Evaluating a clerkship curriculum: description and results.

BACKGROUND: A comprehensive and up-to-date curriculum requires periodic formal review to ensure it continues to meet learners' needs. PURPOSE: This study describes a model for evaluating a surgery clerkship curriculum designed to determine the appropriateness of its learning objectives to the general professional education of a physician. METHODS: A survey was mailed to graduates who pursued generalist residencies. Respondents estimated the number of patients encountered annually with specified presenting complaints or disease entities and the percentage of time these were referred to surgeons. For 23 technical procedures, respondents estimated the frequency done annually and whether remaining proficient in the skill was considered important. RESULTS: The majority of graduates reported the need to remain proficient in 19 technical procedures. Numerous patient problems were identified as requiring careful instruction so that learners know when and when not to refer for surgical intervention. CONCLUSIONS: The clerkship was modified to include skills and topics not previously included or appropriately emphasized.

Toward a better residency.

Residency programs can be improved by careful consideration of seven elements germane to resident life and education. A curriculum, the course of study, should be established. A balance between service and education must be maintained. Supervision by faculty and residents' willingness to be supervised ensures patient safety as well as teaching. Residents, faculty, and the program itself require frequent evaluation. A pleasant working environment is important. Sensitivity to issues of culture, gender, and ethnicity should be maintained by the program director, the faculty, and residents. Finally, the importance of stress in the lives of residents should be understood.

Use of notebook computers for third-year surgical students.

BACKGROUND: Computer-aided instruction has become increasingly popular in medical education. Notebook computers (NCs) are attractive, convenient microcomputers. We hypothesized that use of NCs by third-year surgical students would enhance their performance of educational activities. METHODS: During the 1994-1995 academic year 25 student volunteers used NCs during the surgery clerkship. NC software included questions for self-examination, anatomy self-instruction program, word processing and electronic mail (e-mail) for recording and sending history and physicals (H & Ps) to faculty for review, and MEDLINE search software. Identical software was available to all students at on-campus computer centers. All students were asked to record the number of hours that they used the self-examination and anatomy programs, number of H & Ps performed and reviewed by faculty, and number of literature searches performed. NC users were interviewed regarding the value of NC use and their rating of software programs. RESULTS: NC users (n = 25) used the self-examination and anatomy programs more often, performed more literature searches, and had a greater percentage of their H & Ps reviewed by faculty compared with non-NC users (n = 143) (p < 0.05 for all outcomes). Most NC users agreed that NC use was enjoyable and valuable, and they believed that all students should have NCs during the surgery clerkship. Students rated software in order of preference: e-mail > self-examination > MEDLINE search > anatomy program. CONCLUSIONS: NC use enhanced performance of educational activities in the surgery clerkship. Effort toward developing educational software for surgical students is warranted because students are likely to use such programs.

Cystic neoplasms of the pancreas. A clinicopathologic study, including DNA flow cytometry.

OBJECTIVE: To review the classification, clinical behavior, and appropriate therapy for cystic neoplasms of the pancreas. We examined patient demographics, clinical parameters, preoperative imaging modalities, histologic findings, and tumor DNA content to determine which best predict outcome. DESIGN: Case series and survey of pathologic specimens. SETTING: Tertiary care center. PATIENTS: Twenty-two patients with cystic neoplasms of the pancreas treated at affiliates of Northwestern University Medical School, Chicago, Ill. MAIN OUTCOME MEASURES: Predictive value of preoperative testing, tumor DNA content, patient survival. RESULTS: In 20 patients undergoing computed tomographic scan, the tumor was visualized in every case. All other imaging studies evaluated were less likely to demonstrate the lesion. Eight of 10 patients with serous cystadenomas were alive with no evidence of disease at the time of this report; one patient was alive with local recurrence, and a second patient had died of unrelated causes. All patients with mucinous cystadenomas were alive with no evidence of disease. Three of seven patients with cystadenocarcinomas had aneuploid, high S-phase tumors, and one had a diploid, high S-phase tumor; all four died (mean survival, 4.8 months). Two patients with cystadenocarcinomas had diploid, low S-phase tumors; both were long-term survivors but died of their disease at 8.6 and 9.3 years. CONCLUSIONS: (1) Computed tomographic scan is the most valuable diagnostic imaging study for preoperative evaluation of these patients. (2) Precise preoperative determination of tumor type is not possible. (3) DNA flow cytometry may help identify patients with aggressive tumors who may benefit from adjuvant chemoradiation.

United states research published in major surgical journals is decreasing.

