The urban stormwater farm.

Currently more than 3 billion people live in urban areas. The urban population is predicted to increase by a further 3 billion by 2050. Rising oil prices, unreliable rainfall and natural disasters have all contributed to a rise in global food prices. Food security is becoming an increasingly important issue for many nations. There is also a growing awareness of both 'food miles' and 'virtual water'. Food miles and virtual water are concepts that describe the amount of embodied energy and water that is inherent in the food and other goods we consume. Growing urban agglomerations have been widely shown to consume vast quantities of energy and water whilst emitting harmful quantities of wastewater and stormwater runoff through the creation of massive impervious areas. In this paper it is proposed that there is an efficient way of simultaneously addressing the problems of food security, carbon emissions and stormwater pollution. Through a case study we demonstrate how it is possible to harvest and store stormwater from densely populated urban areas and use it to produce food at relatively low costs. This reduces food miles (carbon emissions) and virtual water consumption and serves to highlight the need for more sustainable land-use planning.

Attrition in graduate surgical education: an analysis of the 1993 entering cohort of surgical residents.

BACKGROUND: Pyramidal surgical residency programs, in which more residents are enrolled than can complete the program, have gradually declined in number in recent years. In 1996, the Residency Review Committee for Surgery established a policy that the number of residents appointed to a program must be consistent with the number who will complete the program. Even so, there is still attrition in the ranks of surgical residents, some of whom hold undesignated preliminary positions and have no guarantee of a position that will lead to completion of the program. This study examined the 1993 entering cohort of surgical residents to determine the rate of attrition as of 1998. STUDY DESIGN: Data were collected from the AMA's Medical Education Research Information Database, the American College of Surgeons Resident Masterfile, and the Association of American Medical Colleges GME Tracking Census database. The data were examined by specialty, gender, ethnic background, and type of medical school attended. RESULTS: The overall attrition rate from surgical GME was 12%; the rate for international medical graduates was 33%; and the rate for osteopathic residents was 28%. African-American United States and Canadian graduates had attrition rates of 16% for men and 8% for women, and Hispanic United States and Canadian graduates had attrition rates of 14% for men and 15% for women. General surgery residents had an attrition rate of 26%, which included residents in undesignated preliminary positions. Gender was not a risk factor except for the significantly higher attrition rate of African-American men. Most (81%) of the residents who dropped out of surgical GME enrolled in GME in other specialties. CONCLUSIONS: The attrition rate from surgical GME is low, and most residents who drop out reenter GME in another specialty. Of concern is the high rate of attrition of African-American men who are United States or Canadian graduates. The highest rate of attrition, by far, is in the group of international medical graduates, many of whom are likely to have held undesignated preliminary positions.

The longitudinal study of surgical residents, 1994 to 1996.

BACKGROUND: The American College of Surgeons (ACS) has conducted a detailed annual survey of residents enrolled in surgical graduate medical education (GME) programs since 1982 and has regularly published the resulting data as the Longitudinal Study of Surgical Residents. This report documents surgical resident enrollment and graduation for the academic years 1994-95 and 1995-96. STUDY DESIGN: The Medical Education Research and Information Database of the American Medical Association was supplemented by the existing ACS Resident Masterfile and by personal contact with program directors and their staffs to verify accuracy and completeness of reporting. Each resident was tracked individually through surgical GME. RESULTS: The total number of surgical residents graduating from surgical GME in 1995 and 1996 has not changed since 1982. Most graduates of surgical residency programs are in obstetrics and gynecology, followed by general surgery; demographic analysis of the graduating cohort shows that most are Caucasian male graduates of US or Canadian medical schools, and that their age at graduation is 33 to 35 years. International medical graduates (IMG) make up 8.9% of entering surgical residents and 6% of graduates. Osteopathic medical school graduates account for 1.2% to 1.3% of entering and graduating surgical residents. Women represent 27% of entering and 23% to 24% of graduates of surgical GME. The largest number and proportion of women in surgical GME are enrolled in obstetrics and gynecology residency programs, where they make up the majority of entering and graduating classes. When all other surgical residency program enrollments are considered together, women make up 17% and 16% of entering residents in 1994 and 1995, respectively, and 13% and 14% of graduates in those years. CONCLUSIONS: Surgical GME enrollment and graduation is stable. Few women and ethnic minorities are enrolled in surgical residency programs. IMG enrollment and graduation in surgical GME is low.

