Training surgeons to do evidence-based surgery: a collaborative approach

BACKGROUND: Three of the Accreditation Council for Graduate Medical Education general competencies contain specific wording indicating that trainees must learn how to locate, appraise, and integrate the best information from the literature into their patient care practices. What is less clear is how to best translate evidence-based concepts into the workday of the resident, fellow, or attending surgeon. In this article we describe our use of the assignment-based training program we developed to ensure that our trainees can actually do what is required to practice evidence-based operations. STUDY DESIGN: Our collaborative program draws on the expertise of an attending surgeon, a medical librarian, and a research coordinator. The curriculum is designed so that all residents in our program develop and refine their evidence-based surgery skills in a context relating to their clinical practice. They are given a practice-related clinical question and are asked to demonstrate their competence in finding the best available evidence to answer it. This involves restating the question as a well-formulated clinical question, doing a focused literature search, critically appraising the results to find the best evidence, and integrating the information into practice, if appropriate. Search assignments are evaluated using a structured form and additional training is designed based on the results. Another question is then assigned to assess improvement. RESULTS: Residents' performance on a first assignment showed specific weaknesses in use of textwords and limiters. Performance was strongly related to a resident's ability to obtain the best evidence in answer to a clinical question (p = 0.011). Substantial improvement was shown on a second assignment after additional training. CONCLUSIONS: Our hands-on, performance-based program allows us to document trainees' progress in developing skills that will allow them to efficiently locate the best evidence available to inform their patient care decisions.     

Soft tissue aneurysmal bone cyst of left hemithorax with review of literature

Soft tissue aneurysmal bone cysts (STABCs) are extremely rare extraosseous counterpart of aneurysmal bone cyst (ABC), with close resemblance to histo-morphologic characteristics of ABC. Here we would like to report a 13-year-old female patient, who presented with a large mass, occupying the entire left hemithorax. Patient underwent resection of the thoracic mass. On histopathological examination, it was found to be a soft tissue ABC. It is a very rare tumor and until date 28 cases have been reported in English literature, to the best of our knowledge. On review of the literature, we found this to be the first case of STABC reported in thoracic cavity. The objective of this case presentation is to provide information regarding clinical presentation, radiological and pathological features, and course of management for this rare disease. Soft tissue ABCs are a new class of tumors, so more extensive research is required to establish standard guidelines for their diagnosis and management, to yield better prognosis.     

Fourteen years follow up of an unclassified Talar body fracture with review of literature

Talar body fractures are rare. Four major types of talar neck fractures are known but talar body fractures are rarely described. An unusual case of a sagittal fracture of the body of talus is reported in this article. No similar cases are reported in the English literature to the best of our knowledge. The risk of avascular necrosis is very high and accurate reduction with solid fixation remains the key to better outcome. We discuss the possible mechanism of injury along with review of literature.     

Nasopharyngeal T-cell monomorphic posttransplant lymphoproliferative disorders and combined IgA nephropathy and membranous glomerulonephritis in a patient with renal transplantation: a case report with literature review

Recurrent and/or de novo glomerular diseases occurring in a renal allograft have been reported in the literature and are an important cause of graft dysfunction and eventual loss. The simultaneous occurrence of two glomerulonephritis, although reported in the literature, is a rare phenomenon. Posttransplant lymphoproliferative disorders (PTLD) are well known and one of the most serious and potentially fatal complications of chronic immunosuppression in the solid organ transplant recipient. Here, we are reporting the first case, to the best of our knowledge, of simultaneous occurrence of nasopharyngeal monomorphic monoclonal PTLD and two distinctive glomerular diseases (IgA nephropathy and membranous glomerulonephritis) in a 49-year-old patient who was 5 years post-renal transplantation. We have provided the clinical history of our patient who presented with nephrotic range proteinuria, microscopic hematuria, and a nasopharyngeal mass as well as a review of the literature.     

