Surgical educator preferences regarding key objective structured clinical examination topics.

BACKGROUND: Numerous methods are used for assessing the performance of surgical residents and students. Unfortunately, these same methods are often unsatisfactory. One technique that is gaining increased favor is the Objective Structured Clinical Examination (OSCE). It is unclear what areas of evaluation might best be included in such an examination so as to optimize its value. Therefore, this study evaluated the opinions of an international body of surgical educators. METHODS: A survey was distributed to 674 attending surgical educators; it asked respondents to select and rank the five most important topics from four areas. These areas included 84 topics from History Taking, Physical Examination, Data Interpretation, and Surgical Technique. A weighted score was calculated for each topic by assigning points according to a Likert scale ranking. RESULTS: Among 674 surveys distributed, 243 responses (36.1%) were received; 25 of the 243 responses were excluded, for a usable response rate of 218/674 (32.3%). The five highest ranked topics were (History Taking) "abdominal pain" 29.2%, "breast mass" 10.8%, "gastrointestinal bleeding" 8.5%, "bowel obstruction" 8.5%, "trauma" 7.2%; (Physical Examination) "acute abdomen" 28.9%, "trauma survey" 18.2%, "breast examination" 15.8%, "peripheral vascular" 8.9%, "cardiopulmonary" 7.5%; (Data Interpretation) "chest X ray" 21%, "abdominal series" 20.2%, "CT scan" 19.6%, "mammogram" 10.1%, "cervical spine films" 5.2%; and (Surgical Technique) "central line" 16.1%, "basic suture skills" 14.2%, "bowel anastomosis" 8.0%, "informed consent" 7.9%, "intubation" 6.4%. CONCLUSION: This survey offers useful data regarding those skills viewed as most important by experienced surgical educators, and offers guidelines for composition of surgical OSCEs.

Objective Structured Clinical Examination technical skill stations correlate more closely with postgraduate year level than do clinical skill stations.

Validity of an examination format is supported by its ability to distinguish levels of training among examinees. The Objective Structured Clinical Examination (OSCE) is a developing format generally composed of various types of task-oriented stations used to evaluate clinical skills of students and residents. The ideal composition of OSCE stations to maximize validity has not been determined. We examined the relative correlation between selected types of stations and level of resident postgraduate year (PGY). A 12-station OSCE was administered to surgical residents of all PGY levels at a university program. Individual station scores were correlated with PGY level. The overall correlation of the total examination score with PGY level was good (R = 0.681). Technical skill stations exhibited a significantly greater correlation with PGY level (0.679 vs 0.203) as compared with clinical skill stations (P < 0.05). These data suggest that technical skill evaluation is more sensitive in distinguishing level of training of surgical residents than is clinical skill evaluation.

Strain differences in neointimal hyperplasia in the rat.

We performed an initial screen of 11 rat strains by use of a standard balloon injury to the left iliac artery to observe whether genetically determined differences existed in the development of neointimal hyperplasia. Neointimal hyperplasia was assayed 8 weeks after the vascular injury on coded microscopic sections. Statistically significant differences in the percentages of the vascular wall cross-sectional areas composed of intima (percentage intima) secondary to neointimal hyperplasia were noted among the different rat strains (P<0.02), with the Brown-Norway (BN), Dark Agouti, and Milan normotensive strain rats having the highest and the spontaneously hypertensive rats (SHR) having the lowest percentages of intima. In a separate experiment, F1 hybrids of SHRxBN strains and parental BN and SHR underwent the vascular injury, and the parental strains again showed a statistically significant difference from one another in the mean percentage of intima (P<0. 0001). The F1 hybrids showed an average percentage of intima intermediate between those of the parental strains. The average lumen size of the injured BN vessels were significantly smaller than that of the noninjured control vessels (P=0.044), but this significance disappeared when the circular areas of these vessels were calculated without taking neointimal growth into consideration (P=0.649). These results provide the groundwork for a genetic linkage analysis to identify the genes that influence the development of neointimal hyperplasia after vascular injury.

Nonheartbeating cadaveric organ donation.

