New standards and criteria for accreditation of hospitals and posts for surgical training

Accreditation of hospitals, other health-care facilities and the surgical posts involved is an important part of ensuring that trainees are working in an environment where their teaching and learning equip them with the competencies necessary to fulfil the many roles expected of a surgeon. To undertake this accreditation, clear processes and objective measurements are required. Recent external reviews of the College showed the necessity for improvement of its existing accreditation methodology. New processes, standards, criteria, factors to be assessed for each criterion and the minimum requirements for each factor have been developed in a uniform framework for the nine surgical specialties. Each criterion relates to the overall objectives of the educational programmes, and the factors to be assessed are explicit, objective and measurable and should be achievable. Consensus was eventually achieved across the nine specialties. Protected time for teaching and learning and safe working conditions including safe hours were considered by the hospitals to have important consequences for service delivery as well as industrial ramifications for surgeons' and trainees' contracts and required extensive dialogue for a successful resolution. The accreditation process has a potentially significant effect on the availability of surgical services. Publicly available information about the process and requirements, consistency in their application and inclusion in the accreditation team of a hospital representative and surgeon from another region helps to ensure confidence and impartiality.     

Validation of the Center for Medicare and Medicaid Services algorithm for eligibility for dialysis

The Center for Medicaid and Medicare Services (CMS) has recently revised their end-stage renal disease (ESRD) Medical Evidence Report, Medicare Entitlement, and Patient Registration CMS 2728 Form. The modified algorithm calls for the use of formulae to estimate glomerular filtration rate (GFR). The new criterion is defined as estimated GFR of less than 20 ml/min per 1.73 m². GFR is either estimated by Schwartz formula (C_SCH) in children or Modification of Diet in Renal Disease formula (C_MDRD) in adults. The purpose of this communication is to test the validity of the new CMS GFR algorithm in detecting children who need renal replacement therapy. We evaluated two cohorts of children. Group I included single-center data from 626 ¹²⁵I-iothalamate clearance studies (C_IO) that were compared with the simultaneous estimation of GFR by C_SCH. Group II included data on 659 children from the patient incidence registry obtained from the ESRD Network of Texas between February 1996 and October 2003. In group I there were 76 children (76 C_IO) with C_SCH less than 20 ml/min per 1.73 m² of whom 50 (67%) had C_IO less than 15 ml/min per 1.73 m². Of children with C_IO less than 15 ml/min per 1.73 m², 62% had a C_SCH less than 20 ml/min per 1.73 m². The ability of C_SCH greater than 20 ml/min per 1.73m² to predict C_IO greater than 15 ml/min per 1.73 m² (negative predictive value) is 0.95. The number of children who were started on dialysis in Texas within the study period was 659 (group II). The mean C_SCH±SD was 10.8±7.7 ml/min per 1.73 m². Of the patients who were initiated on dialysis, 94% had C_SCH less than 20 ml/min per 1.73 m². The results were sustained when race, gender, age range, and type of diagnosis were considered. The new CMS algorithm provides a good negative predictive estimate of GFR less than 15 ml/min per 1.73 m². Disclaimer The analyses upon which this publication is based were performed under contract number 500–03-NW14 entitled End-Stage Renal Disease Networks Organization for the State Texas, sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.     

Intracavernosal therapy for erectile failure--impact of treatment and reasons for drop-out and dissatisfaction.

