Laparoscopy training in United States obstetric and gynecology residency programs.

OBJECTIVES: To assess laparoscopic training curriculums in US Obstetrics and Gynecology residency programs. METHODS: A list of E-mail addresses was obtained for the accredited Obstetrics and Gynecology residency programs in the US from the CREOG Directory of Obstetric-Gynecologic Residency Programs and Directors. An E-mail survey containing 8 questions regarding laparoscopy training was sent to all residency directors with current E-mail addresses. RESULTS: Seventy-four residency directors responded to the survey for a response rate of 41%. Residency programs from all sections of the US were included in the study. Results of the survey indicate that 69% of residency programs had implemented a formal laparoscopy training program. At least half of the program directors surveyed stated that lack of faculty time and funds were the main barriers to laparoscopic surgery training. Seventy-two percent of those surveyed thought that in the future the health-care industry would demand proof of competency in laparoscopy as standard of care. CONCLUSIONS: Most US Obstetrics and Gynecology residency programs have implemented a formal laparoscopy training curriculum, use more than one method to train their residents, and involve almost half of their faculty on average in training residents to perform laparoscopic surgery.     

Strategies for understanding. A case study of occupational therapists' communication behaviour

This study focuses on the communication strategies of occupational therapists. Many recent studies in occupational therapy emphasize the importance of having a client-oriented perspective; the needs and wishes of the patient should form the basis for treatment. Such a perspective brings to the fore the capacity of the therapist to enter into the life-world of the patient. Communication, dialogue between patient and therapist, is the basic source of such knowledge. In this paper, understanding verbal acts is seen as fundamentally problematic. The purpose is to analyse what strategies and tactics occupational therapists use to create a basis for their interpretation of patients' messages. What kinds of questions and other forms of verbal behaviour are utilized to check and verify these interpretations? A case-study of communication behaviour during five meetings between patients and therapists in the homes of the patients was undertaken. Seven types of tactics were observed and categorized as belonging to two different strategic dimensions: active-passive and abstract-concrete. Although active strategies were predominant, only one therapist consistently used a combination of ‘asking open questions’ and ‘verifying’ interpretations, the two most active tactics. Most therapists also asked the patients to concretely ‘show in action’ what they meant, but to a varying degree. A consistent use of active-concrete strategies is arguably an ideal way of seeking knowledge and understanding. Empirically, therapists differ in how closely they fit this ideal. This may be a result of training and experience, but also of degree of empathy. This study points to the importance of carefully developing communication strategies in order to fully understand the problems of the patients. Copyright © 1997 Whurr Publishers Ltd.     

Congenital disseminated malignant rhabdoid tumor and cerebellar tumor mimicking medulloblastoma in monozygotic twins: pathologic and molecular diagnosis.

Malignant rhabdoid tumors are highly aggressive childhood tumors. Recently, all of the malignant rhabdoid tumors, whatever their location, have been related to the inactivation of the hSNF5/INI1 gene. A subset of cerebral tumors, associated with malignant rhabdoid tumors or isolated ones arising in siblings, showed similar molecular alterations. We report for the first time in monozygotic twins a congenital disseminated malignant rhabdoid tumor in one twin and a cerebellar tumor mimicking a medulloblastoma in the other. Molecular analysis revealed similar alterations for both tumors: a deletion of exon 7 of the hSNF5/INI1 gene in one allele, and a point mutation in the same exon in the other, suggesting a common genetic pathway. Analysis of constitutional DNA revealed a germline mutation. These findings are in favor of a common etiology for rhabdoid tumor and a subset of brain tumors developing in infancy.     

Incidence of coronary artery by-pass graft following percutaneous transluminal coronary angioplasty

Two hundred fifty eight patients had percutaneous transluminal coronary angioplasty. Of those, 48 cases underwent surgical revascularization for unsuccessful angioplasty. Sex was not a risk factor. Timely surgical revascularization reversed acute ischemia and/or myocardial infarction or limited the size of the infarction in 32 of the 48 patients or 67%. Revascularization procedures were performed in six out of forty-eight patients who had previous aortocoronary by-pass surgery and attempted PTCA, none had any complications. Death occurred in one out of forty-eight patients, or 2%. Femoral-femoral by-pass devices, in addition to intra-aortic balloon devices, should be available in the cardiac catheterization laboratory. Patients with multi-vessel disease are at greater risk of angioplasty and surgery. Sixteen out of 23 patients (70%) who had emergency revascularization procedures had multi-vessel disease. In one patient with borderline renal function, emergency surgery after PTCA with a large amount of renograffin dye injected caused renal failure and led to permanent dialysis.     