The general surgery workforce.

BACKGROUND: The workforce in general surgery has been the subject of studies in 1975 and 1994, as has the input of residency program graduates, their subsequent subspecialization, and the retirement pattern of practicing general surgeons. This study analyzes the distribution of general surgeons in the United States. DATA SOURCES: Certified general surgeons were identified from files of the American Board of Medical Specialties (ABMS). Included were general surgeons with no additional certificates except for Surgical Critical Care. Excluded were surgeons certified only by an osteopathic board, noncertified surgeons, retirees, missionaries, federal employees, and military surgeons. The Area Resource File of the Bureau of Health Professions was used to classify metropolitan and rural areas, and primary care health professions shortage areas (PC-HPSA). CONCLUSIONS: General surgeons are well distributed in the various states. More general surgeons are located in metropolitan than in rural areas, and few general surgeons practice in counties in which the whole county is designated as a PC-HPSA. The ratio of general surgeons to the population is similar to that found in 1975.

The longitudinal study of surgical residents, 1993 to 1994.

BACKGROUND: The American College of Surgeons (ACS) has collected comprehensive data about surgical residents for the past 12 years and has published an annual report, the Longitudinal Study of Surgical Residents. In 1994, the ACS and the American Medical Association (AMA) agreed to collaborate in collecting data about surgical residents. We report the analysis of these data for residents enrolled in graduate medical education (GME) in surgery during the 1993 to 1994 academic year. STUDY DESIGN: Data about residents and fellows during the 1993 to 1994 academic year, including the 1994 graduates from 13 surgical specialties, were obtained from the AMA. Through additional mailings and telephone contact by the ACS, data were obtained and verified from each of the 1,500 accredited surgical residency programs. The resulting data set was analyzed to derive a count of residents and fellows and graduates for the 1993 to 1994 academic year. The ACS Resident Masterfile was analyzed separately to compare the 1993 to 1994 results with those from previous years. RESULTS: The total number of surgical residents enrolled in GME has changed little since 1982. Since 1987, the number of graduates has increased 2.1 percent. More general surgery graduates are enrolling in advanced specialty GME than were enrolling in 1982. The average age of graduates from core residency programs is 33 years, of advanced program graduates is 35 years, and of international medical graduates is 36 years. International medical graduates represent 7.1 percent of all surgical residents and fellows and 5.5 percent of graduates. Women and ethnic minorities are underrepresented in surgical GME. CONCLUSIONS: Surgical GME enrollment has been stable since 1982, and graduates of general surgery residencies are increasingly likely to enroll in advanced specialty residency programs.

Retirement age and the work force in general surgery.

OBJECTIVE: This study examines the age of retirement of general surgery Fellows of the American College of Surgeons from 1984 through 1995 and analyzes the potential effect on the work force in general surgery of age of retirement. SUMMARY BACKGROUND DATA: Data from the Fellowship files of the American College of Surgeons, the American Board of Medical Specialties, and the American Medical Association disclosed that the number of practicing general surgeons in the United States in 1994 was between 17,289 and 23,502, or approximately 7 general surgeons per 100,000 population in the United States. METHODS: The Fellowship files of the American College of Surgeons from 1984 through 1995 were searched for general surgeons who had written to ask for retirement status or who had died before retirement. Calculations were made of the effect of years in practice on the total general surgeon work force. All living retirees from 1984 to 1985 and 1994 to 1995 were questioned to learn the factors leading to a decision to retire. RESULTS: The average age of retirement for general surgeon Fellows has risen from 60.45 in 1984 to 62.97 in 1995. Because of increasing diversion of general surgery graduates into surgical specialties, total practice years are declining despite increasing length of practice time. The principal factors for retirement decisions in 1984 and 1985 were disability (26%), leisure time (20%), and unfavorable changes in surgery (29%). In 1994 and 1995, disability was a major factor in 14% of decisions, leisure time in 20%, and unfavorable changes in surgery in 56%. CONCLUSIONS: Fewer general surgeons enter the work force each year. Thus, despite working longer, the total number of years practiced by each cohort of new general surgeons has decreased.

