, S., St John, P. A., St John, P. A., Adamas-Rappaport, W. J., & Adamas-Rappaport, W. J. (2015). Lessons learned with a flipped classroom. Medical education, 49(11), 1143. doi:10.1111/medu.12845
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  Nematollahi, S., St John, P. A. and Adamas-Rappaport, W. J. (2015), Lessons learned with a flipped classroom. Medical Education, 49: 1143. doi: 10.1111/medu.12845
• Adamas-Rappaport, W., Benjamin, M., Teeple, M., Waer, A., Ong, E., Glazer, E., Sozanski, J., & Poskus, D. (2013). A comparison of unguided versus guided case-based instruction on the surgery clerkship. Journal of Surgical Education.
• Adamas-Rappaport, W., Czuzak, M. H., Alvarado, J., & Darnell, D. (2013). The challenge of teaching Anatomy in a organ-based curriculum: mistakes made and lessons learned. The FASEB Journal, 27(1), 314-2.
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  FASEB J.April 201327 (Meeting Abstract Supplement) 314.2
• Kaplan, S. J., Carroll, J. T., Nematollahi, S., Chuu, A., Adamas-Rappaport, W., & Ong, E. (2013). Utilization of a non-preserved cadaver to address deficiencies in technical skills during the third year of medical school: a cadaver model for teaching technical skills. World journal of surgery, 37(5), 953-5.
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  Emergency technical procedures performed by medical students have decreased in the last decade. An Emergency Surgical Skills Laboratory (ESSL) using a non-preserved cadaver was developed in response to address this deficiency.
• Lee, E., Teeple, M., Bagrodia, N., Hannallah, J., Yazzie, N. P., & Adamas-Rappaport, W. J. (2013). Postoperative pain assessment and analgesic administration in Native American patients undergoing laparoscopic cholecystectomy. Archives of Surgery, 148(1), 91-93.
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  PMID: 23324844;Abstract: Ethnic disparities in pain assessment and analgesic administration following surgery have received little attention in the surgery literature. We noted that our Native American patients were less likely than others to complain of pain. A retrospective chart review of 21 Native American patients and a control group who underwent outpatient, elective laparoscopic cholecystectomy was performed. Native American patients had a statistically lower numeric pain score (mean, 6.5; 95% CI, 3.6-9.4) than non-Native American patients (mean, 8.1; 95% CI, 6.3-9.9; t38=2.63; P
• Lee, E., Teeple, M., Bagrodia, N., Hannallah, J., Yazzie, N. P., & Adamas-Rappaport, W. J. (2013). Postoperative pain assessment and analgesic administration in Native American patients undergoing laparoscopic cholecystectomy. JAMA surgery, 148(1), 91-3.
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  Ethnic disparities in pain assessment and analgesic administration following surgery have received little attention in the surgery literature. We noted that our Native American patients were less likely than others to complain of pain. A retrospective chart review of 21 Native American patients and a control group who underwent outpatient, elective laparoscopic cholecystectomy was performed. Native American patients had a statistically lower numeric pain score (mean, 6.5; 95% CI, 3.6-9.4) than non-Native American patients (mean, 8.1; 95% CI, 6.3-9.9; t38 = 2.63; P 
• Rappaport, D., Chuu, A., Hullett, C., Nematollahi, S., Teeple, M., Bhuyan, N., Honkanen, I., Adamas-Rappaport, W. J., & Sanders, A. (2013). Assessment of alcohol withdrawal in native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised scale. Journal of Addiction Medicine, 7(3), 196-199.
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  PMID: 23579238;Abstract: Background: The Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) is a commonly used scale for assessing the severity of alcohol withdrawal syndrome in the acute setting. Despite validation of this scale in the general population, the effect of ethnicity on CIWA-Ar scoring does not appear in the literature. The purpose of our study was to investigate the validity of the CIWA-Ar scale among Native American patients evaluated for acute alcohol detoxification. Methods: A case series of all patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until April 1, 2012. The CIWA-Ar scores were recorded by trained nursing staff on presentation to Triage Department and every 2 hours thereafter. At our institution, a score of 10 or greater indicates the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. A multivariate logistic regression model was utilized to identify statistically significant variables associated with admission to the inpatient unit and treatment. The relationship of CIWA-Ar scores and ethnicity was compared using analysis of variance. Results: A total of 115 whites, 45 Hispanics, and 47 Native Americans were included in the analysis. Native Americans had consistently lower CIWA-Ar scores at 0, 2, 4, and 6 hours than the other 2 ethnic groups (P = 0.002). In addition, Native Americans were admitted to the hospital less often than the other 2 groups for withdrawal (P < 0.001). Conclusions: The CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic group such as Native Americans. Further prospective studies should be undertaken to determine the validity of the CIWA-Ar scale in assessing alcohol withdrawal across different ethnic populations. Copyright © 2013 American Society of Addiction Medicine.
• Copeland, H., Jones, M., Duran, M. A., Sozanski, J., Poskus, D., Beita, O., & Adamas-Rappaport, W. J. (2011). Teaching medical Spanish on the surgery clerkship: a response to the increased demand for Spanish proficiency among physicians. The American surgeon, 77(12), 1715-7.
• DiMaggio, P. J., Waer, A. L., Desmarais, T. J., Sozanski, J., Timmerman, H., Lopez, J. A., Poskus, D. M., Tatum, J., & Adamas-Rappaport, W. J. (2010). The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship--a response to the economic pressures facing academic medicine today. American journal of surgery, 200(1), 162-6.
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  In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship.
• Adamas-Rappaport, W., & Melcer, S. (2000). Small bowel obstruction, secondary to a bile acid enterolith formed within a single jejunal diverticulum. Contemporary Surgery.
• Mularski, R. A., Ciccolo, M. L., & Rappaport, W. D. (1999). Nonsurgical causes of pneumoperitoneum. Western Journal of Medicine, 170(1), 41-46.
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  PMID: 9926735;PMCID: PMC1305434;Abstract: The radiographic manifestation of free air in the peritoneal cavity suggests serious intra-abdominal disease and the need for urgent surgical management. Yet, about 10% of all cases of pneumoperitoneum are caused by physiologic processes that do not require surgical management. We retrospectively reviewed cases of nonsurgical causes of pneumoperitoneum at the 2 teaching hospitals of a university medical center between January 1990 and December 1995. Successful management by observation and supportive care without surgical intervention was defined as the diagnostic feature of non perforation. Failure of a laparotomy to delineate a surgical cause or to result in a reparative procedure is congruent with a nonsurgical cause of pneumoperitoneum. During this period, 8 patients (6 men and 2 women; mean age, 61 years) were identified with nonsurgical causes of pneumoperitoneum. Two patients underwent negative laparotomy, and the other 6 were successfully managed nonoperatively and discharged from the hospital. In 6 patients, a cause of the pneumoperitoneum was identified. The causes may be grouped under the following categories: postoperatively retained air, thoracic, abdominal, gynecologic, and idiopathic. In our review of the literature, 61 of 139 re ported cases underwent surgical treatment without evidence of perforated viscus. To avoid unnecessary surgical procedures, both primary medicine physicians and surgeons need to recognize nonsurgical causes of pneumoperitoneum. Conservative management is warranted in the absence of symptoms and signs of peritonitis.
• Stevens, K., & Rappaport, W. D. (1999). Insurance status correlation with advanced breast cancer presentation, delayed diagnosis, and treatment among the hispanic population. Journal of Investigative Medicine, 47(2), 15A.
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  Abstract: PURPOSE: Study the Insurance status of Breast Cancer patients and its relevance to delayed diagnosis and treatment. METHODS: To identify Breast Cancer patients, a search was completed using the Arizona Tumor Registry for years 1991-1996. Hispanic patients were identified using the Tumor Registry designation of ethnicity. The patient charts were reviewed and categorized for ethnicity, year of diagnosis, patient's age at diagnosis, cancer stage at diagnosis, and duration between time of diagnosis and treatment. Statistical analysis will link patient's insurance status with diagnosis and treatment. RESULTS: Of the 50 patients reviewed, 19 have met the study criteria. 10 had insurance at the time of diagnosis, while nine did not. The average age at the time of diagnosis was 52.47 years, with an average weight of 70.93 kg, and average height of 62.53 inches. The stages of the cancer when diagnosed were distributed as follows: stage 1; 6 patients, stage 2; 8 patients, stage 3; 2 patients. Tumor staging was has yet to be determined for 3 patients. Although the difference in cancer stage at time of diagnosis between insured and non-insured patients was insignificant, the time span between diagnosis and treatment of patients with insurance averaged 29.9 days, while the non-insured patients averaged 78.6 days. CONCLUSIONS: From past studies we do know that long-term survival of women with breast cancer is dependent on the stage of the disease at the time of diagnosis. It is also been shown that breast cancer diagnosis at early stages of progression is low in the Hispanic population compared to the white non-Hispanic population. We hope to identify further factors that are contributing to this difference.
• Wong, R. W., Ramsay, E., Adamas-Rappaport, W., Villar, H., & Putnam, C. (1998). Jejunal adenocarcinoma. Surgical Rounds, 494-499.
• Dillavou, E. D., Anderson, L. R., Bernert, R. A., Mularski, R. A., Hunter, G. C., Fiser, S. M., & Rappaport, W. D. (1997). Lower extremity latrogenic nerve injury due to compression during intraabdominal surgery. American Journal of Surgery, 173(6), 504-508.