Early neuromuscular customized training after surgery for lumbar disc herniation: a prospective controlled study

A prospective and controlled study of training after surgery for lumbar disc herniation (LDH). The objective was to determine the effect of early neuromuscular customized training after LDH surgery. No consensus exists on the type and timing of physical rehabilitation after LDH surgery. Patients aged 15–50 years, disc prolapse at L4–L5 or L5–S1. Before surgery, at 6 weeks, 4, and 12 months postoperatively, the following evaluations were performed: low back pain and leg pain estimated on a visual analog scale, disability according to the Roland–Morris questionnaire (RMQ) and disability rating index (DRI). Clinical examination, including the SLR test, was performed using a single blind method. Consumption of analgesics was registered. Twenty-five patients started neuromuscular customized training 2 weeks after surgery (early training group=ETG). Thirty-one patients formed a control group (CG) and started traditional training after 6 weeks. There was no significant difference in pain and disability between the two training groups before surgery. Median preoperative leg pain was 63 mm in ETG and 70 mm in the CG. Preoperative median disability according to RMQ was 14 in the ETG and 14.5 in the CG. Disability according to DRI (33/56 patients) was 5.3 in the ETG vs. 4.6 in the CG. At 6 weeks, 4 months, and 12 months, pain was significantly reduced in both groups, to the same extent. Disability scores were lower in the ETG at all follow-ups, and after 12 months, the difference was significant (RMQ P=.034, DRI P=.015). The results of the present study show early neuromuscular customized training to have a superior effect on disability, with a significant difference compared to traditional training at a follow-up 12 months after surgery. No adverse effects of the early training were seen. A prospective, randomized study with a larger patient sample is warranted to ultimately demonstrate that early training as described is beneficial for patients undergoing LDH surgery.     

Comparison of Methodologies for Calculating Quality Measures Based on Administrative Data versus Clinical Data from an Electronic Health Record System: Implications for Performance Measures

New reimbursement policies and pay-for-performance programs to reward providers for producing better outcomes are proliferating. Although electronic health record (EHR) systems could provide essential clinical data upon which to base quality measures, most metrics in use were derived from administrative claims data. We compared commonly used quality measures calculated from administrative data to those derived from clinical data in an EHR based on a random sample of 125 charts of Medicare patients with diabetes. Using standard definitions based on administrative data (which require two visits with an encounter diagnosis of diabetes during the measurement period), only 75% of diabetics determined by manually reviewing the EHR (the gold standard) were identified. In contrast, 97% of diabetics were identified using coded information in the EHR.The discrepancies in identified patients resulted in statistically significant differences in the quality measures for frequency of HbA1c testing, control of blood pressure, frequency of testing for urine protein, and frequency of eye exams for diabetic patients. New development of standardized quality measures should shift from claims-based measures to clinically based measures that can be derived from coded information in an EHR. Using data from EHRs will also leverage their clinical content without adding burden to the care process.     

Genetic analysis of seven Mediterranean families with multiple endocrine neoplasia type 2A

OBJECTIVE   Genetic analysis is now essential for the accurate screening of families with multiple endocrine neoplasia type 2 (MEN2). We present the genetic analyses by both haplotype and direct RET proto-oncogene mutation analysis in seven Mediterranean MEN 2A families and have compared these results with biochemical screening tests and pathological examinations.
DESIGN  Total DNA was extracted from leucocytes. Linkage analysis was performed using five RFLP systems from three loci that flank the MEN2A locus (FNRB, RBP3, D10S15). RET proto-oncogene analysis was carried out by automatic DNA sequencing and adequate digestion of PCR amplified products for exons 10 and 11. Screening for medullary thyroid carcinoma or C-cell hyperplasia was performed by the pentagastrin provocation test. Adrenal medullary function was assessed by measurements of 24-hour urinary excretion of catecholamines and their metabolites. Serum calcium and phosphate measurements were the initial screen for hyperparathyroidism. Serum PTH was determined only if hyperparathyroidism was suggested by the former determinations.
PATIENT   Genetic study was performed in 59 individuals (39 at risk) from seven kindreds of Mediterranean origin with MEN 2A.
RESULTS   Diagnosis by linkage analysis was not possible in 30% of individuals at risk, but RET proto-oncogene analysis identified all these individuals. Mutations of the RET proto-oncogene were detected in exon 10 (codon 618) in one MEN 2A kindred and in exon 11 (codon 634) in the others. The results of direct analysis were concordant with linkage studies in each case. Three individuals from different MEN 2A kindreds, who were subsequently shown not to be gene carriers, had false positive pentagastrin stimulation tests.
CONCLUSION   Biochemical tests can be replaced by direct DNA mutation analysis as the first line screening test in order to identify gene carriers of MEN 2A.