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The Sabiston Textbook of Surgery and other classic textbooks have been invaluable resources for generations of surgeons. Although they play an important role in medical education, printed textbooks often cannot meet the daily information needs of practicing surgeons because they are inaccessible, incomplete, unstructured, and out of date. Advances in communication technology have radically changed the creation and distribution of medical information. Many clinicians now seek evidence to support clinical decisions on the Internet and handheld devices. This article describes the evolution of surgical textbooks from printed volumes to versatile collections of knowledge that serve as both comprehensive resources and question-answering tools.

Laparoscopic adrenalectomy is well established as the standard technique for all indications of adrenalectomy except adrenal carcinoma; however, some also consider large adrenal masses a relative contraindication. We present a video of a laparoscopic excision of a large ganglioneuroma and right adrenalectomy in a 12-year-old female.Our patient was noted to have a right suprarenal mass on a computed tomography scan following complaints of back and abdominal pain. Upon surgical consultation, she underwent a magnetic resonance imaging, which showed a 7.9 x 4.4 x 5.6 cm heterogeneously enhancing suprarenal lesion that was either arising from or compressing the right adrenal gland. The patient's preoperative work-up included normal urinary metanephrines, alpha-fetoprotein, and beta-HCG. After discussion with the patient and family, the decision was made to proceed with laparoscopic excision of the mass.The patient underwent successful laparoscopic excision of the suprarenal mass and right adrenalectomy and was discharged from the hospital on postoperative day 2. During the procedure, retraction was achieved by using a combination of 5-mm grasping instruments, Endokittner dissectors (Ethicon Endosurgery Cincinnati, OH), and a suction irrigator to provide traction and counter traction. A flexible 5-mm liver retractor (Mediflex; Velmed, Inc., Wexford, PA) was placed directly through the abdominal wall without a trocar in order to elevate the liver from the area of the right adrenal and retroperitoneum. This enabled us to "rotate" the lesion out from behind the vena cava and from along the vertebral bodies. The pathology revealed an 8.5 x 7.0 x 3.0 cm ganglioneuroma, with primarily neural and Schwann cell-type tissue with interspersed large, prominent ganglion cells, and a normal adrenal gland.As demonstrated by our video, large adrenal masses in the pediatric population can be successfully excised laparoscopically with appropriate surgeon comfort and experience.

Crohn’s disease is a debilitating condition that affects the entire gastrointestinal tract and often requires aggressive and invasive therapies. Several studies have suggested dietary triggers for disease activity. We have created a web-based tool to allow participants to record both daily food intake and wellness (i.e., disease-specific quality of life). We seek to determine if measurable correlations exist between these events in patients with Crohn’s disease. Advanced data mining techniques are employed to find such correlations and the efficacies of chosen techniques are assessed. We tested our web-based system in a pilot study involving 7 participants, and we found that traditional statistical techniques identified diet and disease activity correlations in short-term data sets.

As their campaign comes to a close, ICRAM presents a challenge to academic medicine9s invisible leaders

The Sabiston Textbook of Surgery and other classic textbooks have been invaluable resources for generations of surgeons. Although they play an important role in medical education, printed textbooks often cannot meet the daily information needs of practicing surgeons because they are inaccessible, incomplete, unstructured, and out of date. Advances in communication technology have radically changed the creation and distribution of medical information. Many clinicians now seek evidence to support clinical decisions on the Internet and handheld devices. This article describes the evolution of surgical textbooks from printed volumes to versatile collections of knowledge that serve as both comprehensive resources and question-answering tools.

This week's theme issue attempts to provide a framework for thinking about the quality of health information on the internet—a source of anxiety almost since its first appearance. Five years ago Impicciatore and colleagues reviewed website advice on managing fever in children and concluded that it varied widely in terms of accuracy, completeness, and consistency.1 Pick any medical problem today, and the chances are you'll find the same. With at least 80 studies reporting similar findings (G Eysenbach, personal communication), we need no more convincing that the quality of information on the web varies as widely as it does in other media. In 1997 Gagliardi and Jadad identified 47 instruments for measuring healthcare quality on the internet. Four years later, they found another 51—all of them unvalidated (p 569).2 Generating yet more unproved instruments looks like another activity that researchers could usefully stop. However, the proliferation of tools for assessing quality continues unabated, fuelled by anxieties about patient harm. As our international roundup shows (pp 566-7), countries now seem poised to get in on the act, although little beyond urban myths exists to justify the level of their concerns. …

