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A letter to the editor is presented in response to an article regarding a case of recurrent premenstrual psychosis related to an underlying seizure disorder.

War is a malefic force and results in many psychiatric and medical casualties. Psychiatry's involvement with soldiers experiencing psychological stress resulting from combat experience has been reported for many years (Zajtchuk, 1995). It has been demonstrated that a myriad of diagnosis to include depression, anxiety, somatoform, adjustment disorders and psychotic behaviors also emerge (Wain et al., 1996, 2005a). Nearly all survivors exposed to traumatic events briefly exhibit one or more stress related symptoms (Morgan et al., 2003). In many instances these symptoms dissipate within a reasonable amount of time. However, symptoms persisting for a prolonged period following a traumatic event increase the probability of developing stress-related psychiatric disorders.

The authors are Army psychiatrists and were members of the mental health team that responded to the Pentagon attack of September 11, 2001. They were assigned to work at the Hoffman Complex in Alexandria, Virginia, with displaced employees from the Office of the Army Deputy Chief of Staff for Personnel. Never before had anyone committed an unexpected act of war on a garrison unit within the continental United States, making the appropriate psychiatric interventions difficult to discern. The authors conducted a retrospective analysis to examine how closely their interventions paralleled official Army doctrine on Combat Stress Control as detailed in Field Manual 8-51, Combat Stress Control in a Theater of Operations. They discovered that the parallels were considerable but not comprehensive and concluded that following future acts of terror or other disasters on United States soil military mental health providers should apply both traditional and novel principles of Combat Stress Control.

Following the September 11, 2001 attack on the Pentagon many fears remained among survivors of the event. As chief of the mental health team assigned to work with the Office of the Army Deputy Chief of Staff for Personnel, one of the authors (D.W.) had to address predominant unit concerns regarding how many individuals would be emotionally capable of returning to the building. This manuscript presents one of the specific interventions we used, mass desensitization, as a possible technique for reducing environmental anxieties following similarly traumatizing events.

Objective: The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome., Summary Background Data: Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined., Methods: Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively., Results: The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy., Conclusion: Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.

Objective: To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders., Summary Background Data: The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce., Methods: One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients., Results: Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months., Conclusions: LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.

Unlabelled: Two patients developed seromas overlying Marlex mesh repairs of ventral hernias. After repeated unsuccessful attempts at aspiration of the fluid, each patient underwent formal exploration and excision of the cystic mass to the level of the mesh. Histology showed thick, fibrous, trabeculated cysts. Postoperatively, one patient had prolonged closed suction drainage. In the other, suction drains had scant output, but she developed a recurrence of serous fluid, which resolved with two aspirations., Conclusions: 1) Mature fibrous cyst is a rare complication of Marlex mesh herniorrhaphy; 2) Chronic seroma collections may be etiologic; 3) Surgical excision and closed suction drainage, rather than simple aspiration, are required for treatment; 4) Prolonged postoperative drainage may be needed to prevent recurrence.

Leiomyoblastoma is a rare, smooth muscle tumor of the stomach occurring chiefly in the antrum in patients between the fifth and seventh decades. The clinical spectrum, as illustrated in eight patients described in this report, ranges from an incidental finding to a highly malignant, metastasizing neoplasm. Although the large majority of leiomyoblastomas are benign, malignancy has been reported to occur in up to 12% of cases. Resection of the tumor with an appropriate full thickness segment of gastric wall is mandatory.