Calculating the workforce in general surgery.

OBJECTIVE: To provide a reasonable estimate of the patient care and resident physician workforce practicing general surgery in 1994. DESIGN: Data regarding general surgical residents and practicing general surgeons were obtained from four sources and compared with previously published numbers. DATA SOURCES: Information was derived from the American College of Surgeons' Longitudinal Study of Surgical Residents: 1992-1993; the American Medical Association's Physician Characteristics and Distribution in the United States, 1994 Edition; the American Board of Medical Specialties' database on general surgeons; and the American Board of Surgery recertification data from the files of diplomates since 1968. Each of these sources was analyzed separately to derive a count of graduates from general surgery residency programs and an estimate of fully trained general surgeons engaged in patient care activities. RESULTS: We found that approximately 600 graduates of general surgery residency programs enter the practice of general surgery each year, and we found a close correlation between maximum and minimum estimates of the number of fully trained general surgeons engaged in active patient care, certified general surgeons who are not retired, and currently certified general surgeons. This number (17,289 to 23,502) is approximately half that commonly used in calculations of the general surgery workforce (38,239). The larger number includes surgeons with subspecialty training beyond general surgery, surgical residents, and surgeons not engaged in patient care. CONCLUSIONS: Estimations of the workforce in general surgery and predictions of future needs for general surgeons must be derived from the appropriate number of general surgery residents and practicing general surgeons.

Morphine cholescintigraphy in the evaluation of hospitalized patients with suspected acute cholecystitis.

OBJECTIVE: The authors determined if the diagnosis of acute cholecystitis can be accurately made or reliably eliminated by the use of morphine-augmented radionuclide cholescintigraphy (morphine cholescintigraphy [MC]) in hospitalized patients in whom the diagnosis is in doubt. SUMMARY/BACKGROUND DATA: Diagnosis of acute cholecystitis, calculous or acalculous, may be difficult in patients hospitalized for abdominal pain or other illnesses. Clinical signs often are obscure, and routine imaging studies are nonspecific or associated with a high incidence of false-positive tests. The authors report the use of MC in the evaluation of 163 hospitalized patients for acute cholecystitis over an 8-year period. METHODS: All patients suspected to have acute cholecystitis initially had standard cholescintigraphy performed, which showed nonvisualization of the gallbladder, and then were given morphine sulfate (0.05-0.1 mg/kg, intravenously). Patients were divided into the following three groups: I--acute abdominal pain (N = 53); II--hospitalized for associated illness (N = 49); and III--critically ill (N = 61). RESULTS: Overall, MC confirmed the diagnosis of acute cholecystitis in 75 patients (46%), including 23 cases of acalculous cholecystitis. Visualization of the gallbladder occurred within 60 minutes of intravenous administration of morphine sulfate in all patients. Cystic duct obstruction and, presumably, the diagnosis of acute cholecystitis was excluded in 79 patients, including 38 who were critically ill. There were eight false-positive and one false-negative studies. Morphine cholescintigraphy had a sensitivity of 99%, a specificity of 91%, a positive predictive value of 0.9, a negative predictive value of 0.99, and an overall accuracy of 94%. CONCLUSIONS: In hospitalized patients with nonvisualization of the gallbladder after standard cholescintigraphy, MC is highly accurate, especially in predicting the absence of acute cholecystitis in patients with known risk factors.

The effect of prostaglandin E1 analog misoprostol on chronic cyclosporin nephrotoxicity.

Cyclosporin A has markedly improved graft survival in transplant patients but its side effects, such as renal toxicity and hypertension, pose management problems in transplant recipients. This toxicity has been attributed to prostaglandin inhibition. Concurrent administration of misoprostol (a prostaglandin E1 analog) prevents chronic cyclosporin A-induced nephrotoxicity but not hypertension in rats.