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  PMID: 9207163;Abstract: BACKGROUND: Iatrogenic nerve injury due to poor positioning and external compression is a common surgical complication. However, sciatic neuropathy from external compression and femoral nerve injury after self-retaining retraction are less-published complications. METHODS: Surgical Morbidity and Mortality Reports from 1986 through 1995 were reviewed to identify femoral and sciatic neuropathies following intraabdominal vascular and general surgeries. RESULTS: Two sciatic and 5 femoral neuropathies were reported, an incidence of approximately 0.17% of abdominal cases. Sciatic injuries were attributed to external compression, whereas femoral neuropathies were due to compression by self-retaining retraction. The 3 female and 4 male patients had a mean age of 53.4 years, and no patient had a prior history of peripheral neuropathy. Mean operating time for sciatic injuries was 8.2 hours, versus 4.3 hours for femoral neuropathies. Both patients with sciatic neuropathy had complete resolution of symptoms, compared with 1 femoral neuropathy patient. Two femoral neuropathies were permanent, 1 had partial resolution and 1 had improvement at 4 months but was lost to follow-up. CONCLUSIONS: Sciatic and femoral compression neuropathies are rare but serious complications of abdominal surgery. When retracting in the deep pelvis, consideration should be given to using small, well-padded retractor blades and repositioning these regularly. Prevention of sciatic nerve compression requires careful padding of the table surface, especially for longer cases.
• Erstad, B. L., Meeks, M. L., Chow, H., Rappaport, W. D., & Levinson, M. L. (1997). Site-specific pharmacokinetics and pharmacodynamics of intramuscular meperidine in elderly postoperative patients. Annals of Pharmacotherapy, 31(1), 23-28.
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  PMID: 8997460;Abstract: OBJECTIVE: To examine and compare the pharmacokinetics and pharmacodynamics of meperidine when administered intramuscularly at gluteal and deltoid sites in elderly postoperative patients. DESIGN: Prospective, randomized investigation. SETTING: Tertiary care university teaching hospital. PATIENTS: Fourteen patients 60 years of age or older who were undergoing general surgery. INTERVENTION: A single dose of meperidine 0.75 mg/kg given intramuscularly at either a deltoid or gluteal site. MAIN OUTCOME MEASURES: Pharmacokinetic (based on concentration-time curves) and pharmacodynamic (i.e., pain scales, need for additional pain medication) comparisons were made, based on site of meperidine injection. RESULTS: No statistically significant differences were found in the maximum plasma concentration, volume of distribution, or clearance of meperidine by site of injection. Substantial interpatient variability in pharmacokinetic parameters was noted for both sites (range of maximum concentrations: 191-500 ng/mL gluteal, 166-374 ng/mL deltoid). Although pain scores were similar for the two groups, four of the patients in the group given gluteal injection required additional breakthrough pain management within 4 hours of meperidine injection compared with one patient in the group given deltoid injection. CONCLUSIONS: There is no obvious relationship between meperidine pharmacokinetic and pharmacodynamic parameters, regardless of intramuscular injection site. Breakthrough pain is common when patients are given intramuscular injections postoperatively, particularly when the gluteal route is used. When meperidine is used for analgesia in elderly postoperative patients, consideration should be given to more rapid and predictable routes (e.g., intravenous injection) of meperidine administration.
• Fass, R., Hixson, L. J., Ciccolo, M. L., Gordon, P., Hunter, G., & Rappaport, W. (1997). Contemporary medical therapy for gastroesophageal reflux disease. American Family Physician, 55(1), 205-212.
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  PMID: 9012279;Abstract: Gastroesophageal reflux disease is a chronic disorder that requires long-term therapy in most patients. The appropriate medical therapy should be individualized to the severity of symptoms, the degree of esophagitis and the presence of other acid-reflux complications. Lifestyle changes should form the basis of any therapeutic approach. In patients with mild to moderate disease, initial therapy with histamine H2-receptor antagonists in conventional dosages is suggested. Prokinetic agents are potentially useful in patients with impaired esophageal or gastric motor function, but their efficacy as single agents does not appear to surpass that of standard doses of H2 blockers. Sucralfate, a cytoprotective agent, is an additional therapeutic option. For patients with more severe disease, omeprezole and lansoprazole provide unequaled healing rates and accelerated symptom relief. In most patients, maintenance therapy is vital. Surgery is indicated in patients whose disease is refractory to medical therapy and in those who develop complications not amenable to medical therapy.
• Gedebou, T. M., Barr, S. T., Hunter, G., Sinha, R., Rappaport, W., & VillaReal, K. (1997). Risk factors in patients undergoing major nonvascular abdominal operations that predict perioperative myocardial infarction. American Journal of Surgery, 174(6), 755-758.
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  PMID: 9409612;Abstract: BACKGROUND: Perioperative myocardial infarction (PMI) is an uncommon but serious complication of major abdominal surgery. Identifying the patients at risk may potentially reduce morbidity and mortality. In this study we determined risk factors associated with PMI in patients undergoing abdominal, nonvascular surgery (ANVS). METHODS: The utility of risk factors for PMI using Goldman's criteria and nine other variables were compared in patients diagnosed with PMI after ANVS (group I) and a control group (group II) matched for age, gender, and type of operation. RESULTS: Thirty-four patients, 21 men and 13 women, with a mean age of 70 years were diagnosed with PMI, which was associated with a 41% mortality rate (14 of 34). Risk factors for PMI included poor general condition, congestive heart failure, abnormal cardiac rhythm, smoking, previous myocardial infarction (MI), and emergent operation. CONCLUSION: Although PMI following ANVS is uncommon, the mortality rate remains high. Patients classified as Goldman's class III and IV, or with a history of cigarette smoking, previous MI, or angina merit further evaluation in order to reduce the incidence of this complication.
• Gedebou, T. M., Wong, R. A., Rappaport, W. D., Jaffe, P., Kahsai, D., & Hunter, G. C. (1996). Clinical presentation and management of iatrogenic colon perforations. American Journal of Surgery, 172(5), 454-458.
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  PMID: 8942543;Abstract: BACKGROUND: Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema. PATIENTS AND METHODS: The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5- year period were reviewed. RESULTS: Twenty-one patients, 12 males and 9 females aged 66 ± 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 ± 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy. CONCLUSION: We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.
• Jones, J., Hall, K., Brooks, M., Witzke, D., Hunter, G. C., & Adamas-Rappaport, W. (1996). A Survey of Preoperative Fears in General Surgical Patients.. Comtempt Surgery for Residents, 4(4), 14-20.
• Bull, D. A., Hunter, G. C., Holubec, H., Aguirre, M. L., Rappaport, W. D., & Putnam, C. W. (1995). Cellular origin and rate of endothelial cell coverage of PTFE grafts. Journal of Surgical Research, 58(1), 58-69.
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  PMID: 7830407;Abstract: To determine the origin, cell type present, and rate of endothelial cell coverage of PTFE grafts, 5-cm segments of 4-mm-diameter, 60-μm PTFE grafts were implanted end-to-end bilaterally in the carotid arteries of greyhound dogs. An external jugular vein wrap was applied to the outer surface of one of the PTFE grafts; the contralateral PTFE graft, which was unwrapped, served as its control. Two dogs each were sacrificed at 3, 5, 7, 14, 21, 28, and 35 days postimplantation. Anastomotic endothelial ingrowth was analyzed using scanning electron microscopy. Microvessel ingrowth was documented in longitudinal H and E sections. Cell identity was established by immunohistochemistry with factor VIII antibody, Ulex europaes, leukocyte common antigen, and antibodies to α-actin, desmin, vimentin, and basic fibroblast growth factor. All grafts were patent at the time of harvest. Endothelial cell migration from the native artery adjacent to the anastomosis commenced at 7 days, extended to 5 mm beyond the proximal and distal anastomoses by 14 days and to 1.0 cm by 35 days. Endothelialization of the mid-portion of the wrapped grafts occurred via microvessel ingrowth, a process which began at 7 days. Microvessels reached the luminal surface by 28 days and an endothelial cell monalayer was established by 35 days. Wrapping the external surface of the graft with vein increased the rate of graft healing. Basic fibroblast growth factor was detectable by immunohistochemistry at the vein wrap-graft interface in the first 14 days.
• Bull, D. A., Hunter, G. C., Holubec, H., Aguirre, M. L., Rappaport, W. D., & Putnam, C. W. (1995). Erratum: Cellular origin and rate of endothelial cell coverage of PTFE grafts (Journal of Surgical Research (1995) 58:1 (58-68)). Journal of Surgical Research, 58(5), 541-543.
• Fox, K. A., Mularski, R. A., Sarfati, M. R., Brooks, M. E., Warneke, J. A., Hunter, G. C., & Rappaport, W. D. (1995). Aspiration pneumonia following surgically placed feeding tubes. The American Journal of Surgery, 170(6), 564-567.
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  PMID: 7492001;Abstract: Background: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. Patients and methods: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. Results: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). Conclusions: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals. © 1995.
• Hall, K. A., Peters, B., Smyth, S. H., Warneke, J. A., Rappaport, W. D., Putnam, C. W., & Hunter, G. C. (1995). Abdominal wall hernias in patients with abdominal aortic aneurysmal versus aortoiliac occlusive disease. The American Journal of Surgery, 170(6), 572-575.
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  PMID: 7492003;Abstract: Background: This study was undertaken to determine the incidence of ventral incisional hernias (VIHs) and inguinal hernias (IHs) in patients with abdominal aortic aneurysmal (AAA) versus those with aortoiliac occlusive disease (AIOD). Patients and methods: The medical records of 193 patients (128 with AAA and 65 with AIOD) who had undergone elective aortic reconstruction were reviewed to determine the number and location of abdominal wall hernias (AWHs). Results: Forty-one AWHs (28 IHs and 13 VIHs) were detected in patients with AAA compared to 13 (11 IHs and 2 VIHs) in patients with AIOD. There was a significantly greater incidence of VIHs in patients with AAA versus patients with AIOD (10% versus 3%, P
• Shen, G. K., Tsen, A. C., Hunter, G. C., Ghory, M. J., & Rappaport, W. (1995). Surgical treatment of symptomatic biliary stones in patients with cystic fibrosis. American Surgeon, 61(9), 814-819.