OBJECTIVE: The authors hypothesized that less research performed in the United States was reported in the five major general surgical journals in 1993 than in 1983. SUMMARY BACKGROUND DATA: Academic surgeons believe they have less time and fewer funds for research than previously. METHODS: Five journals were analyzed for the number of pages and articles devoted to basic and clinical research in 1983 and 1993 and for the country in which the research was performed. RESULTS: The number of U.S. research pages and articles decreased over the past decade, and the number of non-U.S. pages and articles increased. CONCLUSIONS: The reason(s) for the decrease in U.S. research reported in the general surgical journals should be studied, identified, and, if possible, rectified.

Gastrointestinal tract complications after acute spine injury.

OBJECTIVES: To determine the incidence, risk factors, and mortality rate of gastrointestinal complications in patients with acute spine injury and to derive methods by which mortality can be reduced. DESIGN: Case series. SETTING: Regional tertiary care center. PATIENTS: Consecutive sample of 1952 patients with acute spine injury with complete medical records who were admitted from 1981 through 1990. MAIN OUTCOME MEASURES: Gastrointestinal tract complications, age, sex, time from injury to admission, cause of injury, level of spine injury, neurologic deficit, head injury, injury to other organ systems, incidence of surgical intervention for spine injury, length of hospital stay, and mortality rate. RESULTS: The incidence of gastrointestinal complications was 1.9%. Gastrointestinal hemorrhage was the most frequent complication. Risk factors for gastrointestinal complications were increasing age (P < .02), male sex (P < .01), injury to other organ systems (P < .02), head injury (P < .02), cervical spine injury (P < .02), and neurologic deficit (P < .005). The mortality rate was 19% in patients with gastrointestinal complications, significantly greater (P < .005) than the 2.9% rate in patients without gastrointestinal complications. CONCLUSIONS: Gastrointestinal complications after acute spine injury are uncommon but frequently lethal. Prophylaxis against hemorrhage and earlier diagnosis and surgical intervention are recommended.

Tyrosine inhibits intestinal-phase gastric-acid secretion.

BACKGROUND: Intestinal infusion of leucine augments the maximal gastric-acid secretory response to pentagastrin and serves as a bioassay for intestinal-phase acid secretion. Another action of leucine is to decrease tyrosine flux into neural tissues. We hypothesized that the mechanism of leucine-stimulated acid secretion involves its ability to alter tyrosine absorption. METHODS: We administered tyrosine intrajejunally and intravenously to anesthetized, vagotomized rats during maximal pentagastrin stimulation and measured acid output in response to intrajejunal infusion of leucine. RESULTS: Intrajejunal tyrosine produced a dose-dependent inhibition of leucine-stimulated acid secretion but only mild effects on acid secretion in response to pentagastrin alone. Intravenous tyrosine infusions also decreased acid secretion in response to intestinal leucine but required much higher doses. CONCLUSIONS: Tyrosine exerts a specific inhibitory effect on leucine-stimulated acid secretion, which is mediated intraluminally. Because tyrosine is an important regulator of adrenergic nervous system activity, we speculate that the mechanism of leucine-stimulated acid secretion may involve modulation of the sympathetic nervous system, thereby affecting acid secretion.

Laparoscopic inguinal hernia repair. A preliminary experience.

OBJECTIVE: To evaluate the safety and efficacy of laparoscopic inguinal hernia repair. DESIGN: Nonrandomized trial. SETTING: Veterans Affairs hospital and a large university hospital. PATIENTS: The study included 38 patients (36 male and two female) who had an acceptable risk for general anesthesia, presented electively, and gave informed consent; patients were excluded for whom general anesthesia had a high risk or who had incarcerated or strangulated hernias. INTERVENTION: Laparoscopic inguinal hernia repair was performed with general anesthesia through bilateral, lower-abdominal, 12-mm lateral rectus sheath ports with an umbilical 30 degrees viewing laparoscope. After the peritoneum was incised and flaps were raised, an onlay patch of polypropylene mesh, secured with staples, covered both indirect and direct hernia regions in each patient. Small hernia sacs were usually reduced or excised. RESULTS: From December 1991 through October 1992, 40 inguinal hernias were repaired; two patients had bilateral hernias. There were 22 indirect and 17 direct inguinal hernias and one femoral hernia. Nine of the hernias repaired were recurrent, and five were sliding hernias. Complications occurred in nine patients, but there were no recurrences during a median follow-up of 26 weeks. All but one patient resumed preoperative activities by 7 days after the operation. CONCLUSIONS: Laparoscopic inguinal hernia repair is an effective operation with low morbidity. Long-term follow-up is needed to determine the durability of the repair.

Reduced ileal taurocholate absorption with total parenteral nutrition.

