Surgery in Oman

During the past 3 decades, Oman (a sultanate), a country with deep-rooted history, culture, and traditions, has undergone a remarkable transformation and modernization in all fields, including education and health care. It has progressively established a nationwide network of modern health services that are accessible even at the village level and have ranked Oman with the developed world. More than 300 surgeons provide a full range of surgical services for a population of 2.5 million. Medical education is firmly established, and accredited surgical residency training has assumed increasing importance during the past decade. Given the sustained growth and dynamic planning, the surgical services will continue to develop, with Omani surgeons playing an increasing role in the future.     

Validating three-dimensional imaging of the breast

The potential to extrapolate accurate data from 3-dimensional (3D) images of the breast is enormous and will greatly improve our ability to qualitatively determine differences in shape, size, and contour. The validity of these calculated measurements is important and needs to be determined before any meaningful data can be evaluated. PART I: Premastectomy 3D images (3dMD patient) were obtained on 19 breasts (14 patients). The volume of the mastectomy specimen was determined intraoperatively using water displacement. Two independent raters then calculated breast volumes using the 3D images and software, and these were compared with the intraoperative volume. Inter- and intrarater reliability was determined. Part II: Surface measurements (nipple to notch) were then evaluated on 20 breasts (10 patients) by comparing the 3D image determined distance to the known measurements. PART I: The average breast volume was 500 mL, compared with 489 mL for rater 1 and 490 mL for rater 2. The relative difference between the measured volume and the calculated volume for rater 1 and rater 2 was about -2%, with a standard deviation of +/- 13% to 16%. The coefficient of reproducibility for each reader was excellent, at 0.80 for rater 1 and 0.92 for rater 2. The level of agreement between the readers was also high at 0.975. Part II: The average nipple to notch measurement for each patient was 27.1 cm, compared the calculated average of 25.1 cm for rater 1 and 26.1 cm for rater 2. The mean relative difference between the measured and calculated distances for raters 1 and 2 was about -6%, with a standard deviation of +/- 6% to 7%. The level of agreement between readers was high, at 0.975. The ability to objectively determine breast volume and surface measurements using 3D imaging technology is now available with consistent and reproducible accuracy. Measurements are typically underestimated, with more variability when calculating volumes. Although inherent subjectivity will always exist when evaluating breast measurements, 3D technology provides invaluable information, particularly in the longitudinal evaluation of results.     

Adapting the randomized consent (Zelen) design for trials of behavioural interventions for chronic disease: feasibility study

OBJECTIVES: Standard randomized controlled trials of interventions for chronic conditions that involve behavioural change, or that are highly desired by participants, are difficult to undertake because of problems with recruitment and contamination. Alternatives include cluster-randomized trials or pre-randomization designs such as the Zelen design. The aim here was to develop a pre-randomization design that would overcome ethical and methodological problems associated with the conventional Zelen design, and permit the rigorous evaluation of a complex package of care, involving physical therapy and behavioural changes, for patients with painful patello-femoral osteoarthritis of the knee joint. METHODS: Eligible patients were first consented to a one-year observational study of their arthritis. They were subsequently randomized into intervention and control arms. Those in the intervention arm were then asked if they were willing to participate in a further study involving regular sessions with a physiotherapist. Those in the control arm were not told about this, but were followed up as agreed. RESULTS: Eighty-seven patients consented to the observational study, 43 of whom were subsequently randomized to the intervention arm. All 43 consented to the intervention, although five of these did not receive the full package of care. Assessments were carried out at five months and one year on 82 patients, and concealment was satisfactorily maintained in the majority. CONCLUSIONS: We conclude that this study design could potentially offer an acceptable compromise between the need for scientific rigour and the ethical imperative of fully informed consent in trials that involve behavioural change or interventions that patients might want to obtain.     

Individual variation in daily dosage requirements for phenytoin sodium in patients with epilepsy.

1 Ninety adult patients receiving phenytoin sodium were studied prospectively in an epileptic centre. Serum concentrations of phenytoin under steady state conditions were measured by gas liquid chromatography. When clinically indicated the daily dosage rate was adjusted by 50 mg steps until a serum concentration of 10--20 mg/l was produced. 2 Concentrations within the above range were obtained in 50 patients; the required dosage rate varied from 200--500 mg/day. Twenty-five clinical, biochemical and haematological attributes were recorded for each patient and tested for correlation with dosage requirement. 3 The dosage requirement correlated most strongly (r = 0.57, P less than 0.001) with body surface area. This relationship (approximately 200 mg/day per m2) accounted however for only one third of the total dosage variance. 4 Amongst 18 patients receiving simultaneous treatment with phenobarbitone, the effective plasma clearance of this drug taken in conjunction with body surface area accounted for a significantly greater proportion of the total dosage variance. Multiple regression analysis failed to reveal other, more widely applicable predictors of individual phenytoin dosage requirements.