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  PMID: 7661481;Abstract: Patients with cystic fibrosis have a high incidence of cholelithiasis. However, few studies have addressed the operative therapy for cholelithiasis in this group of patients with poor pulmonary function. We reviewed six patients with cystic fibrosis who were treated for symptomatic biliary stones. Five patients underwent cholecystectomy for chronic cholecystitis. One patient with extremely poor pulmonary status presented with choledocholithiasis and cholangitis, which was successfully treated with endoscopic sphincterotomy followed by ursodeoxycholic acid therapy. Five of these six patients had significant relief of their symptoms. One patient never recovered completely from the operation and eventually died from continued pulmonary deterioration. We conclude that in patients with cystic fibrosis and symptomatic biliary stones, careful attention to pulmonary care can afford safe, elective cholecystectomy. More conservative treatment is indicated in patients with marginal pulmonary reserve.
• Erstad, B. L., & Rappaport, W. D. (1994). Subcapsular hematoma after laparoscopic cholecystectomy, associated with ketorolac administration. Pharmacotherapy, 14(5), 613-615.
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  PMID: 7997396;Abstract: Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. Its adverse effect profile is different from that of the opioid analgesics; in particular, in its lack of respiratory depressive actions. However, ketorolac has risks associated with its perioperative administration, including episodes of substantial gastrointestinal bleeding. A patient undergoing elective laparoscopic cholecystectomy developed a subcapsular hepatic hematoma shortly after receiving a dose of injectable ketorolac. No evidence of parenchymal injury was found on laparoscopy, which argues against iatrogenic trauma. Clinicians should be aware that ketorolac may cause or aggravate bleeding, and it should be used with caution in perioperative patients.
• Erstad, B. L., Campbell, D. J., Rollins, C. J., & Rappaport, W. D. (1994). Albumin and prealbumin concentrations in patients receiving postoperative parenteral nutrition. Pharmacotherapy, 14(4), 458-462.
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  PMID: 7937283;Abstract: This prospective, nonrandomized study was conducted to compare the increases in albumin and prealbumin concentrations in postoperative patients given adequate nutrition support. All surgery patients at least 18 years of age and who required parenteral nutrition were included. Of 86 patients evaluated, 16 met all criteria for study entry. Blood for albumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then weekly. Blood for prealbumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then twice weekly. Albumin concentrations increased from 2.00 ± 0.35 to 2.21 ± 0.42 g/dl (NS). Prealbumin concentrations increased from 11.97 ± 6.31 to 17.29 ± 8.93 mg/dl (p=0.017). All but one prealbumin concentration was in the normal range for our laboratory when parenteral nutrition was discontinued. None of the albumin concentrations were ever in the normal range. The prealbumin concentration is a better indicator than albumin of nutrition status in the postoperative patient. Since prealbumin concentrations typically rise into the normal range within a week after adequate caloric supplementation, clinicians may avoid unnecessary increases in protein-calorie intake and laboratory testing of nutrition status by using this measurement.
• Rappaport, W. D., Gordon, P., Warneke, J. A., Neal, D., & Hunter, G. C. (1994). Contraindications and complications of laparoscopic cholecystectomy. American Family Physician, 50(8), 1707-1711, 1714.
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  PMID: 7977000;Abstract: Laparoscopic cholecystectomy is a commonly performed procedure for the removal of symptomatic gallstones. Compared with open cholecystectomy, laparoscopic cholecystectomy is associated with less postoperative pain, earlier discharge from the hospital and a more rapid recovery. However, there are specific contraindications to the procedure, including empyema of the gallbladder, gangrenous cholecystitis, coagulopathy, portal hypertension and peritonitis. Complications from laparoscopic cholecystectomy include common duct injury, bleeding, bile leakage and wound infection. An understanding of these issues allows the family physician to more appropriately select patients for laparoscopic removal of the gallbladder.
• Sarfati, M. R., Fox, K. A., Warneke, J. A., Fajardo, L. L., Hunter, G. C., & Rappaport, W. D. (1994). Stereotactic fine-needle aspiration cytology of nonpalpable breast lesions: An analysis of 258 consecutive aspirates. The American Journal of Surgery, 168(6), 529-532.
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  PMID: 7977990;Abstract: background: The role of stereotactic fine-needle aspiration cytology (SFNAC) in the diagnosis of nonpalpable breast lesions is poorly defined. patients and methods: Data were prospectively collected from 225 consecutive patients with nonpalpable breast lesions who had aspiration cytology followed by immediate surgical excision. results: Between 1988 and 1993, 258 such procedures were performed. The results of 84 (33%) were interpreted as benign, 84 (33%) as atypical, 28 (11%) as suspicious for malignancy, and 49 (19%) as malignant. In all, 88 (34%) surgical specimens were malignant. SFNAC had an 80% sensitivity, a 96% specificity, a 91% positive predictive value, and an 89% negative predictive value. There were 18 false-negative and 7 false-positive aspirates. conclusions: SFNAC for diagnosing nonpalpable breast lesions is moderately sensitive and highly specific, and has a high positive and negative predictive value. In conjunction with mammography and clinical assessment, the procedure is useful for determining which patients with nonpalpable breast lesions may require surgical biopsy. © 1994.
• Wong, R. W., Rappaport, W. D., Witzke, D. B., Putnam, C. W., & Hunter, G. C. (1994). Factors influencing the safety of colostomy closure in the elderly. Journal of Surgical Research, 57(2), 289-292.
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  PMID: 8028338;Abstract: Although colostomy closure is a commonly performed surgical procedure, there remains concern that the attendant risks may be misjudged, especially in the elderly. The purpose of this study was to evaluate the safety of performing colostomy closure and to define the factors that may influence morbidity and mortality in patients over the age of 70. Three hundred seven patients (178 males, 129 females) underwent colostomy closure over a 5-year period. The mean age was 52 years and 84 (27%) of the patients were 70 years or older. The indications for colostomy included diverticulitis, 115 (38%); malignancy, 47 (15%); perforation 35 (11%); trauma, 34 (11%); congenital anomalies, 26 (8%); obstruction, 13 (4%); bleeding, 6 (2%); colovesical fistulae, 6 (2%); polyps, 2 (0.7%); and miscellaneous, 23 (8%). An end colostomy was performed in 193 (63%) patients and a transverse loop colostomy in the remaining 114 (37%). There were no deaths. Complications occurred in 27 (9%) patients: 17 were directly related to colostomy closure (8 wound infections, 3 intraabdominal abscesses, 3 small bowel obstructions, 2 anastomotic strictures, and 1 anastomotic leak) while 10 were nonsurgical. Risk factors statistically associated with increased morbidity included age >70 years (13% versus 5%), end versus loop colostomy (10% versus 2%), an operative time >2 hr, and estimated blood loss ≥500 ml (P < 0.05). ASA classification was only predicative of postoperative complications in patients over 70 years of age. We conclude that although colostomy closure can be performed without mortality, the increased morbidity associated with this procedure in patients 70 years or older necessitates careful preoperative assessment.
• Wong, R., Rappaport, W., Witte, C., Hunter, G., Jaffe, P., Hall, K., & Witzke, D. (1994). Risk of nonshunt abdominal operation in the patient with cirrhosis. Journal of the American College of Surgeons, 179(4), 412-416.
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  PMID: 7921390;Abstract: BACKGROUND: The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension. STUDY DESIGN: We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome. RESULTS: There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p
• Fass, R., Sampliner, R. E., Mackel, C., McGee, D., & Rappaport, W. (1993). Age- and gender-related differences in 24-hour esophageal pH monitoring of normal subjects. Digestive Diseases and Sciences, 38(10), 1926-1928.
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  PMID: 8404416;Abstract: Twenty-four-hour esophageal pH monitoring is currently the most sensitive test for diagnosing gastroesophageal reflux. Little is known, however, about the effect of aging and gender on esophageal acid exposure in asymptomatic individuals. Thirty asymptomatic volunteers underwent 24-hr esophageal pH monitoring. Fifteen were
• Marian, M., Rappaport, W., Cunningham, D., Thompson, C., Esser, M., Williams, F., Warneke, J., & Hunter, G. (1993). The failure of conventional methods to promote spontaneous transpyloric feeding tube passage and the safety of intragastric feeding in the critically ill ventilated patient. Surgery Gynecology and Obstetrics, 176(5), 475-479.
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  PMID: 8480271;Abstract: Nasoenteral tube feedings are often recommended in critically ill patients when gastrointestinal tract function is intact. Conventional methods of placement include turning the patient on the right side and the use of drugs that stimulate peristalsis to promote transpyloric passage. A prospective study was initially performed to assess the success of conventional methods used to promote transpyloric feeding tube placement in patients requiring assisted ventilation admitted to the Surgical Intensive Care Unit (SICU) (Part I of the study). In 68 critically ill ventilated patients, placement of nasoduodenal feeding tubes was attempted. Successful transpyloric placement was achieved in only ten patients. There was no correlation between age, gender, admitting diagnosis, time of tube placement and successful placement. The second part of the study was initiated to assess the safety of nasogastric feeding in critically ill ventilated patients. Forty-two patients admitted to the SICU were considered candidates for gastrointestinal tract feeding and were fed through the gastric route. Twenty-five patients reached enteral feeding goal rate within 72 hours, while 34 patients achieved goal rate by five days. Eight patients required total parenteral nutrition to meet nutritional needs because of an inability to achieve adequate nutritional support enterally. There were 11 complications noted in ten patients, including one episode of aspiration pneumonia. The presence of complications was not related to age, gender, admitting diagnosis, infusion method or type of formula used. Duodenal intubation using conventional methods in critically ill ventilated patients is unsuccessful in most patients. Nasogastric feeding in this group of patients can be safely administered in selected instances.
• Rappaport, W. D., Valente, J., Hunter, G. C., Rance, N. E., Lick, S., Lewis, T., & Neal, D. (1993). Clinical utilization and complications of sural nerve biopsy. The American Journal of Surgery, 166(3), 252-256.
