They just don't get enough! Variable intern experience in bedside procedural skills.

BACKGROUND: Medical school and resident training programmes offer different learning opportunities and outcomes. The aim of the study was to assess medical student and intern experience in common clinical procedures. METHODS: Interns employed in a metropolitan teaching hospital from 2000 to 2004 completed a survey of experience and confidence in clinical procedures at the beginning and end of their intern year. Attendance at and the contribution to procedural confidence of a voluntary procedural skill-training programme were examined. RESULTS: For the 314 interns, clinical experience before and during internship varied for each procedure and between year cohorts as did training programme attendance (44-84%). Student procedural confidence was predicted by pre-intern experience either on patients or by simulation (beta = 0.17, 95% confidence interval (CI) 0.02-0.21, P = 0.03) and age >30 years on commencing internship (beta = 8.44, 95%CI 3.03-14.06, P = 0.003. Adjusted R(2) = 0.08, P = 0.002). Intern procedural confidence by year's end was predicted by attendance at the training programme (beta = 0.48, 95%CI 0.34-0.62, P < 0.001), intern experience with patient procedures (beta = 0.34, 95%CI 0.21-0.47, P < 0.001) and a clear decision to enter a postgraduate training programme (beta = 0.13, 95%CI 0.04-0.22, P = 0.007, Adjusted R(2) = 0.50, P < 0.001). CONCLUSION: Interns and students receive variable experience to carry out procedural skills on patients. This makes designing training programmes difficult as training needs vary each year. Both mandatory supervision of key skills and opportunities to supplement limited experience are needed during the intern year to ensure a uniform experience.

Relative dispersion of intravascular transit times during isolated human limb perfusions for recurrent melanoma.

AIMS: We have characterized the relative dispersion of vascular and extravascular markers in the limbs of three patients undergoing isolated limb perfusions with the cytotoxic melphalan for recurrent malignant melanoma both before and after melphalan dosing. METHODS: A bolus of injectate containing [51Cr] labelled red blood cells, [14C]-sucrose and [3H]-water was injected into an iliac or femoral artery and outflow samples collected at 1 s intervals by a fraction collector. The radioactivity due to each isotype was analysed by either gamma [51Cr] or beta [14C and 3H] counting. The moments of the outflow fraction-time profiles were estimated by a nonparametric (numerical integration) method and a parametric model (sum of two inverse Gaussian functions). RESULTS: The availability, mean transit time and normalised variance (CV2) obtained for labelled red blood cells, sucrose and water were similar before and after melphalan dosing and with the two methods of calculation but varied between the patients. CONCLUSIONS: The vascular space is not well-stirred but characterized by a CV2 similar that reported previously for in situ rat hind limb and rat liver perfusions. A flow-limited blood-tissue exchange was observed for the permeating indicators. Administration of melphalan did not influence the distribution characteristics of the indicators.

Comparison of injury during cadet basic training by gender.

OBJECTIVES: To describe the rate and distribution of injuries during basic training in male and female cadets and to assess the contribution of pretraining conditioning and height to the male-female differential in injuries. DESIGN: Cohort study. SETTING: The US Military Academy, West Point, NY. PARTICIPANTS: A total of 558 cadets from the class of 1995 at the US Military Academy. MAIN OUTCOME MEASURES: The rate of injuries resulting in 1 or more days excused from physical activities per 100 cadets and the rate of injuries resulting in hospitalization of 1 night or longer per 100 cadets. RESULTS: Women had 2.5 times the rate of injuries as men and 3.9 times the rate of injuries resulting in hospitalization. Women had significantly more stress fractures and stress reactions than men. The median number of days excused from physical activities for women's injuries was significantly higher than that from men's injuries. Pretraining conditioning, measured by performance on a 2-mile (3.2-km) run, accounted for approximately half the difference in rates of injuries between men and women; differences in height among men and women did not account for differences in injury rates. CONCLUSIONS: The women had a higher risk for injury during military training than men. Increased pretraining conditioning may substantially decrease the risk for injury.

