Determining the content of a surgical curriculum

The purpose of undergraduate surgical education is to prepare the student for both the residency and eventual practice of medicine. To help determine the surgical knowledge and skills that would eventually the useful to the student, we conducted a survey of residents in training, physicians in practice, and surgical educators (department chairpersons and clerkship directors). Members of the Curriculum Committee of the Association for Surgical Education developed a questionnaire in which the respondents were asked to grade the functional importance of 84 areas of knowledge and 46 skills (0 = unnecessary, 3 = proficiency necessary). Using a modified Delphi technique to collect information, we sent the questionnaire to eight medical school graduation classes of 1975 (730 persons) and 1980 (776 persons) and all department chairpersons and/or clerkship directors (179). The results of the survey (46% response) revealed considerable agreement about the importance of certain skills and areas of knowledge, enabling us to rank order skills and knowledge based on mean responses (0.0 to 3.0). Physicians in practice, residents, and educators believed that certain areas of knowledge (e.g., acute abdominal problems, appendicitis, shock, cancer of the breasts) and skills (e.g., history taking and physical examination, gowning, suture removal) were very important (greater than 2.250, while other areas of knowledge (e.g., transplantation, liver abscess, soft tissue sarcomas) and skills (e.g., insertion of Swan-Ganz catheter, abdominal paracentesis, cricothyroidotomy) were less important (less than 1.3). This approach allows us to assign priorities to areas of knowledge and skills when determining curriculum content and to include functional criteria when developing educational objectives.     

Malignancies in UK children with HIV infection acquired from mother to child transmission

By April 1995, 302 cases of vertically acquired HIV infection had been reported through the British Paediatric Association Surveillance Unit. Over 50% of these children had developed an AIDS indicator disease, including nine malignancies (seven cases of non-Hodgkin's lymphoma (NHL) and two of Kaposi's sarcoma). There were two other malignancies that were not AIDS indicator diseases. In children less than 5 years of age the incidence of NHL was approximately 2500 times greater than expected in the UK child population. Three children presented with NHL as their AIDS indicator disease and four developed NHL at a median of 14 (range 10-19) months after the initial diagnosis of AIDS. Six of the seven children died at a median of 6.5 (range 2-14) months after the diagnosis of NHL. The seventh child responded to treatment and is alive nearly four years later. Histology was available in five cases, of which four were of B cell and one of T cell origin. Epstein-Barr virus was detected in all three patients with NHL where it was sought; all had B cell lymphomas. Although comparatively rare, malignancies occur in children infected with HIV and may be the presenting illness. Paediatricians now need to consider HIV infection as a predisposing cause of childhood cancer, especially NHL.     

Ectopic pregnancy: a malpractice paradigm

Subtle sonographic findings and other nonspecific clinical presentations often lead to missed diagnoses that can have significant legal implications. This communication discusses current diagnostic and laboratory methods used to evaluate patients with a suspected ectopic pregnancy in light of the concepts of "missed lesions" as they relate to negligence and malpractice theory.     

Multicentre dose-ranging study on the efficacy of USPIO ferumoxtran-10 for liver MR imaging

AIM: A dose ranging multicentre phase-II clinical trial was conducted to evaluate the efficacy of ultrasmall superparamagnetic iron oxide (USPIO) ferumoxtran-10 for magnetic resonance (MR) imaging of focal hepatic lesions. MATERIAL AND METHODS: Ninety-nine patients with focal liver lesions received USPIO at a dose of 0.8 (n = 35), 1.1 (n = 32), or 1.7 (n = 32) mg Fe/kg. Liver MR imaging was performed before and after USPIO with T1-weighted and T2-weighted pulse sequences. Images were analysed by two independent readers for additional information (lesion detection, exclusion, characterization and patient management). Signal intensity (SI) based quantitative measurements were also taken. RESULTS: Post-contrast medium MR imaging showed additional information in 71/97 patients (73%) for reader one and 83/96 patients (86%) for reader two. The results with all three doses were statistically significant (P < 0.05). Signal intensity analysis revealed that all three doses increased liver SI on T1-weighted images and decreased liver SI on T2-weighted images. On T2-weighted images metastases increased in contrast relative to normal hepatic parenchyma whereas haemangiomas decreased in contrast. On T2-weighted images there was statistically improved efficacy at the intermediate dose, which did not improve at the highest dose. CONCLUSION: Ultrasmall superparamagnetic iron oxide was an effective contrast agent for liver MR imaging at all doses and a dose of 1.1 mg Fe/kg was recommended for future clinical trials.     