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  PMID: 8396357;Abstract: Surgeons frequently perform sural nerve biopsy aspart of the work-up of patients with peripheral neuropathy. The indications for the procedure, therapeutic value, and complications associated with the procedure have received little attention in the surgical literature. A retrospective chart review of 60 patients with the suspected diagnosis of peripheral neuropathy undergoing sural nerve biopsy was performed. Vasculitis was suspected in 29 (48%) patients undergoing biopsy. This diagnosis was confirmed in 6 of the 29 patients and resulted in the alteration of therapy in 31% of patients with this suspected diagnosis. In 27 (45%) patients, the etiology of their peripheral neuropathy was unknown. Twelve (44%) patients in this group had sural nerve pathology; however, no change in therapy was required. Ten patients in our series had associated malignant tumors; some of these patients were diagnosed after referral for sural nerve biopsy. Twenty-five (42%) patients remained undiagnosed after biopsy. Nerve conduction studies were performed in 14(22%) patients. Thirteen patients with abnormal lower extremity nerve conduction studies had 6 normal and 7 abnormal biopsy results. The one patient with a normal study had a normal nerve biopsy result. There were six (10%) patients with wound infections, seven (12%) patients with delayed wound healing, and three (5%) patients with new onset of chronic pain in the distribution of the sural nerve, for an overall complication rate of 27%. There was no correlation between the preoperative use of antibiotics, type of local anesthetic used, or length of nerve excised and complication rate. We conclude that the complication rate after sural nerve biopsy is significant. Strict criteria should be employed in selecting patients for sural nerve biopsy including a careful neurologic history and physical examination, nerve conduction studies, appropriate work-up for vasculitis if suspected, and implementation of a search for malignancy if this is not apparent. If the diagnosis is still in question, then sural nerve biopsy would seem appropriate, especially in patients with suspected vasculitis. © 1993 Reed Publishing USA.
• Rappaport, W., & Witzke, D. (1993). Education about death and dying during the clinical years of medical school. Surgery, 113(2), 163-165.
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  PMID: 8430363;Abstract: Background. Although there has been a dramatic increase in education about death and dying in medical school curricula, the physician's interaction with terminally ill patients and their families still causes concern. The purpose of our study was to determine the impact of the third-year clerkship on education of medical students about death and dying. Methods. From August 1, 1988, to August 1, 1990, a questionnaire concerning the care of terminally ill patients was distributed to all students completing the third-year clinical clerkship at our medical school. Results. One hundred and eighty questionnaires were distributed, of which 106 were returned, yielding a response rate of 59%. All students had cared for a terminally ill patient during their third year. Forty-four (41%) students responding had never been present when an attending physician talked with a dying patient, and 37 (35%) had never discussed with an attending physician how to deal with a terminally ill patient. During the surgical clerkship 77 (73%) students had never been present when a surgeon had to tell the family of a patient bad news after surgery, and 90 (85%) had never been present when an attending surgeon had informed a family that their relative had died. Despite the fact that the curriculum addresses the stages of death and dying, almost half of the students could not remember these. When they were discharging a terminally ill patient home, one third of students could not identify problems that would be encountered by the family in caring for the patient. Conclusions. Fifty-seven (54%) felt that they were poorly equipped to deal with terminally ill patients on graduation from medical school, and 91% welcomed the opportunity to be educated in this area during the clinical years. © 1993.
• Sarfati, M. R., Hunter, G. C., Witzke, D. B., Bebb, G. G., Smythe, S. H., Boyan, S., & Rappaport, W. D. (1993). Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis. The American Journal of Surgery, 166(6), 660-665.
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  PMID: 8273845;Abstract: The diagnosis of acute appendicitis is usually made from the history and physical examination. Recently, abdominal ultrasonography (US), laparoscopy, computerized tomography (CT), and barium enema (BE) have been used in the preoperative evaluation of patients with presumed appendicitis in order to improve the diagnostic accuracy. However, the usefulness of these tests in verifying the diagnosis of appendicitis has not been established. We reviewed the medical records of 203 patients who underwent appendectomy. One hundred patients were surgically treated before 1984 (group I) and 103 patients underwent surgery after 1988 (group II). Patients in group II were more likely to have preoperative US, laparoscopy, CT, or BE (24 in group II versus 3 in group I, p
• Sedwitz, J. L., & Rappaport, W. D. (1993). Complications associated with needle localization biopsy of the breast. Surgery Gynecology and Obstetrics, 176(3), 283-.
• Giangobbe, M. J., Rappaport, W. D., & Stein, B. (1992). The significance of fever following cholecystectomy. Journal of Family Practice, 34(4), 437-440.
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  PMID: 1556537;
• Hall, K. A., Wong, R. W., Hunter, G. C., Camazine, B. M., Rappaport, W. A., Smyth, S. H., Bull, D. A., McIntyre, K. E., Bernhard, V. M., & Misiorowski, R. L. (1992). Contrast-induced nephrotoxicity: The effects of vasodilator therapy. Journal of Surgical Research, 53(4), 317-320.
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  PMID: 1405611;Abstract: The increasingly frequent use of contrast-enhanced imaging for diagnosis or intervention in patients with peripheral vascular disease has generated concern about the incidence and avoidance of contrast-induced nephrotoxicity (CIN). In this prospective study, we sought to identify those patients at greater risk of developing CIN and to evaluate the efficacy of vasodilator therapy with dopamine in limiting this complication. Baseline serum creatinine (Cr) concentrations were obtained on admission and daily for up to 72 hr after angiography in 222 patients undergoing 232 angiographic procedures. The preangiographic treatment was varied at 2-month intervals for 1 year. All patients received an intravenous infusion of 5% dextrose and 0.45% normal saline at a rate of 75 to 125 ml/hr. During the first interval patients received 12.5 g of 25% mannitol immediately prior to their contrast load, in addition to intravenous fluids. During the next 2-month period the patients were given renal dose dopamine intravenously (3 μg/kg/min) commencing the evening before angiography and continued to the next morning. During the latter half of the study the treatment regimens were modified so that the use of mannitol was restricted to patients with diabetes mellitus and dopamine to patients with serum creatinine concentrations of ≥ 2 mg/dl. Postangiographic elevation in Cr occurred in 2, 10.4, and 62% of studies in patients with baseline creatinine levels of ≤ 1.2 mg/dl, 1.3 to 1.9 mg/dl, and ≥ 2.0 mg/dl, respectively. None of the patients receiving dopamine experienced an elevation in creatinine. There was no statistical correlation between age, diabetes, or medication with calcium channel blockers and CIN. Our preliminary results suggest that renal dose dopamine may reduce the incidence of contrast-induced nephrotoxicity in high risk patients. © 1992.
• Halldorsson, A., Esser, M. J., Rappaport, W., Valente, J., Hunter, G., & McIntyre, K. (1992). A new method of diagnosing diaphragmatic injury using intraperitoneal technetium: Case report. Journal of Trauma, 33(1), 140-142.
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  PMID: 1635099;Abstract: The diagnosis of diaphragmatic laceration following blunt or penetrating trauma is often difficult to establish. Delay in recognition of this injury can be life threatening, resulting in herniation of abdominal viscera with possible strangulation or respiratory embarrassment. Previous animal studies from our institution have documented that intra-abdominal instillation of technetium sulfur colloid is a sensitive method to diagnose diaphragmatic disruption. We now present a case of diaphragmatic injury where the preoperative diagnosis was accurately made using this method when other imaging studies were inconclusive.
• Holubec, H., Hunter, G. C., Putnam, C. W., Bull, D. A., Rappaport, W. D., & Chvapil, M. (1992). Effect of surgical manipulation of polytetrafluoroethylene grafts on microstructural properties and healing characteristics. The American Journal of Surgery, 164(5), 512-516.
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  PMID: 1443379;Abstract: The effects of graft healing of alterations in the microstructure of polytetrafluoroethylene (PTFE) grafts induced by surgical instruments have not been fully elucidated. This study evaluates changes in the structural and physical properties of PTFE grafts resulting from the intentional application of commonly used surgical instruments and the influence of these changes on cellular ingrowth. The extent of cellular ingrowth into intact (10, 30, and 60 μm unreinforced and 30 μm reinforced [R]) and structurally compromised PTFE grafts (30 reinforced and 60 μm nonreinforced) implanted subcutaneously in Sprague-Dawley (n=14) rats was evaluated at 7 and 21 days. The thrombogenicity of 10-, 30-, 60-, and 80-μm intact graft segments was determined gravimetrically after suspension in the internal jugular vein of dogs for 90 minutes. Cellular ingrowth consisting of fibroblasts, macrophages, and microvessels was directly related to porosity and was most extensive in 60-μm uncompromised graft segments, being 7-, 17-, and 20-fold greater than was observed in 60- and 30R-μm compromised grafts and undamaged 10-μm grafts, respectively. There was a direct relationship between porosity and thrombogenicity of intact graft segments suspended in the jugular vein. The amount of thrombus adherent to 80-μm graft segments was eightfold greater compared with 10-μm grafts. Manipulation of PTFE with surgical instruments significantly impairs healing and may be a possible etiologic factor in the poor long-term performance of these grafts. © 1992 Reed Publishing USA.
• Lesnik, I., Rappaport, W., Fulginiti, J., & Witzke, D. (1992). The role of early tracheostomy in blunt, multiple organ trauma. American Surgeon, 58(6), 346-349.
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  PMID: 1596033;Abstract: During a 9-year period, 101 patients sustaining blunt, multiple organ injury underwent tracheostomy. Group I consisted of 32 patients who underwent tracheostomy within the first 4 days of injury (early tracheostomy) and Group II comprised 69 patients who underwent tracheostomy more than 4 days after surgery (late tracheostomy). There was no statistical difference between the two groups in terms of age, Injury Severity Score, Glasgow Coma Score, and associated injuries. The mean time of mechanical ventilatory support was 6.0 ± 3.4 days in Group I as compared to 20.6 ± 12.2 days in Group II (P < 0.001). Early weaning from the ventilator was accomplished in 32 (100%) patients who underwent early tracheostomy versus 43 (62%) of those who underwent late tracheostomy (P < 0.001). Finally, the incidence of nosocomial pneumonias was also significantly less in patients undergoing early tracheostomy. There were three nonlethal complications associated with tracheostomy. The authors conclude that early tracheostomy helps in early weaning from the ventilator and reduces the incidence of nosocomial pneumonias and time of mechanical ventilatory support in patients with blunt, multiple organ injury.