Serial measures of plasma homocyst(e)ine after acute myocardial infarction.

To determine whether plasma levels of homocyst(e)ine are affected by the acute phase response, we studied 10 subjects serially after acute myocardial infarction. Our data indicate that measurement of homocyst(e)ine in patients with myocardial infarction should ideally be deferred for 7 days if spuriously low levels are to be averted.

Hyperthermic isolated limb perfusion for malignant melanoma: response and survival.

Response to and survival after hyperthermic isolated limb perfusion (HILP) with melphalan in patients with malignant melanoma at the Royal Brisbane Hospital were reviewed in order to assess the major determinants of response to treatment. Data were collected by clinical chart review and direct patient contact. Response was assessed by clinical observation and measurement of nodules. Survival was calculated from the date of perfusion to the date of patient death. Since 1965 there have been 85 patients (38 men, 47 women) who have undergone 109 limb (102 leg, 7 arm) perfusions. The mean age was 58 years (range 32-82 years). The number of patients per disease stage (M.D. Anderson classification) was as follows: stage I, 5 patients; stage II, 8 patients; stage IIIa, 41 patients; stage IIIab, 25 patients; and stage IIIb, 8 patients. The mean duration of perfusion was 81 minutes. Melphalan was given in divided doses, with a mean total dose 1.39 mg/kg. The mean maximal limb temperature was 41.5 degrees C. Major complications occurred during 20 perfusions (18%). There was one postoperative death from myocardial infarction, and one patient required amputation. Median patient follow-up was 2.65 years (range 1-27 years). A complete response was noted in 34 patients (40%), a partial response in 36 patients (42%), and no response in 11 patients (13%). Response could not be assessed in four patients. The actuarial 5-year survival for the whole group was 45%: stage I, 80%; stage II, 75%; stage IIIa, 44%; stage IIIab, 23%; stage IIIb, 56%. The two significant determinants of response to perfusion were disease stage (p = 0.00005) and nodal status (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Health care delivery system in Australia and its effect on surgical education and training.

Surgical education and training in Australia and New Zealand are based on 6-year undergraduate medical curricula covering the scientific foundations of medical practice. One-year rotating internships are required in all states of Australia to allow medical graduates to satisfy statutory requirements for completing basic medical education prior to gaining credit for training within a specialty. The Royal Australasian College of Surgeons defines the duration and content of training as well as the standards of supervision and guidance that enable surgical trainees to satisfy the requirements leading to Fellowship of the Royal Australasian College of Surgeons. Licensing authorities in several states and the Commonwealth of Australia recognize the award of Fellowship of the Royal Australasian College of Surgeons as sufficient evidence of competence to practice as a specialist surgeon. No formal process of recertification of surgical competence has yet been promulgated in Australia.

Two cases of pseudo-aneurysm of the gastroduodenal artery.

Pseudo-aneurysm of the gastroduodenal artery is a rare cause of bleeding-complicated pancreatitis. The use of computerized tomography and angiography lead to early diagnosis. The key to surgical treatment is arterial inflow occlusion prior to opening the aneurysm.

The Martin Titanline arterial clamp. A new lightweight alternative.

When haemostatic clamps are applied, evidence of injury at the site of clamp application may be seen when the clamp is removed. Rarely, the intima may be disrupted. When a new arterial clamp became available, a study was designed to compare the Martin Titanline arterial clamp (13-143-35, curved arterial clamp) with several other arterial clamps already in use. The Martin clamp is a modified pivot-point, preset-tension, spring-controlled arterial clamp. The closing pressures of several clamps were measured objectively. The injury produced when the clamps were applied to occlude the blood flow on the carotid artery of a dog was assessed by histological study of the excised segments of the arterial wall. Histological cross-sections were prepared from canine carotid artery which had been perfused for 1 h after the clamp had been applied for 1 h. Histological evidence of injury was limited to disruption of the intimal layer and compression of the medial layer. No significant difference between the amount of damage caused by the DeBakey, Satinsky or Martin clamp was identified. When compared to the other varieties of clamp listed above, the Martin clamp had a significantly lower closing pressure (304 g) compared with 580g (Bulldog), 580 g (Satinsky), and 686 g (DeBakey). The Martin clamp was easier to apply, did not obstruct the operative field as readily and had good clamp-retention characteristics throughout the procedure.

