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In this example generic lansoprazole 15mg overnight delivery gastritis diet , case fatality in patients in two hospitals mortality and complication rates: The importance of severity is the same on aggregate (19 order lansoprazole on line gastritis home remedy. If one looks at the top row for the total alone in this table order lansoprazole 15mg without prescription gastritis diet ultimo, it =21103304694767 would seem that the two hospitals have nearly the same case-fatality rates 15 mg lansoprazole overnight delivery gastritis symptoms in child. The breakdown by age in the next two rows shows that both the hospitals have nearly the same case-fatality rates in each age case reports group also. But further breakdown by severity of illness in the sub- sequent rows shows that hospital A has less fatality in every group. The detailed documentation of an unusual case is called a case Why then are the rates in the aggregate the same? The details may include the demographic particulars of hospital A is catering much more to serious cases and to older cases. The breakdown clearly establishes better performance of timeline, any complications, photographs, laboratory and radio- logical investigation reports, diagnosis, current treatment, outcome, and prognostic implications. An informed written consent is taken from of Patients and Severity of Disease the patient or his/her relative, yet the reporting is done in a manner Hospital A Hospital B in which the identity of the patient remains undisclosed. The question of the selection of cases is relevant mostly for case–control studies because, calibration 73 cyclic model/trend for these studies, random selection is not all that important, and the to be part of a series. For example, they may be suffering from selection of cases can substantially affect the results. Case–control the same disease, or they may be undergoing the same regimen of studies are discussed under the topic retrospective studies. In medical research, a case series signifes a descrip- The source of cases with disease or any other outcome of interest tive study, although here no specifc design for selection of cases can be hospital inpatients, patients seen as outpatients, cases iden- is formulated. Neither a provision of control nor any protocol for tifed in a survey, cases listed in records of a health facility, etc. No cause–effect, not even Hospital-based studies may be biased for, say, subjects from upper associations, can be concluded by a case series, but they are capable C socioeconomic class, whose nutritional status may be different, or of generating a hypothesis for planning an analytical study. Population-based There is a question regarding the minimum number of cases studies can become very expensive. The authors suggest that a case series should contain particularly for chronic disease, can easily increase the sample size, no less than four cases. If they are so few, the cases are individu- but care is required at the time of interpretation of results because ally described, but if they are many, the results can be summarized the factors determining the duration of disease can be important. Note that duration decides that a case is prevalent or noThat a particu- Inclusion and exclusion criteria should be specifed in any case. Mild cases or those physically strong may survive Popular among the case series is the frst offcial documenta- longer and add to the prevalence. At the same time, cases surviving tion in 1981 of fve young gay men with pneumocystis Pneumonia for long are more likely to have recall lapse. Selection bias is said to have occurred when the study group has a Case Studies different composition with regard to etiologic factors such as hered- ity, age, gender, nutrition status, and addictions, compared with the A case study is the detailed study of an event and its origin, pro- composition in the target population. Studies on volunteers or on cess, and consequences, with the purpose of deriving learning for clinic subjects almost invariably suffer from such a bias. Case studies have been found to be effective tools of selection that has a random component is considered insulation for teaching and learning various aspects of subjects such as their against such bias. But such selection fails to take cognizance of spe- management with informatics technology. The primary advantage cial bias that can result from sources such as improper defnition with this methodology is its fexibility, as case studies do not have of the population.

However discount lansoprazole express gastritis diet , because a large proportion of investigation discount lansoprazole 15 mg otc gastritis symptoms last, with no evidence of systemic metas- of these lesions do not demonstrate any malignant tases and given the patient’s young age purchase lansoprazole 30mg on-line gastritis diet , an octreotide features buy 15mg lansoprazole visa gastritis healing process, reporting tendencies and inclusion in can- scan is not performed. It remains important, however, to deal appropriately with a Discussion pathology report of an incidental carcinoid tumor in an appendix specimen, because these are still The surgical management of appendiceal carcinoid common. A female predominance is still evident, although Lesions between 1 and 2 cm in the distal appen- not as pronounced as originally thought. Asymp- dix, with typical carcinoid histology, no angiolym- tomatic carcinoids may be found coincidentally at phatic or mesoappendiceal invasion, and a low pro- laparoscopy for pelvic disease in women; however, liferative index will generally not require further even when this is taken into account, a true higher surgery because the metastatic risk is low. Other factors that may influence decision mak- Carcinoid tumors of the appendix present as an ing when the lesion is between 1 and 2 cm include asymptomatic incidental finding in up to 60% of positive resection margins and location at the base cases, and very rarely present with metastases. Tumor features that should also be Luminal obstruction may result in acute appendici- taken into account are raised mitotic or Ki67 indices tis, although this is not common because two thirds (indicative of high-grade malignant carcinoids), are located at the tip of the organ. Patient factors may also influence man- distinctly different and rare variant of carcinoid agement, because the risk of metastatic disease over- tumors. In younger patients, one may differentiate into both mucinous and neuroen- prefer surgery, whereas in patients with associated docrine