• Lieurance, R., Benjamin, J. B., & Rappaport, W. D. (1992). Blood loss and transfusion in patients with isolated femur fractures.. Journal of orthopaedic trauma, 6(2), 175-179.
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  PMID: 1602337;Abstract: A retrospective study of 53 patients with isolated femur fractures was performed to evaluate blood loss and transfusion incidence. Patients with other long bone fractures, abdominal, chest, mediastinal, and vascular injuries were excluded. Twenty-one patients required transfusion during the initial hospitalization averaging 2.5 units PRBCs. Admission hematocrit, preoperative and total EBL were found to be significant variables in determining transfusion. Fracture patterns, classified as high or low energy, were not found to correlate with pre- or intraoperative blood loss, incidence of transfusion, delay to surgery or duration of hospital stay. The estimated blood loss in the study group averaged 1,276 cc, stressing the significance of long bone fractures in trauma patients. Preoperative hemorrhage determined transfusion need in contrast to intraoperative blood loss.
• Quint, H. J., Drach, G. W., Rappaport, W. D., & Hoffmann, C. J. (1992). Emphysematous cystitis: A review of the spectrum of disease. Journal of Urology, 147(1), 134-137.
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  PMID: 1729506;Abstract: Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymptomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged.
• Rappaport, W. D., Putnam, C. W., Witzke, D., & Amil, B. (1992). Helping residents' families cope.. Academic medicine : journal of the Association of American Medical Colleges, 67(11), 761.
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  PMID: 1418254;
• Shen, G. K., & Rappaport, W. (1992). Control of nonhepatic intra-abdominal hemorrhage with temporary packing. Surgery Gynecology and Obstetrics, 174(5), 411-413.
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  PMID: 1570620;Abstract: The use of temporary packing to obtain hemostasis has long been an adjunct for surgical procedures in the pelvic area and has recently become an acceptable approach to control hemorrhage resulting from hepatic injuries. In an unstable patient with coagulopathy and diffuse capillary bleeding, packing may be the easiest way to control intra-abdominal bleeding through the simple effect of tamponade. The patient can be re-explored after a period of stabilization, when a more definitive control of hemostasis can be undertaken. Herein, we report six patients with severe underlying disease states that contributed to massive intra-abdominal bleeding refractory to control by conventional means when temporary packing was used to control hemorrhage.
• Valente, J. F., Rappaport, W. D., & Crowe Jr., C. P. (1992). Ischemic stricture and perforation: An unusual complication after successful barium reduction of an intussusception. Archives of Surgery, 127(10), 1252-1253.
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  PMID: 1417495;Abstract: Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception.
• Valente, J., Rappaport, W., Neumayer, L., Witzke, D., & Putnam, C. W. (1992). Influence of spousal opinions on residency selection. The American Journal of Surgery, 163(6), 596-598.
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  PMID: 1595839;Abstract: Fourth-year medical students face the difficult task of choosing a residency consistent with their career goals. Our study investigates the input of the spouse on the residency selection. From July 1, 1988, to July 1, 1990, questionnaires were sent to all 69 spouses of fourth-year medical students at the University of Arizona Medical Center. Fifty-six were returned for a response rate of 81%. Of the 16 women and 40 men who responded (mean age: 27 years), 55 (98%) spouses stated that there had been family discussions on the choice of a residency program, and 41 (73%) respondents thought that they had significant input. When asked to rank the items that most influenced their support for a particular training program, career goals of the medical student (68%) and lifestyle (21%) were most important, whereas prestige, earning capacity, and program length were ranked lowest. Specific concerns expressed by spouses on the selection of a surgical residency included time commitment as the most commonly cited (79%), followed by fatigue (48%). A statistically significant correlation existed between those spouses actively discouraging the choice of general surgery and those objecting to the time commitment during residency (p < 0.05). We conclude that spouses have significant preferences regarding the choice of a training program following medical school. Career goals and lifestyle appear to be the most important factors; however, despite concern about the time commitment, the majority of spouses are supportive of the selection of a surgical residency. © 1992.
• Witte, C. L., Esser, M. J., & Rappaport, W. D. (1992). Updating the management of salvageable splenic injury. Annals of Surgery, 215(3), 261-265.
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  PMID: 1543399;PMCID: PMC1242430;Abstract: Because of the ready availability of autotransfusers and risk of transfusion-transmitted disease, the authors reexamined the management of splenic trauma. During the past 6 months, 20 adult and pediatric patients were treated for blunt splenic trauma. Nine had "minor" lacerations and were successfully managed nonoperatively. Eleven had ongoing hemorrhage or associated visceral injury necessitating laparotomy. In two, coexistent injuries were life threatening and total splenectomy was performed. The other nine had major splenic trauma that was either an isolated phenomenon or was associated with an injury not jeopardizing survival; eight spleens were salvaged. Mean intra-abdominal blood loss was ∼ 1250 mL and, using a "cell saver," an average of ∼ 790 mL was reinfused. Six received no other blood transfusion whereas three received 2250 mL homologous blood in addition to 4250 mL via the "cell-saver." With hilar laceration, repair was facilitated by temporarily occluding the splenic pedicle atraumatically, and suturing torn polar branches via the laceration site. In both children and adults with major splenic injury, the authors now recommend early laparotomy with reinfusion of autologous blood. The spleen or a large remnant can usually be salvaged, and homologous blood transfusion with its attendant complication can often be obviated altogether.
• Allen, R., Rappaport, W., Hixson, L., Sampliner, R., Case, T., & Fennerty, M. B. (1991). Referral patterns and the results of antireflux operations in patients more than sixty years of age. Surgery Gynecology and Obstetrics, 173(5), 359-362.
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  PMID: 1948584;Abstract: The role of antireflux operations in the elderly is ill-defined. Often, these patients are managed medically despite refactory symptoms for fear of surgical morbidity and mortality by referring physicians. This investigation was done to review the referral patterns and results of antireflux operations for patients more than 60 years old. The charts of all patients undergoing operation for reflux were reviewed during an eight year period from 1981 to 1989. One hundred and three patients underwent Nissen fundoplication. All patients had been treated with H2 blockers or antacids, or both, prior to referral for operation. Group 1 (N=43) consisted of all patients who were 60 years of age and group 2 (N=60), all patients less than 60 years of age. The mean age of those in group 1 was 70.6 years versus 43.7 years for those in group 2. The mean duration of symptoms was far greater in the elderly group versus the younger group (14.4 versus 4.1 years) (p
• Erstad, B. L., Gales, B. J., & Rappaport, W. D. (1991). The use of albumin in clinical practice. Archives of Internal Medicine, 151(5), 901-911.
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  PMID: 1902657;Abstract: The use of albumin in the clinical setting continues to generate controversy. Periodic shortages and the high cost of albumin have compelled many hospitals to develop guidelines regarding albumin administration. Our purpose is to review the human studies involving albumin. Particular emphasis will be placed on comparative trials involving albumin and the less expensive crystalloid solutions. It is hoped that this review will assist the clinician in making judgments concerning the appropriate use of albumin.
• Hansen, V. A., Johnson, M. B., & Rappaport, W. D. (1991). Splenic Salvage vs Splenectomy. Care Of The Trauma Patient. AORN Journal, 53(6), 1519-1520,1522-1523,1525-1528.
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  PMID: 1863067;
• Kumagai, S. G., Rosales, R. F., Hunter, G. C., Rappaport, W. D., Witzke, D. B., Chvapil, T. A., Chvapil, M., & Sutherland, J. C. (1991). Effects of electrocautery on midline laparotomy wound infection. The American Journal of Surgery, 162(6), 620-623.
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  PMID: 1670238;Abstract: This study compared the healing of midline fascial incisions made with either scalpel or electrocautery and inoculated with Escherichia coli in 57 Sprague-Dawley rats. At 7 days, tensile strength was significantly less when incisions were made with electrocautery than with a scalpel. Additionally, wound strength was inversely related to the concentration of the inoculum of E coli. The use of electrocautery was also associated with more frequent bacteremia at 48 hours and higher mortality at 7 days. Our results suggest that the technique used to incise the abdominal fascia influences subsequent wound healing, particularly in contaminated wounds. © 1991.
• Lick, S., Rappaport, W. D., & McIntyre, K. E. (1991). Successful epicardial pacing in blunt trauma resuscitation. Annals of Emergency Medicine, 20(8), 908-909.
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  PMID: 1854078;Abstract: Epicardial pacing wires were used successfully in the resuscitation of a moribund victim of blunt trauma after fluid resuscitation and chemical measures had failed. Application of these wires to treat the bradycardia of shock should be considered in selected patients when standard measures fail. © 1991 American College of Emergency Physicians.
• Rappaport, W. (1991). A technique for repair of recurrent indirect inguinal hernias. American Journal of Surgery, 162(5), 484-485.
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  PMID: 1951915;Abstract: The repair of a recurrent inguinal hernia can be a technically demanding operation. Due to scar tissue from prior surgery, injury to the spermatic cord or compromise of the testicular blood supply is possible. A technique for repair of recurrent indirect inguinal hernia that allows minimal dissection of the spermatic cord structures is described.
• Rappaport, W., Prevel, C., Witzke, D., Fulginiti, J., Ballard, J., & Wachtel, T. (1991). Education about death and dying during surgical residency. The American Journal of Surgery, 161(6), 690-692.