Alternative or additional diagnoses on unenhanced helical computed tomography for suspected renal colic: experience with 1000 consecutive examinations

OBJECTIVES: To determine the incidence and spectrum of significant alternative or additional diagnoses established or suggested on unenhanced helical computed tomography (CT) in a large series of patients with suspected renal colic. METHODS: One thousand consecutive unenhanced helical CT examinations were performed for suspected renal colic. All official CT reports were retrospectively reviewed, which was followed by review of all available relevant follow-up radiology reports. A selected image and chart review was also performed. RESULTS: Ureteral calculi were identified on 557 examinations, findings consistent with a recently passed stone were discovered on 67 examinations, and 275 CT examinations were unremarkable. An alternative or additional diagnosis was established or suggested on 101 examinations, including in 26 patients with concurrent ureteral calculi. There were 62 genitourinary and 39 nongenitourinary tract diagnoses. Eighty-seven of the diagnoses could be confirmed on retrospective image review combined with patient follow-up. There were two false-positive diagnoses for significant, alternative pathologic findings. CONCLUSIONS: A wide spectrum of significant, alternative, and additional genitourinary and nongenitourinary diagnoses can be reliably established or suggested on unenhanced helical CT performed for suspected renal colic. These abnormalities were identified in 10% of cases in this series of 1000 consecutive CT examinations.     

Amphetamine and fenproporex levels following multidose administration of fenproporex.

Drugs that are metabolized to amphetamine or methamphetamine are potentially of significant concern in the interpretation of positive drug-testing results for amphetamines. A number of different drugs have been reported to produce amphetamine in the urine of users. One of these compounds, fenproporex, has been shown to be metabolized to amphetamine, and previous reports indicated the parent compound could be detected at low levels for up to 48 h. Administration of fenproporex for seven days (one 10-mg dose per day) to five healthy volunteers resulted in amphetamine being detected in the urine of all subjects. Peak concentrations of amphetamine ranged from approximately 2850 to 4150 ng/mL. Amphetamine could be detected (> or = 5 ng/mL) in the urine for up to nearly 170 h after the last dose. Analysis of the metabolically produced amphetamine showed the presence of both enantiomers, which can be helpful in the differentiation of some illicit amphetamine use from the use of this precursor drug. In addition, evaluation of the enantiomeric composition of the metabolite (amphetamine) can be a valuable tool in the interpretation of time since last dose. More significantly, all samples that contained amphetamine at a concentration of > or = 500 ng/mL were shown to also contain detectable amounts of the parent compound.     

Index for US state tobacco control initial outcomes

Public health tobacco control efforts have increasingly targeted communities in addition to individuals. Before population smoking decreases, effectiveness might be detected from initial outcomes reflecting these efforts, such as higher cigarette prices or more workplace and home smoking restrictions. Presumably, these initial outcomes will eventually influence smoking behavior. State-specific estimates of percentages of the population working or living under smoking bans are available from the 1992-1993 tobacco use supplement to the Current Population Survey, conducted annually by the US Bureau of the Census. In addition, the tobacco industry reports the average state cigarette price yearly. The authors constructed a tobacco control initial outcomes index (IOI) by using values of these variables for each state and correlated it with state-specific adult (aged > or =25 years) and youth (aged 15-24 years) smoking prevalence computed from the Current Population Survey and per capita cigarette consumption data computed from sales and Census Bureau data. Both adult smoking prevalence (r = -0.70) and per capita consumption (r = -0.73) were significantly correlated with the IOI; youth smoking prevalence correlated less well (r = -0.34). Although the analysis is not definitive, deseasonalized 1983-1997 consumption trends for IOI-based tertile groups were divergent beginning in 1993, with the high IOI group showing the greatest decrease. A high relative IOI index may be predictive of future smoking decreases and should be considered when tobacco control efforts are evaluated.     

Opportunities for improving inpatient smoking cessation programs: a community hospital experience

BACKGROUND: This cohort study examined the role of smoking during hospitalization, duration of cessation counseling, patient awareness of the hospital's smoke-free policy, belief that smoking is associated with a current symptom or disease, and the presence of withdrawal symptoms with 12-month smoking cessation among inpatients enrolled in a smoking cessation program. METHODS: Inpatients in four community hospitals (N = 1,317) participated in a smoking cessation intervention consisting of face-to-face counseling at baseline and four follow-up counseling phone calls. Patients were classified as nonsmokers only if they reported not smoking at both the 6- and the 12-month interviews. All patients lost to follow-up were considered smokers. RESULTS: At 1 year the smoking cessation rate was 22.5%. Cessation was independently associated with reporting no smoking during hospitalization, noting no withdrawal symptoms at baseline, and believing that a current illness or symptom is related to smoking. Length of counseling interview and awareness of the hospital's smoke-free policy were not independently associated with cessation. CONCLUSIONS. Smoking cessation programs and hospital policies that decrease smoking during hospitalization, address withdrawal symptoms during hospitalization, and make clear the connection between a patient's health and cigarette smoking may increase the effectiveness of their smoking cessation efforts.