cells, and behave very differently from typi- comorbid conditions, the risks of a right hemicolec- cal carcinoids. Case 27 113 Lesions larger than 2 cm have a significant risk carcinoid tumors smaller than 2 cm in diameter. Carcinoid tumors may be indolent and slow growing; Because appendiceal carcinoids usually spread pri- however, those that do metastasize are often more marily by the lymphatic route, an oncological resec- aggressive and often behave like true carcinomas. In all reported series of appendiceal carcinoid tumors, the significance of associated malignancies is noticeable. It is estimated that up to 18% of ■ Surgical Approach patients with appendiceal malignant carcinoids may A right hemicolectomy is performed through a mid- develop or have coexisting neoplasms, the most line incision. The exact nature of ing colon, and hepatic flexure, the vascular pedicles this risk is unknown, but a high index of suspicion (ileocolic branch of the superior mesenteric and right should prevail. Attention is Treatment of advanced disease is generally con- paid to identifying the right ureter and the second sidered to be as for other midgut carcinoid tumors, part of the duodenum. An ileocolic hand-sewn or although limited evidence for tumors originating in side-to-side stapled anastomosis is performed. Carcinoid tumor of the Histologic examination of the right hemicolectomy appendix. Primary malignant neo- specimen demonstrates no residual carcinoid tumor plasms of the appendix: a population-based study from the in the appendicular stump or cecum. There is no surveillance, epidemiology, and end-results program, 1973– evidence of lymph node metastases. Carcinoid tumor The patient recovers well with no postoperative of the appendix: treatment and prognosis. Discussion Recurrence in this case in highly unlikely, and this may well be said for the vast majority of appendiceal case 28 nous adenocarcinoma are referred to as hybrid or intermediate histologic type. Presentation A 48-year-old man with no significant past medical Discussion history presents with a new-onset right inguinal her- nia. Increasing abdominal distention was noted over The most common symptom in both men and approximately 1 year. He is taken to the operating women with pseudomyxoma peritonei syndrome is a room for a hernia repair under local anesthesia. In women, the the hernia sac is opened, a large volume of mucoid second most common symptom is an ovarian mass, fluid is released into the operative field.

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The associa- Characteristic 1 (x) tion between severity of disease and obesity is high if more severe cases are obese cheap 30 mg lansoprazole with mastercard gastritis ibs diet. If less severe cases are Characteristic 2 (y) Low Medium High mostly obese cheap lansoprazole 15mg with visa gastritis diet , this is discordance purchase lansoprazole 30mg fast delivery gastritis diet . However generic lansoprazole 30 mg with mastercard gastritis diet of worms, in this case, you need to Low a b c consider all possible pairs of pairs. If one pair is (x1, y1) and the other High d e f pair is (x2, y2), they are concordant if x1 < x2 and y1 < y2 or if x1 > x2 abortion rate/ratio 24 average linkage method of clustering Beside these variations of tau, there are two other popular mea- 187 − 32 A sures of ordinal association. For this reason, many workers do not rely much discordant pairs is the same as concordant pairs, γ = 0. All these measures are symmetric in the sense that it does not matter which characteristic is in the rows and which is in the col- umns (or, in other words, there is no distinction between anteced- association between polytomous ent and outcome). For a directional characteristics (degree of) hypothesis such that x predicts y (or x is the antecedent and y is the outcome), use Association is the tendency of two characteristics of subjects mov- ing together at least in some subjects. Association between dichoto- P −Q Somer d = , mous categories of the two characteristics and association between P Q Y0 ordinal characteristics are discussed separately. Note that only the pairs Consider classifcation of disabled persons by type of disability 0 tied for x are excluded from the denominator. Moreover, a measure of overall Discordant pairs Q = 1(6 + 2) + 4 × 6 = 32 association will not be available. Tied on x (smoking) X0 = 35 × 6 + 4 × 2 + 1 × 3 = 221 2 2 An alternative is to compute the usual chi-square χ = Σ(O − E) /E Tied on y (drinking) Y0 = 35(4 + 1) + 4 × 1 + 6(2 + 3) + 2 × and use this as a measure of association. To counter this, the follow- ing measure is proposed: These numbers give Phicoefficient: = 2 n, 187 − 32 Tau-a = = 01. Note that the concept of negative association is not relevant 187 − 32 in the case of polytomous nominal categories except for the order Tau-b = = 03. This section is restricted to two characteristics: one ante- Contingencycoefficient: C =. The results χ2 + n in this setup are easily described by a 2 × 2 contingency table, as shown in Table A. The notation in this table is as follows: Orc This cannot exceed unity but could also never be one, even when the is the observed frequency in the (r, c)th cell (r = 1, 2; c = 1, 2), association is perfect. The value of χ2, and hence of ϕ and of C, can and inside parentheses in each cell in the table are the correspond- be severely affected by the cutoff points of categories when they are ing probabilities. The dot in the subscript is for the corresponding for a variable on a metric scale. Prospective, retrospective, and cross-sectional studies provide three different situations for such a table, as described next. The row totals O and O become known 2 1• 2• The value of χ for the data in Table A. In terms of notations in Table quencies are proportionately decreased to one-ffth, rounded off to A. In this large difference between this value of χ2 for n = 200 and the previous case, π11 + π21 = 1 and π12 + π22 = 1. A pro- portionate decrease (or increase) in cell frequencies does not affect Structure in a Retrospective Study the degree of association but affects the value of χ2. For these data, The direction of the investigation in a retrospective study is from (a) For n = 1000, as in Table A. The null hypothesis now is that the rate of presence of antecedent in those with a positive outcome is the same Note that ϕ, C, and V for the two n’s are the same, while the value as in those with a negative outcome, i. Structure in a Cross-Sectional Study A major objection to the measures ϕ, T, C, and V is that they lack underlying substantive meaning.