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  PMID: 1862830;
• Rappaport, W., Thompson, S., Wong, R., Leong, S., & Villar, H. (1991). Complications associated with needle localization biopsy of the breast. Surgery Gynecology and Obstetrics, 172(4), 303-306.
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  PMID: 2006456;Abstract: A review of 144 consecutive needle localization biopsies of the breast (NLBB) was performed to assess complications associated with this procedure. Thirty-four complications occurred in 27 patients. There were 11 wound infections associated with NLBB. During this time period, there were 1,583 clean general surgical operations performed, other than biopsy of the breast, yielding an over-all wound infection rate of 1.2 per cent (p
• Reisner, E., Dunnington, G., Beard, J., Witzke, D., Fulginiti, J., & Rappaport, W. (1991). A model for the assessment of students' physician-patient interaction skills on the surgical clerkship. The American Journal of Surgery, 162(3), 271-273.
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  PMID: 1928592;Abstract: Physician-patient interaction skills are predominantly taught by successful role modeling but are rarely evaluated formally and systematically. This study describes a new model for the assessment of student physician-patient interaction skills and reports results of use in 78 third-year medical students on clerkships at two institutions. A single nurse instructor at each institution evaluated these skills using an 18-item checklist during student performance of wound care and dressing changes. Students were focused on the evaluation of their technical skills and were unaware of the evaluation of their interaction skills. Immediate feedback on performance was provided. The mean percentage score for the interaction skills was 35%, and no improvement was noted with greater clinical experience (later rotations). We conclude that there is a striking deficiency in physician-patient interaction skills among third-year students. The model described is effective for both evaluation and feedback. © 1991.
• Reisner, L., Mohr, J., Dunnington, G., & Rappaport, W. D. (1991). Teaching mechanical ventilation. Surgery Gynecology and Obstetrics, 173(3), 227-228.
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  PMID: 1925885;Abstract: Participants have stated that having actually experienced the modes of the ventilator and the components of weaning parameters, they are better able to understand and manage ventilated patients, as opposed to trying to memorize them as in the past. They also have a much greater appreciation for the discomfort experienced by the ventilated patient. (Most students cannot tolerate a PEEP of 10 centimeters of H2O for more than a few minutes). Many remarked that they are much more tolerant with their agitated, intubated patients because they can now understand their agitation. The session has proved to be an effective teaching tool. It is cost effective, does not take loug and is enthusiastically received by the participants who believe they have gained a better understanding of how to properly care for their anxious, intubated patients.
• Shen, G. K., Wong, R., Daller, J., Melcer, S., Tsen, A., Awtrey, S., & Rappaport, W. (1991). Does the retrocecal position of the vermiform appendix alter the clinical course of acute appendicitis? A prospective analysis. Archives of Surgery, 126(5), 569-570.
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  PMID: 2021337;Abstract: Ninety-four adult patients undergoing appendectomy for acute appendicitis were prospectively studied during a 2-year period. Patients were divided into retrocecal (group 1; n = 27 [29%]) and anterior (group 2; n = 67 [71%]) groups according to the position of the appendix. There was no statistical difference between the two groups in duration of symptoms, presenting signs and symptoms, and initial white blood cell count. Furthermore, retrocecal appendicitis was not associated with a higher rate of perforation or increased morbidity. We conclude that the retrocecal position of the appendix does not alter the presentation of appendicitis.
• Sreekantaiah, C., Leong, S., Karakousis, C. P., McGee, D. L., Rappaport, W. D., Villar, H. V., Neal, D., Fleming, S., Wankel, A., Herrington, P. N., Carmona, R., & Sandberg, A. A. (1991). Cytogenetic profile of 109 lipomas. Cancer Research, 51(1), 422-433.
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  PMID: 1988102;Abstract: Cytogenetic analysis of short-term cultures was carried out on 109 lipomas from 92 patients. Clonal chromosomal abnormalities were present in 50% of the tumors analyzed. Based on the results, three main cytogenetic groups were identified and included: (a) tumors with normal karyotypes, (b) tumors with abnormalities involving region q13-15 on chromosome 12, and (c) tumors with other clonal aberrations. Within each of these groups, cytogenetic subgroups could be identified, each characterized by a specific anomaly. Tumors with abnormalities of 12q included specific subgroups with t/ins(1;12)(p32-33;q13-15), t(2;12)(p21-22;q13-14), t(3;12)(q28;q14), t(12;21)(q13;q21), complex, and nonrecurrent aberrations. The group containing heterogeneous clonal aberrations included subgroups with del(13)(q12q22), der(6)(p21-23), der(11)(q13), and nonspecific aberrations. Chromosome bands 1p36, 1p32-33, 2p21-22, 3q27-28, 6p21-23, 11q13, 12q13-15, 13q12, 13q22, 17p13, 17q21, and 21q21-22 were preferentially involved in structural rearrangements in lipomas. The identification of these sites of nonrandom rearrangements may serve to identify genes (at or near the junctions of chromosomal aberrations) involved in normal cellular growth control. Statistical analysis of the data revealed a correlation among karyotypic abnormalities and clinical data, such as age and sex of the patient, and tumor depth, site, and size.
• Valente, J. F., Bull, D. A., Fennerty, B. P., & Rappaport, W. D. (1991). Gallstone pancreatitis: Choosing and timing treatment. Postgraduate Medicine, 89(2), 123-124,126-128,130.
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  PMID: 1990385;Abstract: Patients with gallstone pancreatitis are often seen initially by primary care physicians. Prompt diagnosis and timely intervention are crucial in reducing morbidity and mortality. Initial management should include supportive medical care and surgical consultation. The timing of surgery is then dictated by serum enzyme levels and liver function test results as well as by the patient's condition. The role of endoscopic intervention is currently evolving. Whether surgery or endoscopic sphincterotomy is preferable as primary therapy for gallstone pancreatitis remains unresolved. However, sphincterotomy with stone extraction is a viable option in selected cases, especially in patients who have severe gallstone pancreatitis.
• Wong, R., Rappaport, W., Gorman, S., Darragh, M., Hunter, G., & Witzke, D. (1991). Value of lymph node biopsy in the treatment of patients with the human immunodeficiency virus. The American Journal of Surgery, 162(6), 590-593.
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  PMID: 1670231;Abstract: The indications and value of lymph node biopsy in patients infected with the human immunodeficiency virus (HIV) are not clearly defined. We reviewed 29 consecutive lymph node biopsies performed on 24 patients with the HIV over a 4-year period. Indications for biopsy included: (1) new or worsening medical symptoms with no detectable etiology in patients with lymphadenopathy, (2) disproportionately larger or enlarging lymph node in patients with generalized adenopathy, and (3) exclusion of concomitant disease in patients with previously defined infectious or neoplastic processes. The biopsy samples exhibited a diversity of histologic appearances including atypical and reactive hyperplasia, malignancy, and infection. Nineteen biopsies (64%) resulted in the institution or alteration of treatment. The absolute number of T-helper cells prior to biopsy was significantly lower in patients with a diagnosis of malignancy or infection (p < 0.05), as well as in those who eventually died (p < 0.05). Four (14%) minor complications resulted from lymph node biopsy. Based on our results, we conclude that lymph node biopsy is indicated in the above three subsets of HIV-infected patients. Biopsy can be performed with minimal morbidity and significantly alters therapy in the majority of patients. © 1991.
• Zuniga, R. E., Rappaport, W., Valente, J., Allen, R., Lesnick, I., & Kligman, E. (1991). Preoperative screening for perioperative cardiac risk. American Family Physician, 44(4), 1285-1291.
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  PMID: 1927843;Abstract: Preoperative screening for potential cardiac complications is crucial in making rational decisions about surgery. A number of classification schemes are available to aid the primary care physician in assessing a patient's perioperative cardiac risk. In general, these schemes enable the physician to place patients in low-risk, moderate-risk and high-risk categories. Patients at low risk can often be safely referred for surgery with minimal preoperative evaluation, while those at potentially high risk frequently need further assessment and medical or surgical treatment of cardiac disease prior to surgery. The classification schemes are most accurate in identifying patients at high risk for perioperative cardiac complications. However, patients with silent underlying cardiac disease are often underclassified with respect to potential risk. For those patients, accurate prediction of perioperative cardiac complications can be challenging.
• Adamas-Rappaport, W. (1990). Left lower quadrant pain in an elderly man. Drug Therapy, 20, 65-67.
• Mecham, T., & Adamas-Rappaport, W. (1990). Airway compromise from prevertebral soft tissue swelling during placement of a halo-traction for cervical spine injury. Anesthesiology, 73, 775-776.
• Rappaport, W. D., Hunter, G. C., Allen, R., Lick, S., Halldorsson, A., Chvapil, T., Holcomb, M., & Chvapil, M. (1990). Effect of electrocautery on wound healing in midline laparotomy incisions. The American Journal of Surgery, 160(6), 618-620.
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  PMID: 2147542;Abstract: The effect of electrocautery on midline fascial wound healing was studied in 108 Sprague-Dawley rats. Midline wound tensile strength was significantly reduced in fascia incised with the coagulation current compared with the cutting current or scalpel. In addition, tissue necrosis and inflammation as well as adhesion formation between the incision and abdominal viscera were more extensive in animals with incisions made using coagulation current. The results of the study indicate that the use of electrocautery coagulation current is associated with increased tissue damage and a significant reduction in the tensile strength of healing wounds. The contribution of electrocautery to wound complications in patients needs further evaluation. © 1990 Reed Publishing USA.
• Rappaport, W. D., Hunter, G. C., McIntye, K. E., Ballard, J. L., Malone, J. M., & Putnam, C. W. (1990). Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery. Surgery, 108(5), 930-932.
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  PMID: 2237774;Abstract: Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation. © 1990.
• Rappaport, W. D., McIntyre, K. E., Stanton, C., Carmona, R., Witzke, D., Fulginitti, J., Putnam, C. W., & Witte, C. L. (1990). The effect of alcohol in isolated blunt splenic trauma. Journal of Trauma, 30(12), 1518-1520.