Extracorporeal venovenous recirculation for the treatment of hypothermia during elective aortic surgery: a phase I study.

BACKGROUND: Hypothermia caused by massive transfusion or prolonged exposure during operation is difficult to reverse and is associated with adverse side effects. This prospective, randomized study evaluated a technique using extracorporeal venovenous recirculation (EVR) through a roller pump-driven device with a commercial countercurrent heat exchanger used for treatment of hypothermia (temperature < 35.5 degrees C) occurring during elective aortic operation. METHODS: Patients undergoing aortic operation had routine prophylaxis against hypothermia including ventilator cascades, warming blankets, and low-velocity fluid warmers. When core temperature was less than 35.5 degrees C, patients were randomized to continue existing therapy (control, n = 7) or EVR (n = 8), performed through two large-bore venous lines. RESULTS: There were no differences in age, sex, weight, body surface area, Acute Physiology and Chronic Health Evaluation II score, fluid replacement, length of operation, blood lost or given, induction temperature, red blood cell or platelet structure, hemolysis, length of intensive care unit or hospital stay, complications, or mortality rates. EVR was associated with increased final core temperature (35.5 degrees +/- 0.8 degrees [EVR] vs 33.8 degrees +/- 0.9 degrees [control]; p < 0.005) and body heat content (-13.9 +/- 62.3 kcal [EVR] vs -118.2 +/- 62.2 kcal [control]; p < 0.01), with heat gained being proportional to flow rate. CONCLUSIONS: These data show that EVR provides a safe and effective method for the treatment of hypothermia.

Women as leaders in organized surgery and surgical education. Has the time come?

Women have entered medicine in large numbers during the past three decades, and are increasing their representation in some surgical fields at a rapid pace. Few women are found in senior roles in organized surgery or at the senior ranks of academic surgical faculty. Factors influencing this imbalance include family demands, sexism, and stereotypes that hinder the advancement of women into leadership roles. Strategies for correcting this imbalance include affirmative recruitment of women into surgery, particularly into academic surgical faculties; support systems, such as child care and adjustment of promotion and tenure timetables; mentoring; and programs of career development that emphasize skills in management as well as research and teaching.

Streptococcal toxic shock-like syndrome. The importance of surgical intervention.

Pyrogenic exotoxins A, B, and C produced by group A beta-hemolytic streptococci (Streptococcus pyogenes) may cause a syndrome characterized by fever, rash, desquamation, hypotension, and multi-organ-system dysfunction. This syndrome, the streptococcal toxic shock-like syndrome (TSLS), has a rapid and fulminant course closely resembling the staphylococcal toxic shock syndrome (TSS) caused by the staphylococcal toxic shock syndrome toxin-1 (TSST-1). The recent recognition of this syndrome is thought to stem from the appearance of more virulent strains of streptococci that have a greater tendency to produce potent exotoxins than prior strains. During the past 6 years, the authors have treated six patients with TSLS; three of these patients have presented recently. The sites of streptococcal infection associated with the development of the syndrome are frequently in soft tissue and skin. Early diagnosis, treatment with penicillin, and radical operative debridement are required.

Single dose cephalosporin prophylaxis in high-risk patients undergoing surgical treatment of the biliary tract.