Mark Frisse describes how he, as a tenured professor, left medicine for the business world and returned to academic medicine with valuable lessons and skills

Gretchen P Purcell describes how she paid for her undergraduate and professional education while working at unique jobs that advanced her career

We have some answers, but implementing good decision support is still hard C linical decision support is the provision of “clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.”1 Medical institutions are increasingly adopting tools that offer decision support to improve patient outcomes and reduce errors. Healthcare providers and administrators with little or no training in computer science may be asked to evaluate, select, or contribute to the development of decision support systems for their practices. Is there an easy way to determine which clinical decision support systems are good? In this issue Kawamoto and colleagues provide some evidence based guidance in a systematic analysis of the ability of decision support systems to improve practice in …

Supporting your studies with evening or weekend work may make sense. Gretchen P Purcell describes how she paid for her undergraduate and professional education doing unique jobs that advanced her career

only and 352 underwent small bowel resection. Thirty-seven percent undergoing adhesiolysis only and 47% undergoing small bowel resection had 1 complications (p 0.001). The overall 30-day mortality was 7.7% and did not differ significantly between the groups. Odds of death were highest for dirty or infected wounds, ASA class 4 or 5, age 80, and dyspnea at rest. Morbidity ranged from 22%, among patients with 0-7 risk points, to 62% for those with 19 risk points. Mortality ranged from 2%, among patients with 0-12 risk points, to 28% for those with 31 risk points.

Karen Sliwa-Hahnle explains how she became a world expert in a rare form of cardiomyopathy while seeing the world and starting a family, and she offers advice to aspiring academics

Hypothesis High-resolution ultrasound and technetium Tc 99m sestamibi scanning can be used for preoperative localization of abnormal parathyroid glands in patients with hyperparathyroidism. Design Ultrasound and sestamibi scanning were performed in patients undergoing neck exploration for hyperparathyroidism. If the 2 scans agreed in identifying a single adenoma, and surgery confirmed the location of a single adenoma and an ipsilateral normal gland, a unilateral exploration was performed. Setting University tertiary care center. Patients Sixty-one consecutive patients undergoing surgery for hyperparathyroidism from September 1, 1994, through September 30, 1997. Interventions High-resolution ultrasound was performed in 59 patients and sestamibi scanning in 58 patients; all patients underwent neck exploration by a single surgeon. Main Outcome Measures The results of preoperative ultrasound and sestamibi scanning were compared with operative and histological findings. Results All patients were cured of hypercalcemia. Specificity of ultrasound and sestamibi scanning was 98% and 99%, respectively; however, their sensitivity was only 57% and 54%, respectively. Both imaging modalities had lower sensitivities in the setting of multigland disease. If both imaging studies were considered as a single test, sensitivity for imaging in patients with primary hyperparathyroidism reached 78%. Our localization protocol allowed a unilateral approach in 43% of patients (23 of 53). Conclusions These results confirm the value of preoperative localization in patients with hyperparathyroidism. A unilateral approach can be used with a high degree of success in cases when ultrasound and sestamibi scanning agree in the identification of a single adenoma confirmed by surgical exploration with the identification of a normal ipsilateral gland.

Context.—Biomedical manuscripts undergo substantive change as a result of the peer review and editorial revision processes.Objective.—To characterize quantitatively problems in manuscripts identified during peer review and changes made to address these problems.Design and Setting.—Descriptive analysis of manuscripts submitted to and articles published by the Annals of Internal Medicine. A taxonomy of problems that occur in reporting clinical research was developed from analysis of changes made to 7 manuscripts between submission and publication (published October 15, 1996, and November 1, 1996). The taxonomy was used to characterize changes to 12 additional manuscripts (published January 15, 1997, to April 1, 1997).Main Outcome Measure.—Types of problems necessitating changes to manuscripts during peer review and revision.Results.—Changes occurred because of 5 types of problems: too much information, too little information, inaccurate information, misplaced information, and structural problems. Changes most often occurred because information was missing or extraneous. The distribution of changes seemed to be influenced by the type of information involved (such as background or conclusions).Conclusion.—The proposed framework may be useful for characterizing quantitatively the effects of peer review and for comparing those effects across editors, journals, and specialties.