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  PMID: 2258965;Abstract: The effect of alcohol on trauma patients is controversial, with numerous authors citing no difference in mortality in acutely intoxicated patients. The purpose of our study was to retrospectively investigate the effect of alcohol in adult patients with isolated blunt splenic injury. From 1980 through 1989, 47 adult patients with splenic trauma as the only major injury were admitted to the Trauma Service. There were 37 males and ten females with a mean age of 29 years (range, 15 to 61). Motor vehicle accidents were responsible for 44 (94%) of the injuries. Group 1 consisted of 24 patients with a mean blood alcohol level of 185 mg/dl (range, 15 to 380). In Group 2 there were 23 patients without detectable blood alcohol. There were no statistically significant differences between the two groups in age, Abbreviated Injury Severity Score, initial hematocrit, and grade of splenic injury. Hypotension was present in 13 patients (55%) in Group 1 versus six patients (26%) in Group 2 (p < 0.05). Significant abnormalities in clotting studies were present on admission in six patients (25%) in the alcohol-detected group versus one in the other group (p < 0.05). Blood transfusion requirements in the first 24 hours were significantly greater in Group 1 (mean, 3.9 units) versus Group 2 (mean, 0.5 units) (p < 0.001). If alcohol was present, there was much less chance for splenic conservation, as 18 patients (75%) underwent splenectomy versus seven patients (30%) in the nonalcohol group (p < 0.05). There was one death and this occurred in a patient acutely intoxicated who suffered a cerebral infarct. We conclude that there is an association between the presence of alcohol and increased morbidity from splenic injury.
• Rappaport, W., & Guzauskas, A. (1990). Tube enterostomy after small bowel resection. American Journal of Surgery, 159(2), 256-257.
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  PMID: 2301721;Abstract: Ostomy formation can be technically difficult when mesenteric shortening and thickening are present. In addition, the high output that follows a small bowel ostomy can be debilitating in the elderly patient or the patient with underlying medical illness. We describe a technique to avoid these difficulties.
• Rappaport, W., & Haynes, K. (1990). The retained surgical sponge following intra-abdominal surgery: A continuing problem. Archives of Surgery, 125(3), 405-407.
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  PMID: 2306189;Abstract: The surgical sponge retained following intra-abdominal surgery is a continuing problem. Despite precautions, the incidence of this problem is grossly underestimated. During the past 10 years, we have treated four patients with this problem. The presentation of a retained surgical sponge is highly variable, as is the time before the onset of symptoms. The clinical presentation, predisposing factors, and management are presented as well as guidelines for prevention.
• Rappaport, W., Allen, R., Chvapil, M., Benson, D., & Putnam, C. (1990). A comparison of parallel versus perpendicular placement of retention sutures in abdominal wound closure. American Surgeon, 56(10), 618-623.
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  PMID: 2221612;Abstract: A new technique for placement of retention sutures is described. Twenty-five rats underwent midline laparotomy incision. The control group was closed with traditional placement of through-and-through retention sutures placed in a perpendicular direction to the wound. The experimental group was closed with retention sutures placed in a parallel direction to the wound as described below. Wound bursting strength was significantly (P < 0.001) greater at one to five days in the experimental group compared with the control animals. In addition, inflammatory reaction and pressure necrosis were greater in the control group. It appears that parallel placement of sutures has less of a tendency to cut through tissue when subjected to the distracting forces on a midline wound.
• Rappaport, W., Dunington, G., Norton, L., Ladin, D., Peterson, E., & Ballard, . (1990). The surgical management of atypical mycobacterial soft-tissue infections. Surgery, 108(1), 36-39.
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  PMID: 2360188;Abstract: Group IV atypical mycobacterial infections, especially Mycobacterium fortuitum and M. chelonei, are being reported with increased frequency. We report our experience with five cases of soft-tissue infection with these acid-fast bacilli. Often these infections are chronic, with formation of abscesses and multiple fistulas. Optimal surgical treatment often requires wide excision of all diseased tissue followed by delayed closure. Presentation, optimal surgical management, and antibiotic therapy are discussed.
• Rappaport, W., McIntyre Jr., K. E., & Carmona, R. (1990). The management of splenic trauma in the adult patient with blunt multiple injuries. Surgery Gynecology and Obstetrics, 170(3), 204-208.
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  PMID: 2305345;Abstract: An analysis of 106 adult patients with blunt multiple organ injury and splenic trauma was carried out during an eight year period. Three groups were studied - group 1, splenectomy; group 2, splenorrhaphy, and group 3, observation. There was no statistically significant difference in initial blood pressure, pulse or hematocrit among the three groups. The mean injury severity score (ISS) was higher for those in groups 1 and 2 (26.8 and 25.6, respectively) versus patients in group 3 (17.9) (p). There were a total of 38 intraabdominal injuries in 34 patients of which 21 required surgical repair. No patient in the nonoperative group required laparotomy for a missed associated intra-abdominal injury. There were a total of 15 intra-abdominal complications related to splenic management. In the observation group, seven patients ultimately required laparotomy for continued splenic bleeding. In the splenorrhaphy group, the complication rate was significantly lower versus the other two groups (p). We concluded that, if technically feasible, splenorrhaphy is a safe procedure in the multiply injured patient in the absence of hypotension and coagulopathy. Nonoperative management of blunt splenic trauma should be viewed with caution because of the higher failure rate in the multiply injured patient.
• Shen, G., Carnahan, W., & Adamas-Rappaport, W. (1990). The varied presentation of retroperitoneal appendicitis. Contemporary Surgery, 37, 9-13.
• Valente, J., & Rappaport, W. (1990). Continous ambulatory peritoneal dialysis associated with peritonitis in older patients. American Journal of Surgery, 159(6), 579-581.
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  PMID: 2349984;Abstract: Our recent experience with peritonitis in patients over the age of 55 years undergoing continuous ambulatory peritoneal dialysis between 1979 and 1989 is reviewed. Thirty-seven patients in this age group underwent Tenckhoff catheter insertion. Severe catheter-related peritonitis occurred at a rate of 1.41 episodes per patient per year. Overall, there were 61 episodes of peritonitis in 31 patients, with an overall mortality rate of 7%. When systemic signs of sepsis were present, this rate rose to 25%. All deaths were associated with fungal, pseudomonal, or polymicrobial infections. Management of these infections may require aggressive measures including repeated laparotomy for control of sepsis.
• Pattison, B., & Rappaport, W. D. (1989). A new technique for stabilization of the sump drain. Surgery Gynecology and Obstetrics, 169(2), 163-164.
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  PMID: 2667175;
• Rappaport, W. D. (1989). Modified Gambee intestinal anastomosis. Surgery Gynecology and Obstetrics, 169(5), 464.
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  PMID: 2814763;
• Rappaport, W. D., & Putnam, C. (1989). Sidewinder retention sutures for closure of the abdominal wall. Surgery Gynecology and Obstetrics, 169(1), 73-74.
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  PMID: 2525819;Abstract: Reported herein, a technique of sutures placement that avoids certain objections to the traditional style of retention sutures is described. It is particularly useful in patients undergoing repeated laparotomy and in patients whose wounds are closed in a layered manner and who are at high risk for dehiscence.
• Rappaport, W. D., & Roeder, V. (1989). Rapid technique for splenectomy. Injury, 20(3), 157-158.
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  PMID: 2599640;Abstract: The spleen is the most commonly injured organ in blunt trauma of the abdomen. In the haemodynamically unstable patient bleeding from a splenic injury, rapid control of the splenic hilum can be a technically demanding operation. We describe a technique which allows for rapid control of the splenic hilum and unhurried ligation of splenic vessels. This technique has been used on 30 patients without any complications related to splenectomy. It is most helpful when one is working with an inexperienced assistant. © 1989.
• Rappaport, W. D., & Warneke, J. A. (1989). Subhepatic appendicitis. American Family Physician, 39(6), 146-148.
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  PMID: 2729041;Abstract: Intestinal malrotation is a developmental anomaly that occasionally causes an unusual array of symptoms in adults. The delay in diagnosis that is common in patients with malrotation frequently results in a ruptured appendix. Appendicitis should be considered when characteristic signs and symptoms are present, even if the location of abdominal pain is atypical.
• Rappaport, W. D., Holcomb, M., Valente, J., & Chvapil, M. (1989). Antibiotic irrigation and the formation of intraabdominal adhesions. The American Journal of Surgery, 158(5), 435-437.
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  PMID: 2817225;Abstract: The efficacy of antibiotic peritoneal lavage in the prevention of postoperative infection is controversial. The role of intraperitoneally administered cefazolin and tetracycline in the formation of adhesions was studied in the rodent model. Thirty-two rats were divided into 3 groups. Group 1 underwent midline laparotomy with instillation of 10 ml of normal saline solution. Group 2 and Group 3 underwent the same procedure with instillation of 0.2 percent saline solutions of cefazolin or tetracycline, respectively. Animals were sacrificed after 2 weeks. Intraabdominal adhesions were graded and samples of parietal peritoneum were processed for histologic data. Group 2 and Group 3 had significantly higher adhesion scores compared with Group 1 (p < 0.001). Histologic appearance of both antibioticirrigated groups showed mesothelial thickening with presence of fibroblasts and collagen. Cefazolin and tetracycline irrigation of the abdominal cavity contributes to the formation of peritoneal adhesions in the rat model. © 1989.
• Rappaport, W. D., Lee, S., Coates, S., & McIntyre, K. (1989). Diagnosis of diaphragmatic injury using intraperitoneal technetium. American Surgeon, 55(10), 621-624.