Total parenteral nutrition is associated with decreased primary bile acid output. This may result from reduced synthesis or decreased absorption of primary bile acids in the enterohepatic circulation. Ileal atrophy occurs with total parenteral nutrition, and we postulated that absorption of primary bile acids is reduced. Ileal absorption of taurocholate was investigated in miniswine on total parenteral nutrition and this was compared to orally fed animals. Following cholecystectomy and bile duct cannulation, 20 cm, of ileum was perfused with taurocholate. Since miniswine have no significant endogenous taurocholate secretion, the measured taurocholate output reflected ileal absorption. To examine uptake and secretion of taurocholate by the liver, pigs on total parenteral nutrition and controls were infused with intravenous taurocholate (0.5 to 2.5 mumole/kg/min), and bile acid output was determined. Baseline bile acid output was decreased in animals on total parenteral nutrition, yet the response to intravenous taurocholate was similar to controls. When taurocholate was perfused in the ileum, taurocholate output was markedly different. Taurocholate output (pmole/cm ileum/min) at the taurocholate perfusate concentrations of 3 and 20 mM was, respectively, 65 +/- 14 and 183 +/- 63 for controls and 18 +/- 3 and 63 +/- 17 for miniswine on total parenteral nutrition. The latter group's output was significantly lower, at P < 0.05. Both groups of pigs had equal increases in bile acid output with intravenous infusion of taurocholate, suggesting normal hepatic uptake and secretion. Ileal perfusion with taurocholate, however, resulted in decreased taurocholate output with total parenteral nutrition due to decreased ileal absorption of bile acids.(ABSTRACT TRUNCATED AT 250 WORDS)

Gallstone lithotripsy.

Extracorporeal shock-wave lithotripsy (ESWL) has been applied to patients with gallstones since the mid-1980s. Lithotriptors differ by their means of shock-wave generation, the mechanisms by which they are coupled to the patient, and their imaging systems. Entry in most treatment protocols is limited to symptomatic patients with one to three radiolucent stones having a diameter of 30 mm or less and a functioning gallbladder according to oral cholecystography. Treatments are given on an out-patient basis using intravenous analgesia and include adjuvant bile acid therapy. Deaths have not been reported, and the incidence of serious complications, related to the presence of fragments in the biliary system, is low. The studies show that ESWL is a safe and effective treatment for patients with a single gallstone less than or equal to 20 mm in diameter, but the efficacy for larger single stones and multiple stones is poor. To date, the Food and Drug Administration has not approved lithotriptors for the treatment of gallstones in the United States.

Treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis.

We reviewed an experience with treatment of peripancreatic fluid collections in patients with complicated acute pancreatitis to identify clinical and computed tomography (CT) parameters that are helpful in the selection of patients for treatment and to assess treatment outcome. The extent of CT abnormalities determined a CT severity score (mild = 1, severe = 4). From 1985 to 1990, 650 patients were hospitalized with acute pancreatitis; a peripancreatic fluid collection was found in 36 patients (5.5 percent). Ten of 11 patients with successful outcome after no invasive treatment (group 1) had a low CT severity score of 1 or 2; mean serum albumin was 4.0 gram percent. Of 25 patients who had some form of drainage, 12 had a high CT severity score of 3 or 4 (p < 0.05) and a mean serum albumin of 3.4 grams percent (p < 0.05). Nine patients had only operative drainage (group 2) and 16 had CT-directed percutaneous catheter drainage (group 3). In group 3, percutaneous catheter drainage successfully drained the fluid collection in six patients, while ten patients needed an operation, in addition to percutaneous drainage, to effectively débride and drain the necrotizing pancreatic problem. As a result of the current review, we propose an algorithm for treatment of these patients.

Computed tomography in the initial evaluation of patients with blunt trauma.

Two hundred sixty-six of 374 consecutive blunt trauma patients underwent emergency computed tomographic (CT) scanning during evaluation at a level I trauma center. The purpose of this study was to develop guidelines for use of CT scanning in the initial evaluation of blunt trauma patients. Of the 131 CT scans of the head obtained, 20 (15%) had positive results. Seven patients whose initial neurologic examinations were normal had abnormal results on head CT scans; none required emergent treatment of their head injury. This suggests that, in the presence of a normal neurologic examination, head CT scans can safely be delayed until other more serious injuries are addressed. Twenty-six CT scans of the chest were performed and ten (38%) were interpreted as abnormal. Chest CT scans provided information about the extent of the injury but did not alter the initial management of any patient and therefore are rarely indicated in the acute evaluation of trauma patients. A total of 110 abdominopelvic CT scans were performed and 20 (19%) were interpreted as positive. Seventy-five percent of those patients with positive CT scans were treated successfully in a nonsurgical fashion.