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He specifically denies fevers order lansoprazole 15mg free shipping gastritis sweating, chills generic lansoprazole 15 mg line gastritis ginger, night drome and requires immediate tissue diagnosis fol- sweats cheap lansoprazole 15mg with visa gastritis symptoms empty stomach, and weight loss buy generic lansoprazole 30mg acute gastritis symptoms treatment. With this presentation, and especially with the invasive nature of this lesion, we did not consider an exci- sional procedure. With the high likelihood of lymphoma, we felt it was not prudent to attempt needle biopsy because it is critically impor- Figure 11. This requires the cooperation of 4141 42 Case 11 the pathologist, ideally the hematopathologist, who section, immunohistochemistry, and special studies. Even with a large mass, this may sometimes be difficult, espe- cially in the more fibrous lesions where there is very Case Continued little cellularity. Entering the anterior mediastinum via a parasternal approach allows us to stay The frozen section diagnosis of large cell lymphoma extrapleural, that is, out of the pleural space. This is was confirmed 48 hours later by immunohisto- particularly important if the lesion proves to be a chemistry. The Discussion bulk of this lesion occurred to the right of the ster- num, and therefore we selected a right parasternal There is never an indication to treat a patient who approach. In the past, many of these patients elected to approach the lesion via the third inter- received urgent radiation therapy to the medi- space, a procedure known as anterior mediastino- astinum without first obtaining tissue. The lateral aspect of the Often there is a temptation to operate and attempt cartilage was incised with the scalpel after the to resect the mass when faced with an anterior Matson periosteal elevator was placed posterior to it, mediastinal lesion. Removing the costal cartilage facilitates our situations, one may occasionally find that one has ability to stay extrapleural. Usually it is not possible on tion was swept laterally, taking care not to enter into frozen section for the pathologist to distinguish a it while the internal mammary vessels were identi- thymoma from a lymphoma. A needle may be able definitive tissue diagnosis is of utmost impor- inserted to ascertain bleeding potential, but most tance. This tech- incision directly into the mass to allow for the inser- nique is associated with a high nondiagnostic rate, tion of a standard biopsy forceps, as usually used for and if suggestive of a lymphoma does not provide mediastinoscopy. It the lesion because this may hinder the interpreta- also often results in further delay in diagnosis and tion if additional material is needed. A applied, and this usually suffices to take care of the similar comment can be made regarding the use of a bleeding from the lesion. Although histologic taken and brought fresh to the waiting pathologist, evaluation is possible with this technique, differenti- who performed a touch preparation and frozen sec- ation between a lymphocyte-rich invasive thymoma tion and assessed the adequacy of the material and frank lymphoma can be difficult. Anterior mediastinal masses cannot be ap- The touch preparations and frozen sections suggest- proached via mediastinoscopy, a technique useful for ed a malignant neoplasm consistent with large cell lesions, or more commonly adenopathy, in the supe- lymphoma, but the definitive diagnosis was deferred rior mediastinum, a region distinct and posterior until the permanent sections could be studied. The mediastinoscope Additional fresh tissue was obtained for permanent is placed just anterior to the trachea far from the Case 11 43 location of an anterior mediastinal lesion. The most direct approach to diagnosis of an anterior medi- Case Continued astinal mass is the anterior mediastinotomy (Chamberlain procedure) or a modification of this The patient was transferred to the oncology service to procedure as described earlier for this patient. The interven- ing the aortopulmonary window in primary lung tional radiologist inserts a port for long-term venous cancer. In this patient we performed a right-sided access, and the patient is commenced on chemother- procedure via the third costal cartilage. After one cycle of therapy, some improvement Anterior mediastinal masses in patients present- was noted in the patient’s symptoms.