Observations on the American Board of Surgery In-Training Examination,board results,and conference attendance

Based on an evaluation of the results of 119 In-Training tests taken by 60 residents from 1975 to 1981, guidelines were developed for using the test in surgery training programs. Regression analysis revealed a high correlation (r = 0.79, p < 0.001) between scores on the In-Training test and the American Board of Surgery Qualifying Examinations. At the 95 percent confidence level, a PGY V resident scoring higher than the 25th percentile on the final In-Training Examination will pass the Qualifying Examination. Residents who do not continue the general surgery residency (dropouts, those with a subspeciality year on general surgery, those not selected for further training) score significantly lower (p < 0.002) than general surgery residents. This selection process tends to lower (2.5 percentile points per year) the percentile scores of general surgery residents in later years of training. Participation in key teaching conferences has a positive correlation, although it is disappointingly low, with In-Training results. Objective guidelines can assist the teaching staff when they consider residents for selection or retention in the training program.     

Evaluation of internal carotid stenosis with the chronopulse,an automated ocular pulse arrival time recorder

The diagnostic value of ocular pulse time measurement with the Chronopulse was evaluated in 67 patients who had carotid arteriography. The diagnostic accuracy of 85.5 percent was comparable to that obtained by two other groups using a different timing device. Identification of bilateral stenosis was the major problem encountered and resulted from measuring the external carotid circulation at the ear. Ocular pneumoplethysmography performed in the same patients yielded a higher diagnostic accuracy than the pulse timing, and combining the two did not enhance the results. Therefore, we recommend that the Chronopulse not be used as part of the routine ocular pneumoplethysmographic examination but that it be reserved for selective application.     

Hygiene in Operationsabteilungen – Empfehlungen des Nationalen Referenzzentrums für Krankenhaushygiene

Zusammenfassung. Viele Hygienema?nahmen in Operationsabteilungen sind durch wissenschaftliche Untersuchungen nicht belegt. Die in dieser Arbeit vom Nationalen Referenzzentrum für Krankenhaushygiene, das 1996 vom Bundesgesundheitsministerium eingerichtet wurde, zusammengestellten Empfehlungen stützen sich auf die Ergebnisse wissenschaftlicher Untersuchungen und trennen so die unbedingt notwendigen von den weniger bzw. nicht sinnvollen Ma?nahmen.

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Summary. Many hygienic procedures performed in operation units are not supported by scientific investigations. The following recommendations by the National Reference Center for Hospital Epidemiology, founded by the German Ministry of Health in 1996, are based on the scientific literature and separate necessary from less necessary and unnecessary procedures.

     

Management of the patient with emphysema,coronary artery disease,and lung cancer

Coronary artery disease, emphysema, and lung cancer often occur together and have cigarette smoking as a common etiologic contributor. The management of the patient with lung cancer, coronary artery disease, and emphysema is complex. The patient with significant coronary artery disease should undergo coronary artery bypass before or concurrently with pulmonary resection. Only proven carcinomas should be resected at the time of coronary artery bypass grafting because immunosuppression secondary to cardiopulmonary bypass can result in the life-threatening spread of fungal or other infections if biopsy is performed at the time of cardiopulmonary bypass. The risk of pulmonary resection is increased in the patient with emphysema because of decreased efficiency of the lungs and chest wall. Likewise, emphysema results in greater risk in the patient with coronary artery disease because of increased demands on the heart.     

Influence of prosthetic graft fabrication on graft healing,I

The object of this report was to analyze graft healing by comparing the content of collagen and noncollagen protein among seven commonly used prostheses: light-weight knitted dacron concentric crimp (USCI), Sauvage filimentous external velour knitted dacron with concentric crimp, random crimp, or no crimp (USCI), microvel double-velour knitted dacron concentric crimp (Meadox), PTFE Impra, and PTFE Gortex. Grafts (6 mm) were used to replace 4-cm segments of infrarenal abdominal aorta in 85 experimental dogs and five autograft aorta control animals. At 3 and 6 months postimplantation the grafts were aseptically harvested, inspected for completeness of neointimal healing and submitted for biochemical analysis. After 3 months implantation, uncrimped external velour grafts had less hydroxyproline than all dacron grafts except random crimp external velour (P < 0.05) but not less than both PTFE grafts and most dacron and PTFE grafts were not significantly different in noncollagen protein. After 6 months implantation, all dacron grafts had more hydroxyproline than both PTFE grafts (P < 0.03) and most dacron grafts had significantly more noncollagen protein than PTFE Impra (P < 0.05). Of all the grafts analyzed, only uncrimped external velour knitted dacron grafts had both rapid neoendothelial healing and a significant increase in both hydroxyproline and noncollagen protein between 3 and 6 months after graft implantation (P < 0.01). These data indicate that dacron prostheses heal in a manner different from that of PTFE grafts, that there may be differences among the various types of dacron prostheses, and that external velour uncrimped grafts would appear to have the best healing characteristics.     