OBJECTIVE: The authors evaluated the potential use of nonheartbeating (NHB) cadaver donors as an additional source to the current supply of brain-dead cadaver donors. SUMMARY BACKGROUND DATA: The numbers of cadaveric donors has not increased significantly during the last 5 years, despite a rising need for transplantable organs. Any improvement in cadaveric organ procurement will depend on the use of previously unrecognized potential donors. METHODS: During a 2-year period, 24 kidneys were retrieved from 12 NHB donors. Nineteen kidneys were transplanted. RESULTS: These kidneys sustained a mean warm ischemia time of 26 minutes (range 20-35 min). A mean lowest creatinine level of 2.0 mg/dL, (range 1.1-3.0 mg/dL), the rate of postoperative dialysis (22%), and a 1-year graft survival rate of 76% for kidneys from NHB-donated kidneys compare favorably to expected results achieved nationally from brain-dead cadaveric donors. CONCLUSIONS: Nonheartbeating donor kidneys can yield acceptable graft function and be of no disadvantage to recipients of cadaver transplants.

Analysis of a new technique to stabilize the chronic peritoneal dialysis catheter.

A significant cause of morbidity for peritoneal dialysis patients is catheter dysfunction. In our experience, the most common cause of catheter dysfunction was cephalad migration of the catheter tip out of the true pelvis. A new technique for catheter placement that reduces catheter migration from 35% to 6% (P less than .01 chi 2) is described. Our results demonstrate that peritoneal catheters which dysfunction because of catheter flip generally do so in the first 3 months.

Clinical significance of antimonocyte antibody in kidney transplant recipients.

Monocytes appear to contain an antigen system very similar to the "cell-specific" antigen system previously identified on the vascular endothelial cell (VEC). By using a crossmatch technique with monocytes as the target cell, we tested for the presence of antibody to donor vascular endothelial cell antigens in kidney transplantation recipients, as well as performed mixed lymphocyte cultures, and T and B cytotoxicity testing. This technique detected clinically significant sensitization in some (living related) donor-recipient combinations not detected with standard T and B lymphocyte techniques. Patients with positive monocyte crossmatches but negative T or B lymphocyte crossmatches have a very high incidence of severe rejection and graft failure.

Adult hypertrophic pyloric stenosis. Report of an unusual case detected by saline load test.

A case of adult idiopathic hypertropic pyloric stenosis whose radiographic study was repeatedly normal is presented. Only a functional test of gastric emptying disclosed the degree of outlet obstruction present. Vagotomy and pyloroplasty resulted in prolonged relief of obstructive symptoms and a return of the saline load test to normal. The saline load test may be of value when gastroduodenal x-rays or endoscopy do not reveal the cause or extent of gastric outlet obstruction.

Glomerular basement membrane--reactive antibody in anti-lymphocyte globulin.

Equine immunoglobulin was detected along the glomerular basement membrane of three human homograft recipients who had been treated with equine anti-lymphocyte globulin. Anti-lymphocyte globulins, given these patients, were obtained by immunization of horses with lymphocytes from human spleens and/or lymph nodes and contained glomerular basement membrane-reactive antibodies. Quantitative paired-label isotope experiments (in rats) demonstrated that 30-170 mug/ml of kidney-fixing antibodies were present in these preparations. The anti-lymphocyte globulins formed a line of identity with a sheep anti-human glomerular basement serum when reacted against collagenase-solubilized human glomerular basement membrane in double diffusion in agar. The renal fixation of these antibodies was blocked by absorption with human glomerular basement membrane, but not by buffy-coat leukocytes, indicating that they were directed specifically toward antigens in the basement membrane and were not cross-reacting anti-lymphocyte antibodies. Anti-lymphocyte globulin preparations for human use were studied for glomerular basement membrane-reactive antibodies by a direct immunofluorescent assay in rats. Anti-lymphocyte globulin from 13 of 20 horses, and 7 of 10 serum pools from horses immunized with lymphocytes derived from solid lymphoid organs (spleen, thymus, lymph node, tonsil), contained glomerular basement membrane-reactive antibodies. Sera from 18 horses injected with thoracic duct cells or cultured lymphoblasts had no glomerular basement membrane-reactive antibodies. An equine anti-human thymus serum containing glomerular basement membrane-reactive antibodies, which produced fatal glomerulonephritis in monkeys, was shown to cause both immediate and delayed glomerular injury in monkeys after intravenous injection. The reaction of this antibody with glomerular basement membrane in vivo was associated with little complement deposition in spite of the fact that the antibody could fix complement. This lack of glomerular complement fixation resulted from almost complete in vivo decomplementation of the monkeys receiving this anti-lymphocyte globulin.