Are we using the right irrigation system?

The relationships between bladder pressure and irrigant fluid flow rate were tested using two commonly used supply systems and a 27 FG Storz resectoscope. Simple and inexpensive modifications would enable transurethral prostatectomy to be carried out with reduced intravesical pressure and less risk of fluid absorption. With a continuous suction resectoscope, the modified system allows accurate balance of the inflow and outflow of the irrigant fluid.     

Ensuring vascular surgical training is on the right track

Approval of the primary certificate in vascular surgery eliminated the requirement for certification in general surgery before vascular surgery certification. New training paradigms for training in vascular surgery have emerged driven by the desire to offer greater flexibility of training and to shorten the length of training. Many of these changes are based upon "expert opinion," promise, and "logic" without objective evaluation of the residents or the training programs themselves. To be on the forefront of surgical education, vascular surgery will need to adopt methods of curriculum development firmly grounded in educational principles and use modern assessment tools for the evaluation of competence and performance. This report presents the evolution and challenges to the current vascular surgical training model and then argues for a more rigorous and scientific approach to training in vascular surgery. It presents an analysis of potential avenues for placing education and training in vascular surgery on the forefront of modern surgical education.     

Are we ready for the next disaster?

The time, location and number of injuries sustained in major disasters are unpredictable. The medical response is usually swift and appropriate, but manpower and resources may be quickly stretched to their limits. The hypothesis is advanced that optimal medical management of the victims of major disasters requires the development of a trauma system in the UK, and greater emphasis on education and research in trauma and critical care.     

Pilonidal sinus: finding the right track for treatment

Management of pilonidal sinus is frequently unsatisfactory. No method satisfies all requirements for the ideal treatment--quick healing, no hospital admission, minimal patient inconvenience, and low recurrence--but greater awareness of the strengths and weaknesses of existing methods would lead to improved management. Early excision of the pilonidal pit at the time of treatment of pilonidal abscess reduces the high (40 per cent) risk of subsequent sinus. Treatments for pilonidal sinus that flatten the natal cleft halve the risk of recurrence. En block excision of pilonidal sinus with secondary healing should be abandoned and emphasis given to development of treatments, such as primary asymmetric closure, which have more potential. Some treatments are operator-dependent and, to achieve the best results, junior surgeons must be correctly trained and supervised. Future treatment studies must be prospective and randomized, and should compare healing time, recurrence rates beyond 3 years, nurse and hospital visits, patient inconvenience and loss of income.     

Surgical feeding gastrostomy: Are we overdoing it?

Feeding gastrostomy is a commonly performed procedure in North America. Our aim was to study the outcome of patients undergoing feeding gastrostomy to better define patients who will benefit from the procedure as opposed to those in whom it may be futile. A cohort of the most recent 100 consecutive patients undergoing feeding gastrostomy in a community teaching hospital was retrospectively studied. The main indication for gastrostomy was neurologic disorder interfering with eating/swallowing (group A—54 patients), followed by debilitating systemic disease (group B—26 patients) and obstructive malignancy of the head and neck or esophagus (group C—20 patients). Forty-one patients died within 30 days of the procedure (41%). The overall 30-day survival rates in groups A, B, and C were 70%, 15%, and 85%, respectively. In four patients death was caused by intraperitoneal leak from the gastrostomy site; the remaining patients died of their underlying disease. Five patients required reoperation for gastric leakage around the gastrostomy within 30 days. Only nine patients could be traced who were alive and still using the gastrostomy a year after its placement: two in group A, none in group B, and seven in group C. APACHE II scores at tube insertion also predicted survival; 30-day survival rates in patients with scores of 10 and below, 11 to 15, 16 to 20, and over 20 were 96%, 71%, 48%, and 18%, respectively. No patient with an APACHE score above 15 belonging to group B (debilitating disease) survived more than 30 days. We conclude that to have a beneficial therapeutic effect feeding gastrostomy should be performed selectively. Severe debilitating systemic conditions that interfere with normal eating, when combined with a high APACHE II score, indicate the futility of gastrostomy.     

Academic otolaryngology in the new millennium: Are we falling behind?

OBJECTIVE: To determine if differences in publication rates have evolved over the past 3 decades for academic otolaryngologists. METHODS: Three random samples with 50 academic otolaryngologists each were studied. These otolaryngologists completed training in 1 of the 3 time periods (1970-74, 1980-84, 1990-94) studied. Articles published within the first 5 years after graduation were tabulated and statistically analyzed. RESULTS: Academic otolaryngologists graduating in the 1970s, 1980s, and 1990s averaged 8.7, 8.9, and 6.4 publications during their first 5 years of academic practice, respectively. The first 2 cohorts averaged 5.4 and 5.7 publications in the 4 major otolaryngology journals, versus 3.3 for 1990s graduates. Basic science publications increased for 1990s graduates over those of the 1970s and 1980s graduates. The percentage of first author articles remained stable. Despite these trends, only the drop in case reports was statistically significant (P = 0.023, ANOVA). CONCLUSION: Trends may be developing that predict decreasing publication rates for newly trained otolaryngologists entering academic practice.