Giant perineal hernia: laparoscopic mesh repair complemented by a perineal cutaneous approach

Symptomatic perineal herniation after abdominoperineal resection is a rare complication and its management remains challenging. Perineal laparoscopic mesh repair is safe and effective and can be performed with minimal complications. We report a giant perineal hernia treated by a combined laparoscopic mesh repair approach and plastic resection of the cutaneous perineal wound. To the best of our knowledge, this is the first report with this technical approach that we could find in the English literature.     

Editorial Commentary: What Irks a Hip Arthroscopist? Intraoperative Anchor Failure

Intraoperative suture anchor failure is a seemingly unavoidable event during hip arthroscopy and it can happen to the best of us. To date, biomechanical cadaveric studies saturate hip anchor failure literature with only one known, published in vivo investigation. We now know that intraoperative anchor failure is an uncommon occurrence that does not significantly vary between basic population demographics. However, we have only been provided with foundational knowledge, and our community must continue to expand upon the basics.     

Editorial Commentary: Single Versus Double-Row Abductor Tendon Repair: Is the Juice Worth the Squeeze?

Anatomical understanding of the peritrochanteric space and abductor insertions has been well documented in the literature. Extrapolating this knowledge to perform a “successful” abductor tendon repair has led to controversy over the best method to achieve a durable, stable repair and improve patient outcomes. I feel that the debate in the hip over single- versus double-row fixation is only beginning and we are in for a ride to uncover the best method, as we have with the shoulder over the last 15 years. What is best? Single or double row?     

The use of calcium phosphate cements in the maxillofacial region

Defects in the maxillofacial region may result from many causes, including injury and tumor excision. Such defects must be repaired as completely as possible so that the best possible restoration of function and cosmesis can be achieved. Calcium phosphate cements (CPCs) are a blend of amorphous and crystalline compounds that are used in paste form and become solid HA when they set. This article will review literature regarding various types if CPCs, their application to maxillofacial surgery, and the contraindications and complications associated with their use.     

Beurteilung des Verfahrens Hüftendoprothetik durch deutsche Hausärzte

To assess the general knowledge and individual views of general practitioners (GPs) on total hip arthroplasty (THA), we performed a questionnaire-based survey involving 200 GPs in Germany.Ninety-four GPs returned the questionnaire. They had treated a mean of 37.7+/-38.6 patients (range 0-300) with THA. Their general knowledge can be estimated as good. They assessed the potential for complications in association with THA as higher than that reported in the literature. If the GPs had been exposed to more complications in their practices, they estimated a lower patient satisfaction rate 10 years after surgery and were less satisfied with the indications given by their operating colleagues.A broad spectrum of individual responses indicates the need to improve information transfer between orthopaedic surgeons and referring GPs.     

A rare co-existence of focal xanthogranulomatous pyelonepheritis,angiomyolipoma and renal cysts simulating renal cell carcinoma

A 70-year-old male presented with left flank pain and history of gross, total painless haematuria of 6 months duration. Investigations revealed a large solid and cystic mass suggestive of renal cell carcinoma in left kidney with possible infiltration of left psoas muscle. Histology of radical nephrectomy showed angiomyolipoma with multiple cysts lined by columnar epithelium suggestive of tuberous sclerosis and focal area of xanthogranulomatous pyelonepheritis. The rare combination of such lesions leading to diagnostic dilemma has not been reported in medical literature to the best of our knowledge.     

Renal metastasis from primary hepatocellular carcinoma. A case report and review of the literature

Secondary malignant tumors of the kidney are uncommon. These secondary tumors are usually the result of hematogenous spread from solid or hematologic malignancies. These tumors are almost always discovered at autopsy, with only 40 cases diagnosed prior to death reported in the literature. Primary tumors of the lung, breast and gastrointestinal tract are the most common sources of renal metastases. The occurrence of a renal secondary from a primary hepatocellular carcinoma is the subject of this presentation. To the best of our knowledge, such an occurrence has not been reported previously.     

Surgical fellowship training in Canada: What is its current status and is improvement required?