A puborectal sling in the management of anal incontinence and rectal prolapse.

A review is presented of 11 years experience in the use of a synthetic puborectal sling in the treatment of rectal prolapse and faecal incontinence. This perineal approach operation has been performed on 24 patients from 1973 to 1984. In over 60% of the patients rectal prolapse and anal incontinence were controlled.

Portal vein perfusion of the isolated rat liver: some markers of hyperthermic liver damage.

The cytotoxic effects of hyperthermia on tumours are readily measured. Parameters of injury to normal tissues are needed to evaluate therapeutic potential. Fifty-five isolated rat livers were perfused in vitro for 180 min in order to determine parameters of hyperthermic injury. During this period they were heated for 1 h at temperatures ranging from 37 degrees to 45 degrees and then assessed for evidence of hyperthermic injury. The most critical indicator of hyperthermic injury was sustained depression of bile production. Bile secretion decreased by 80% after heating at temperatures above 42 degrees. Aspartate amino transferase (AST) release increased significantly at temperatures of 42 degrees and above. Potassium and variable amounts of glucose were released into the medium during heating, reflecting temporary changes in metabolism at high temperatures.

An electron microscopic study of the mode of donor cell death in unmodified rejection of pig liver allografts.

The only type of cell death found in pig liver allografts 1 week after technically successful operation was apoptosis. Its extent paralleled the degree of mononuclear cell infiltration of the liver parenchyma, and mononuclear cells were found applied to the surfaces of hepatocytes showing early stages of the process. The results suggest that cellular immune attack induces apoptosis of donor cells, and that the action is a direct one. However, implication of other factors such as vascular damage in the induction of apoptosis in the grafts could not be excluded.

An improved M.B., B.S., "final" examination in surgery.

A new final year examination in surgery has been devised. It consists of a clinical assessment made by a surgical tutor over a period of six weeks throughout a student's surgical term, a visual, clinically orientated written examination a "spotter-type" practical examination and a viva-voce examination. Correlation with students' previous performances has been good and the examination appears to have solved many of the problems which necessitated its development.

Experimental coronary occlusion in calves: the effect of hyperglycaemia on ventricular fibrillation threshold.

Measurements of ventricular fibrillation threshold (VFT) were made in two groups of bovine calves, each weighing 25 to 30 kg, before and after ligation of the anterior descending branch of the coronary artery. In the control group, the VFT was determined before occlusion of the anterior descending coronary artery, and the observations were repeated at 20-minute intervals after occlusion. A 33% reduction in VFT was observed 20 minutes after the occlusion. Prior loading with glucose by infusion of 100 ml of 10% glucose prevented the significant fall in VFT.

Early jaundice after pig liver transplantation.

Of a series of pigs surviving orthotopic liver allotransplantation with end-to-end anastomosis of the bile duct, 70% were noted to be jaundiced at the end of the first week after transplantation. Seven animals in a subsequent series were investigated biochemically, but operative cholangiography, and by liver biopsy seven days after transplantation, when the jaundice was maximal. There was definite cholangiographic obstruction in only one animal, and this finding was subsequently confirmed at autopsy. This was also the only animal in which bile culture was positive. Jaundiced animals appeared to have more marked histological evidence of rejection than non-jaundiced ones. The jaundice was probably a result of transient rejection and usually resolved spontaneously without immunosuppression.

Changes in Left Ventricular Function Produced by Excision of a Myocardial Infarct.

Left ventricular function has been measured in calves before and after the production of a myocardial infarct by ligation of the anterior descending coronary artery. In 20 animals function was measured after the area of the acute infarct had been excised and the left ventricle repaired by direct suture. Infarcts equal to 20% of the left ventricle were found to impair left ventricular function, and significant immediate improvement in function was measured in one-third of the animals in which an infarct was resected.