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  PMID: 2802387;Abstract: The diagnosis of diaphragmatic injury following blunt or penetrating trauma is often made after appreciable delay. The purpose of the present study was to evaluate the use of intraperitoneal technetium in diagnosing diaphragmatic tears in dogs. Six dogs were divided into two groups. In Group 1, thoractomy was performed bilaterally and 1 cm diaphragmatic tears were made. Peritoneal lavage with technetium-99 sulphur colloid was then performed after closure of the thoractomy sites. In Group 2 animals, only lavage instillation of technetium was done. Scans were then performed and counts recorded over the chest and abdomen. A ratio of two body areas was then computed and compared between the two groups of animals. There was a statistically significant difference in the ratio between the two groups (P < 0.05). We conclude that intraperitoneal technetium is a sensitive test for diagnosing diaphragmatic injuries.
• Rappaport, W. D., Peterson, M., & Stanton, C. (1989). Factors responsible for the high perforation rate seen in early childhood appendicitis. American Surgeon, 55(10), 602-605.
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  PMID: 2802384;Abstract: The incidence of perforated appendicitis has remained high in the infant and young child resulting in substantial morbidity. The purpose of the present study was to investigate the factors contributing to the high perforation rate seen in this age group. A retrospective analysis was done on 77 patients under the age of seven who underwent appendectomy for appendicitis. The perforation rate was 72.7 per cent. Duration of pain correlated with patient age and perforation rate. Under the age of five, only 17 per cent had symptoms for less than 36 hours. Children with symptoms that lasted longer than 48 hours had a perforation rate of 98 per cent. Associated illnesses including respiratory infections, otitis media, and gastroenteritis were common in both simple and perforated appendicitis, often leading to a delay in diagnosis. Of patients with perforation, 36 per cent were seen at least once by the primary physician and discharged. The keys to the diagnosis of the appendicitis in this young age group were history and physical exam. Right lower quadrant findings were present in 95 per cent of patients with simple appendicitis and 71 per cent of patients with perforation. The primary-care physician and consulting surgeon have crucial roles in diagnosing the disease early in its course.

Presentations

• Amini, R., Adamas-Rappaport, W., Situ-LaCasse, E., Bates, J., Kelley, R., Johnsone, C., Ratesic, A., Viscusi, R. K., & Fisher, J. (2017, February). Clinical Skills Temporal Degradation Assessment in Undergraduate Medical Education. Western Group on Educational Affairs. Salt Lake City, Utah.
• Fisher, J., Viscusi, R. K., Ratesic, A., Johnsone, C., Kelley, R., Bates, J., Situ-LaCasse, E., Adamas-Rappaport, W., & Amini, R. (2017, March). Clinical Skills Temporal Degradation Assessment in Undergraduate Medical Education. American Institute of Ultrasound in Medicine Annual Meeting. Orlando, Florida.
• Goel, H., Nematollahi, S., Dandorf, S., Kaplan, S., & Adamas-Rappaport, W. (2016, Fall). Pre-matriculation clinical experience correlates with higher USMLE Step scores. WGEA Meeting 2016.
• Adamas-Rappaport, W. (2015, October 4-8). Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students. AWS Conference.
• McCrary, H., Krate, J., Savilo, C., Ho, H., Viscusi, R. K., Ley, M., & Adamas-Rappaport, W. J. (2015, Oct. 4-8, 2015). Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students. Clinical Congress 2015 - American College of Surgeons. Chicago, IL: American College of Surgeons.
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  McCrary H, Krate J, Savilo C, Ho H, Viscusi RK, Ley M, Adamas-Rappaport A. "Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students; Journal of the American College of Surgeons; Vol 221, Issue 4, Supp 1, Pg S50, Oct 2015 (Presented at Clinical Congress 2015 - American College of Surgeons; Chicago, IL; October 4-8, 2015)
• Viscusi, R. K., Adamas-Rappaport, W. J., Ley, M., McCrary, H., Ho, H., & Savilo, C. (2015, Oct. 4-8, 2015). Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students. Clinical Congress 2015 - American College of Surgeons. Chicago, IL; October 4-8, 2015): American College of Surgeons.
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  McCrary H, Krate J, Savilo C, Ho H, Viscusi RK, Ley M, Adamas-Rappaport A. "Development of a Fresh Cadaver Model for Instruction of Ultrasound-Guided Breast Biopsy During the Surgery Clerkship: Pre-and Post-Test Results Among Third Year Medical Students; Journal of the American College of Surgeons; Vol 221, Issue 4, Supp 1, Pg S50, Oct 2015 (Presented at Clinical Congress 2015 - American College of Surgeons; Chicago, IL; October 4-8, 2015)
• Kaplan, S., Knapp, C., & Adamas-Rappaport, W. (2014, Spring). Skills and knowledge acquisition in a cadaver-based emergency surgical skills lab during the third-year surgery clerkship. ASE meeting 2014.
• Nematollahi, S., Chuu, A., Hulett, C., Serrano, M., Gibson, B., Poskus, D., Waer, A., & Adamas-Rappaport, W. (2014, Spring). Investigating Modifiable Factors that Correlate with USMLE Step 1 Score: Length of Study Time Correlates with Step 1 Score. WGEA Meeting.
• Harris, J., Amini, A., Waer, A., Poskus, D., & Adamas-Rappaport, W. (2013, Spring). USMLE Step 2 vs Step 1 in predicting overall academic performance in surgery residency. Association of Surgical Education 2013.
• Benajamin, M., Waer, A. L., Ong, E., Poskus, D. M., & Adamas-Rappaport, W. (2012, March). Preparing medical students for subinternship and beyond: refining surgical skills through an unembalmed cadaver laboratory course. Association for Surgical Education Out of the Box Lunch.
• Waer, A., Poskus, D., Adamas-Rappaport, W., & Gruessner, R. (2012, Spring). The Native American experience in surgery. International Education meeting 2012.
• Waer, A. L., Glazer, E., Copeland, H., Ong, E., Sozanski, J., Doskocil, B., Poskus, D. M., & Adamas-Rappaport, W. (2011, March). A comparison of unguided versus guided case-based instruction on the surgery clerkship. The Association for Surgical Education.
• Adamas-Rappaport, W. (1995, Spring). Management of anorectal disease. Twentieth Annual Primary Care Update. Tucson, AZ: University Medical Center.
• Adamas-Rappaport, W. (1991, Spring). AIDS related surgical problems; Sixteenth Annual Primary Care Update. University Medical Center. Tucson, AZ: University Medical Center.

Poster Presentations

• Adamas-Rappaport, W., Ellis, S. C., Wildner, C., Gordon, P. R., Leko, E. O., Gura, M., Koch, B., Adhikari, S. R., Czuzak, M. H., & Parikh, T. M. (2017, June). Using standardized patients and ultrasound to enhance reproductive physical exam skills & pelvic anatomy identification. Association of Standardized Patient Educators Annual Conference. Alexandria, VA: ASPE.
• Parikh, T. M., Adhikari, S. R., Czuzak, M. H., Koch, B. D., Gura, M., Ellis, S. C., Gordon, P. R., Adamas-Rappaport, W., Leko, E. O., & Wildner, C. M. (2017, June). "Novel Use of Ultrasound to Aid in Medical Student Reproductive Physical Examination Skills and Pelvic Anatomy". Association of Standardized Patient Education. Alexandria, Virginia.
• R, P., M, W., M, S., D, S., Adamas-Rappaport, W., & Viscusi, R. K. (2017, April 28). Incorporating Technology Into Today’s Surgery Clerkship. Academy of Medical Education Scholars. Tucson, AZ.
• Wildner, C. M., Leko, E. O., Adamas-Rappaport, W., Gordon, P. R., Ellis, S. C., Gura, M., Koch, B. D., Czuzak, M. H., Adhikari, S. R., & Parikh, T. M. (2017, April). "Novel Use of Ultrasound to Aid in Medical Student Reproductive Physical Examination Skills and Pelvic Anatomy". AMES Medical Education Research Day. University of Arizona College of Medicine: AMES.
• Coverley, C., Sherrow, D. R., Adamas-Rappaport, W. J., & Viscusi, R. K. (2016, April 12 - 16). Frequently Utilized Scholastic Resources in the Third Year Surgical Clerkship and Subsequent NBME Surgical Shelf Performances. Association for Surgery Education, 2016 Surgical Education Week, Boston, MA; April 12-16, 2016. Boston, MA: Association for Surgical Education, 2016 Surgical Education Week.
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  Coverley C, Sherrow D, Adamas-Rappaport W, Viscusi R; Frequently Utilized Scholastic Resources in the Third Year Surgical Clerkship and Subsequent NBME Surgical Shelf Performances; Association for Surgical Education, 2016 Surgical Education Week, Boston, MA; April 12-16, 2016
• Coverley, C., Sherrow, D. R., Adamas-Rappaport, W. J., & Viscusi, R. K. (2016, April 12 - 16). Frequently Utilized Scholastic Resources in the Third Year Surgical Clerkship and Subsequent NBME Surgical Shelf Performances. Association for Surgery Education, 2016 Surgical Education Week. Boston, MA: Association for Surgical Education.
  More info

  Coverley C, Sherrow D, Adamas-Rappaport W, Viscusi R; Frequently Utilized Scholastic Resources in the Third Year Surgical Clerkship and Subsequent NBME Surgical Shelf Performances; Association for Surgical Education, 2016 Surgical Education Week, Boston, MA; April 12-16, 2016
• Viscusi, R. K., Mcclenathan, J. H., Sherrow, D. R., Adamas-Rappaport, W., & Beliveau, L. (2015, April 21-25). Integrating a flipped classroom model into a surgery clerkship.. Association for Surgical Education, 2015 Surgical Education Week. Seattle, WA: Association of Surgical Education (ASE).
• Adamas-Rappaport, W., Chuu, A., Hullett, C., Gibson, B., Nematollahi, S., Poskus, D. M., Serrano, M., & Waer, A. L. (2014, March). Investigating Modifiable Factors that Correlate with USMLE Step 1 Score: Length of Study Time Correlates with USMLE Step 1 Score. 2014 WGEA Conference.