OBJECTIVES: To examine the impact of intracavernosal therapy on libido, ejaculatory control, quality of life and treatment dependency in men with erectile failure. Furthermore to assess the drop-out rate and reasons for dissatisfaction with the technique. SUBJECTS AND METHODS: Questionnaires were sent to 1116 subjects with erectile failure who had previously elected to use intracavernosal therapy in the period 1995-1997. RESULTS: The response rate was 72.5%. The majority of erections lasted 30-60 min, 10-20% of the erections were considered unsatisfactory for intercourse and 15% of subjects reported erections lasting longer than 5 h on at least 10% of the occasions. Bleeding at the injection site occurred in 60% on at least 10% of the occasions and various degrees of deformation of the penis shaft were reported by 10%. The latter was related to the age of the subject and not the type of medication employed. Forty percent experienced at least partially improved control over ejaculation and almost 50% experienced some degree of increase in libido. One quarter retained penile rigidity after ejaculation but this was age-dependent. In those satisfied with intracavernosal treatment, 80% admitted that it had improved the quality of their lives. Sixty percent did not feel that their dependency on intracavernosal treatment had lessened during the treatment period. Approximately 40% of subjects admitted to dropping out of the programme, the majority within the first six months. The age of the subject did not influence the decision and the type of medication or the mode of injection had only a minor impact on drop-out rate. Of those currently using IC therapy, 87% were either fully or partly satisfied with this form of treatment. The corresponding figure for those discontinuing treatment was 58%. Dissatisfaction was higher in the younger age groups and could not be clearly related to the mode of injection. The major reasons for drop out or dissatisfaction were inadequate penile rigidity, the expense of the treatment, penile discomfort and the lack of spontaneity it necessitated. Penile discomfort was more associated with younger age groups, whilst an inadequate response to medication was more often experienced by men over 60 y. Deformation of the penile shaft was observed in 5% of those dissatisfied with IC therapy and was four times more often reported by those over 70 compared to subjects younger than 40 y. In 6% of cases, a return of spontaneous erections was given as reason for drop-out. This was more often associated with younger subjects. In 16% of the subjects, the partner had expressed dissatisfaction with the technique primarily because of inadequate rigidity, lack of spontaneity or the complicated nature of the treatment. CONCLUSIONS: Intracavernosal treatment for erection failure is associated with side-effects such as penile fibrosis and bleeding at the injection site but has advantages including increased libido, an increase in the quality of life and ejaculatory control. Only a small proportion of men reduce their dependency on the technique with time. The therapy has a relatively high attrition rate. In many cases, the reasons for subject and partner dissatisfaction are potentially correctable e.g. by altering the medication used, by the use of injector devices or by obtaining financial support for IC medication from medical welfare.     

甲状腺再次手术的临床特点及相关并发症预防

目的 通过分析甲状腺再次手术的临床特点,探讨手术并发症的预防措施.方法 回顾性分析2004年11月至2010年10月间我科收治的72例甲状腺再次手术患者的临床特点及并发症发生情况.结果 72例甲状腺再次手术患者共发生并发症6例,占8.3%,其中喉返神经损伤4例(5.6%),甲状旁腺损伤2例(2.8%),均为暂时性结构损伤,术后一段时间后恢复,随访过程中未诉相应并发症发生.结论 甲状腺再次手术难度较大,应充分掌握手术特点,术前认真完成准备,术中谨慎、小心,时刻注意保护喉返神经和甲状旁腺,从而最大限度地减少并发症的发生.     

Indications for and results of surgical therapy for male gynecomastia.

BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n = 81) and clinical examination (n = 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results.     

Indications for and results of nephrectomy for metastatic renal cell carcinoma

We find that, when metastases are present, a nephrectomy for renal cell carcinoma is not justified in the vast majority of cases. The only noncontroversial indication is for palliative nephrectomy which is performed to relieve intractable symptoms in the properly chosen patient. However, it is unusual to see a patient with tumor-related symptoms that cannot be conservatively managed. A relative indication for nephrectomy is found in the patient with osseous metastases only, as some studies have demonstrated a prolongation of survival by adjunctive nephrectomy in this setting. Another relative indication is in the patient with limited metastases that are amenable to surgical or radiation ablation coupled with nephrectomy; patients in whom the metastasis appears years after the nephrectomy have the best chance for a successful outcome. When therapy that is effective against metastatic tumor is eventually found, adjunctive nephrectomy as a debulking procedure may become indicated; until then, surgery is not justified. On the basis of data presently available, adjunctive nephrectomy in the hope of inducing spontaneous regression of metastases is never indicated.