Study of patients with community-acquired abscesses.

BACKGROUND: Abscess incision and drainage (I&D) operations form the bulk of surgical procedures in the emergency department (ED). Nevertheless, epidemiologic, clinical, and bacteriology data are lacking for patients with abscesses presenting at Sudanese hospitals. Information also is unavailable on the magnitude of the problem of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and its susceptibility to the most commonly used antibiotics. Our objectives were (1) to identify and document the epidemiologic and clinical variables of patients with superficial abscesses; (2) to isolate the causative organism(s) from the pus and determine their antibiotic sensitivity; (3) to determine the prevalence of CA-MRSA and its antibiotic susceptibility; and (4) to audit our practice of I&D of abscesses. METHODS: A prospective observational study, involving a convenience sample of patients who presented with community-acquired skin and soft tissue (superficial) abscesses to a single unit at Khartoum North Teaching Hospital (KNTH) ED, was done for the years 2009-2010. A pro-forma was designed to record the personal, epidemiologic, and clinical data of each patient. All I&D operations were performed as day cases. Swabs of pus drained from the abscess were sent to the laboratory for culture. Isolates underwent sensitivity testing against the most commonly used antibiotics. RESULTS: A total of 248 patients were included. The majority (84%) were younger than 40 years of age. There were twice as many male as female patients (69% vs. 31%, respectively). The majority of patients did not have a known predisposing factor, but 13% had a history of an abscess. A history of trauma was found in 27% of the patients, whereas diabetes mellitus was found in only 6%. The most common site of the abscess was the upper limb (46%) followed by the lower limb (20%). Most (85%) of the abscesses were drained under local anesthesia. Sensitivity tests were performed on 151 pus isolates. No growth was obtained in 28 (18.5%) of the specimens. Of the 123 specimens yielding growth, S. aureus was the most common organism (90%), followed by Klebsiella spp. (6.5%). The proportion of CA-MRSA was 24%. Many of these S. aureus isolates were resistant to other antibiotics also. CONCLUSION: This study documents some epidemiologic and bacteriological data on one of the most common surgical problems. We found a substantial proportion of the infecting organisms to be CA-MRSA. This reflects the abuse of antibiotics in the community and stresses the importance of health education. Standardized surgical and anesthetic guidelines should be followed for I&D of abscesses to avoid recurrence. Further studies are needed urgently.

Use of computer-based clinical examination to assess medical students in surgery.

INTRODUCTION: To improve the viewing of the video-projected structured clinical examination (ViPSCE), we developed a computerized version; the computer-based clinical examination (CCE). This was used to assess medical students' higher knowledge and problem solving skills in surgery. We present how we did this, test score descriptive statistics, and the students' evaluation of the CCE. METHODS: A CCE in surgery was administered to assess a class of 43 final year medical students at the end of their surgical clerkship. Like the ViPSCE, the exam was delivered as a slide show, using a PowerPoint computer program. However, instead of projecting it onto a screen, each student used a computer. There were 20 slides containing either still photos or short video clips of clinical situations in surgery. The students answered by hand writing on the exam papers. At the end, they completed evaluation forms. The exam papers were corrected manually. Test score descriptive statistics were calculated and correlated with the students' scores in other exams in surgery. RESULTS: Administration of the CCE was straightforward. The test scores were normally distributed (mean = median = 4.9). They correlated significantly with the total scores obtained by the students in surgery (r = 0.68), and with each of the other exam modalities in surgery, such as the multiple choice and structured essay questions. Acceptability of the CCE to the students was high and they recommended the use of the CCE in other departments. DISCUSSION: CCE is feasible and popular with students. It inherits the validity and reliability of the ViPSCE with the added advantage of improving the viewing of the slides.

Optimising laparoscopic cholangiography time using a simple cannulation technique.

BACKGROUND: Opponents of the routine use of intraoperative cholangiography (IOC) express concern over its technical difficulty and the length of time it takes. AIM: To evaluate the impact of our cystic duct cannulation (CDC) technique, as implemented by one consultant and his trainees, on the IOC time. METHODS: IOC is done routinely in all the laparoscopic cholecystectomies (LCs) undertaken in our unit. We carried out a prospective audit over a period of 18 months, recording the IOC time in consecutive patients undergoing laparoscopic cholangiography (LC) with and without laparoscopic common bile duct exploration (LCBDE). The total IOC time was considered to consist of two components: cystic duct cannulation (CDC) time and fluoroscopy time. The IOC time was further analysed according to the difficulty of cannulation and the operator experience. Special consideration was given to the LCBDE cases. We also describe the detailed steps of our CDC technique. RESULTS: Over a period of 18 months 243 patients underwent LC. IOC was completed in 240 patients (98.8% success rate). Of those, 194 were females (81%). The mean age was 50 years (range 18-85 years). The mean total IOC time was 6 min, with a CDC time of 2 min, and fluoroscopy time of 4 min. On further analysis, CDC was considered easy in 86% of cases with a mean CDC time of 1.5 min and total IOC time of 4.3 min. When cannulation was difficult (14% of cases) a cholangiography clamp had to be used to prevent leakage of contrast. In difficult cases, the CDC and IOC mean times were 5 and 8.5 min, respectively. As would be expected, trainees spent more time performing cannulation and completing the IOC than the specialist surgeon (3.8 versus 1.8 min, and 7.2 versus 5.6 min, respectively). These differences were statistically but not clinically significant. Similarly, the IOC time was also significantly increased in LCBDE (13 min). This was mainly due to an increase in fluoroscopy time (10 min) rather than CDC time (3 min). CONCLUSION: The IOC time could be optimised by using a simple and learnable cannulation technique to less than 5 min in most LCs. Surgeons should not, therefore, refrain from using this important investigation on selective or routine basis, subject to their policy for dealing with patients with suspected bile duct stones.

Use of Video-Projected Structured Clinical Examination (ViPSCE) instead of the traditional oral (Viva) examination in the assessment of final year medical students.

CONTEXT & BACKGROUND: Assessment of medical students using the traditional oral (viva) system has been marred by being highly subjective, non-structured, and biased. The use of the objective structured clinical examination (OSCE) would circumvent these disadvantages. The OSCE is, however, costly and time-consuming particularly if used for assessment of large numbers of students. The need for another form of examination that enjoys the advantages of the OSCE while avoiding its disadvantages in the face of limited resources has been the inspiration behind this innovative approach. OBJECTIVES: (1) To identify the characteristics of the new Video-Projected Structured Clinical Examination (ViPSCE). (2) To compare the acceptability of ViPSCE and OSCE by students and tutors. (3) To compare the time-effectiveness of ViPSCE and OSCE. METHODS: We used a slide video projection to assess the surgical knowledge, problem solving and management abilities of 112 final year medical students at Alazhari University, Khartoum, Sudan. Students completed evaluation forms at the end of the examination. RESULTS: The administration of the ViPSCE was smooth and straightforward. Feedback of the students showed that they preferred the ViPSCE to both traditional oral (viva) examination and OSCE. The examination time was 2 hours using video projection compared to the 6 hours that it used to take a class of 112 students to complete a classical OSCE. CONCLUSION: The ViPSCE is a better replacement for the traditional oral exam. It is much less time- consuming than traditional OSCE.