This paper examines current issues concerning surgical fellowship training in Canada. Other than information from a few studies of fellowship training in North America, there are scant data on this subject in the literature. Little is known about the demographic characteristics of those who pursue fellowship training in Canada, what the experiences and expectations are of fellows and their supervisors with respect to the strengths and weaknesses of this level of training, or how this level of education fits in with Canadian undergraduate and postgraduate medical training. We summarize current knowledge about fellowship training in Canada as it pertains to demographic characteristics, finances, work hours, residency training, preparation for clinical and research work and satisfaction with training. Most information on surgical fellowship training comes from the United States. As such, we used information from American studies to supplement the Canadian data. Because a surgical fellowship experience in Canada may be different from that in the United States, we propose that Canadian surgical fellows and their supervisors should be surveyed to gain an understanding of such information. This knowledge could be used to improve surgical fellowship training in Canada.     

Multiple subcutaneous nodules leading to the diagnosis of pulmonary aspergillosis in a renal transplant recipient

Abstract:  Aspergillosis is the second most frequent opportunistic fungal infection in solid organ transplant recipients; however, cutaneous aspergillosis occurs very rarely. Herein, we report a 34-yr-old male renal transplant recipient with secondary cutaneous aspergillosis due to Aspergillus fumigatus in whom cutaneous lesions led to the correct diagnosis. To the best of our knowledge, this is the first case of secondary cutaneous aspergillosis reported in the setting of a solid organ transplantation.     

Preconception healthcare: what do men know and believe?

BackgroundThe objectives of this study were to determine if men realize the importance of optimizing their health prior to a pregnancy, whether the pregnancy is planned or not; and to evaluate their knowledge level and beliefs about preconception healthcare. Additionally, we sought to understand how and when men wanted to receive information on preconception health.MethodsA survey study was performed using consecutive patients presenting to two primary care practices for care. Patients were recruited based on willingness to complete the survey at the time of their appointment, but prior to being seen by the physician.ResultsA total of 132 men completed the survey. Nearly all men (93.2%) realized the importance of optimizing their health prior to a pregnancy, and realized the best time to receive information about preconception health was before conception. The majority of patients surveyed (75.0%) preferred to receive information about preconception health from their primary care physician. Only 8.3% of men could recall their physician ever discussing this topic. The population studied revealed some significant knowledge deficiencies about factors that may threaten their health or the health of their partner's fetus.ConclusionsA majority of men do understand the importance of optimizing their health prior to conception, and look to their primary care physician as their preferred source for such information. Study participants demonstrated deficiencies in their knowledge of risk factors that impact paternal and fetal health suggesting that physicians are not addressing preconception healthcare during routine care.     

Bone transplantation methods]

Author sums on the basis of the literature of this country and of the international literature the more frequently used methods of bone substitution, their mechanical and biological characteristics. On the basis of the practice of their institute and of the international publications it can be stated that beside the usual transplantation of preserved bone the always increasing clinical claim makes the introduction and the knowledge of other methods also necessary. The advantages and disadvantages of the bone grafts of different types are detailed. It is stated that none of the implantates of different characteristics fulfils perfectly the ideal mechanical and biological requirements. To obtain the possibly best result it is recommended to choose, and on individual indication, the bone substitution method that will fulfil in the given case the requirements desired.     

Show me the evidence

Reporting outcomes based on clinical evidence is going to set the standards for hand surgery practice. Hand surgeons will be judged by the evidence that their interventions are doing the most good for the most people at a price that patients and/or insurance companies are willing to pay. Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values. The best evidence comes from randomized clinical trials, which are expensive, time consuming, and not always possible. Sometimes we have to settle for good evidence, which may be the best evidence that is available. Nevertheless, if the future demands good evidence, then as hand surgeons and researchers we need to supply that evidence. Thus, first we have to know how and where to look for what's out there and then what we can do to add to this body of knowledge.     

Skeletal muscle metastasis from carcinoma of the bladder

Metastasis to skeletal muscle from carcinoma of the bladder is extremely rare. To the best of our knowledge, there is no reported case in the English literature. In this report, we describe a 41-year-old man with bladder carcinoma with metastasis to the right deltoid muscle.