During June 1985 through October 1986, 292 patients considered to be at high risk for having postoperative complications develop underwent cholecystectomy and were evaluated in a multicenter, randomized, prospective, double-blind study. Risk factors included age greater than 70 years, acute cholecystitis within the previous six months, obstructive jaundice, obesity and diabetes mellitus. One gram of cefamandole was administered intravenously to 144 patients and 148 patients received 1 gram of cefotaxime intravenously 30 minutes prior to skin incision. Culture-proved bactibilia was found in 55 patients and 11 of the patients had choledocholithiasis. Of the risk factors considered to place patients at high risk for postoperative infectious complications, obesity and acute cholecystitis proved to be the more common. However, age greater than 70 years, diabetes mellitus and obstructive jaundice were more significant risk factors predisposing to bactibilia. The most common organisms isolated from the bile and gallbladder intraoperatively were Staphylococcus, Streptococcus and Klebsiella species along with enterococcus, Escherichia coli and diphtheroids. Clinically significant postoperative infections occurred in eight patients, including six patients in the cefamandole group and two patients in the cefotaxime group. Antibiotic concentrations were measured in the serum, muscle, subcutaneous fat, gallbladder and bile, with cefamandole showing statistically significant greater concentrations in bile, gallbladder and muscle tissue. There was no statistical significance between the postoperative infection rates, total period of hospitalization or total hospital charges for each group. Therefore, there is no significant advantage between a single prophylactic dose of cefamandole versus cefotaxime for high-risk patients undergoing biliary tract operation.

Incidence and timing of hypothermia in trauma patients undergoing operations.

Hypothermia is a major problem in patients who have sustained trauma. We reviewed the cases of 100 consecutive trauma patients transferred directly to the operating room (OR) from the Emergency Department (ED) in a Level I trauma center; 26 cases could not be evaluated. Forty-two patients (57%) became hypothermic at some time between injury and leaving the OR. Fifty-five patients (74%) had a temperature (T) recorded on arrival to the ED; but only 7 (12%) were hypothermic (34.7 degrees +/- 1.5 degrees C). In contrast, 34 patients (46%) arrived in the OR hypothermic (34.8 degrees +/- 0.9 degrees C) and 26 (76%) of these left the OR hypothermic (34.8 degrees +/- 0.9 degrees C). Eight additional patients (20%) arriving in the OR with a T greater than 35.9 degrees C left the OR hypothermic (35.1 degrees +/- 0.4 degrees C). The mean T loss in the ED was significantly greater than that lost in the OR (-0.8 degrees +/- 0.7 degrees C vs. 0.0 degrees +/- 0.6 degrees C; p less than 0.0001, ANOVA). Ninety-two percent of the patients lost temperature in the ED, while 43% of the patients gained temperature in the OR. Hypothermia was associated with lower Trauma Scores, and those patients who were severely hypothermic received more intravenous fluids. However, the impact of fluid infusion was not independent from Trauma Score and did not fully explain the magnitude of the heat loss. These data suggest that hypothermia in trauma patients has a multifactoral etiology related to the magnitude of injury and that the major T loss occurs in the ED rather than in the OR.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence that HLA class II disparity is required for the induction of renal allograft enhancement by donor-specific blood transfusions in man.

We studied 46 living-related primary renal allograft recipients between June 1980 and Jan 1988 to determine if enhancement of allograft survival by donor specific transfusions requires a major histocompatibility complex mismatch between the blood/kidney donor and the recipient. Recipients were matched for a single HLA haplotype, but differed at various HLA loci on the unshared haplotype. DST (200 ml) was administered either 3 times at two-week intervals pretransplant (n = 17), or once 3-4 weeks pretransplant, together with oral azathioprine (1 mg/kg/day/28 days) (n = 29). Patients were followed for at least 1 year and all clinical rejection episodes were confirmed histologically. Enhanced graft survival by DST was defined as a rejection-free posttransplant course. Incompatibility for class II determinants on the unshared haplotype of donor had a beneficial effect. A significantly greater proportion of recipients had stable, rejection-free, allograft function if incompatible for the DR locus (80% vs. 44%, P = 0.012), for class II public determinants (100% vs. 58%, P = 0.013), or for at least one of the class II gene products (DR, DQ, class II public) (81% vs. 40%, P = 0.006). Graft loss occurred in 7 of 46 (15%); 6 of the 7 recipients were HLA class II-compatible with their blood/kidney donor. Mismatches for HLA class I private or public determinants and other factors known to affect graft outcome did not influence the results. We conclude that enhanced kidney allograft survival by DST may be predicated by factors within the MHC--specifically class II disparity. These observations also suggest that better HLA matching at the class II locus may account for the apparent "disappearance" of the transfusion effect in cadaver renal transplants in the cyclosporine era.