Epidermoid cancer of the anal margin. Pathologic features, treatment, and clinical results

Epidermoid cancer of the anal margin should be distinguished from that in the canal because of its different clinical and pathologic characteristics, the suitability of local excision for its treatment, and its better overall prognosis. In addition, margin cancer rarely metastasises to visceral sites. Forty-eight patients with epidermoid cancer of the anal margin were reviewed. Two refused treatment, 4 had palliative therapy for advanced, inoperable disease, 31 had local excision, and 11 were treated by abdominoperineal resection. Local excision provided satisfactory results with a corrected 5 year survival of 88 percent, although locoregional recurrence developed in 46 percent of these patients during follow-up. A second local excision or inguinal lymphadenectomy provided good results in the patients with recurrence. Abdominoperineal resection did not provide better overall survival figures.     

Interaction of hindlimb blood flow,A-V shunting and A-V oxygen difference

The interactions of blood flow, A-V O₂ difference (AVDO₂), and A-V shunting were measured in normal hindlimbs of nine anesthetized dogs. An aorto-iliac nonpulsatile perfusion pump was used to change femoral artery blood flow from zero (collateral flow only) to twice its baseline level. Femoral AVDO₂ was measured by in-line spectrophotometric O₂ analysis. A-V shunting was measured with radio-labeled microspheres. Systemic hemodynamic parameters and temperature remained constant during the experiments. Despite changes in femoral mean arterial pressure (160 to 54 mm Hg) and AVDO₂ (1.8 to 8.2 ml O/₂/dl) that occurred with femoral blood flow reduction, peripheral A-V shunting remained constant at 4.1–5.5%. Alpha-adrenergic ablation (sympathectomy) was used to increase A-V shunting (up to 20%) during part of this experiment. When hindlimb blood flow was normal or increased, autoregulation of O₂ extraction maintained constant hindlimb O₂ consumption, despite sympathectomy-induced changes in A-V shunting. Subnormal femoral artery blood flow reduced hindlimb O₂ consumption, and in this setting the increased A-V shunting further decreased femoral AVDO₂ and O₂ consumption. Since AVDO₂ is dependent upon both blood flow and the variable efficiency of cellular O₂ extraction, it cannot be used as an accurate indicator of A-V shunting. Direct microsphere techniques should be applied to A-V shunt measurements in clinical settings where A-V shunting is suspected.     

Gastrointestinal bleeding in the elderly. Morbidity, mortality and cause

One hundred thirty-six consecutive patients with upper gastrointestinal bleeding were divided by age into three groups, young, middle aged and elderly, and evaluated for the causes and complications of the bleeding episode. Hemorrhagic gastritis was the most frequent source of bleeding in the young, while gastric ulcer was more common in the middle aged and elderly groups. The high mortality in the young (20 percent) was often attributable to associated liver functional abnormalities secondary to alcoholism. The elderly fared better than the young when the source of bleeding was hemorrhagic gastritis, although the results were not statistically significant. On the other hand, the elderly had a significantly higher mortality than the young when the source was gastric ulcer. All three groups did poorly when the source of bleeding was esophageal varices. The mortality rate was essentially the same in the young and elderly patients requiring surgery, suggesting that age alone should not be a deterrent for surgical management of acute gastrointestinal bleeding.     

Ulcer recurrence,morbidity, and mortality after operations for duodenal ulcer

Due to fear of duodenal ulcer recurrence, PGV is not yet accepted by most surgeons in the United States as a satisfactory operation for treatment of intractable duodenal ulcer. Currently PGV has a 30 day operative mortality of 0.3 percent, a severe morbidity of 1 percent, and a long-term ulcer recurrence rate of about 11 percent. Truncal vagotomy and pyloroplasty has a mortality of 0.7 percent, a morbidity of 5 percent, and a recurrence rate of about 10 percent. Truncal vagotomy and antrectomy has a mortality of 1 percent, a morbidity of 5 percent, and a recurrence rate of about 2 percent. Thus, PGV is preferable to vagotomy and pyloroplasty since vagotomy and pyloroplasty has higher mortality and morbidity rates. The recurrence rate is similar. Furthermore, since postoperative morbidity is more difficult to manage than ulcer recurrence, a cogent argument can be made that PGV is superior to vagotomy and antrectomy as an operation for intractable duodenal ulcer.     

Argentaffin adenoma of the trachea

Argentaffin adenoma of the trachea is very rare. Since these tumors are usually discussed together with bronchial tumors, their relative frequency is not known. Cure can be effected if the tumors are resected at an early stage. The common presenting symptoms are hemoptysis and airway obstruction.     

John Allan Wyeth,MD: Surgeon,soldier, author and founder of postgraduate medical education in America

John Allan Wyeth, surgeon, soldier and author, received his medical training during the era immediately after the Civil War. After realizing the inadequacy of American medical education, Wyeth sought to establish a system of postgraduate medical instruction in the United States. The New York Polyclinic, founded in 1882, was the first facility to provide such training in America and was an important factor in the movement to revolutionize the teaching and practice of medicine and surgery in this country. Wyeth's other contributions include a classic textbook of surgery, the development of numerous surgical procedures, narratives of battles and leaders of the Civil War, and progressive leadership in prominent medical organizations of the period.