Dissecting the surgeon's personality: cross-cultural comparisons in Western Europe.

AIM: The surgeon's personality contributes to variation in surgical decision-making. Previous work on surgeon personality has largely been reserved to Anglo-Saxon studies, with limited international comparisons. In this work we built upon recent work on gastrointestinal surgeon personality and aimed to detect international variations. METHOD: Gastrointestinal surgeons from the UK and the Netherlands were invited to participate in validated personality assessments (44-item, 60-item Big Five Inventory; BFI). These encompass personality using five domains (open-mindedness, conscientiousness, extraversion, agreeableness and negative emotionality) with three subtraits each. Mean differences in domain factors were calculated between surgeon and nonsurgeon populations from normative data using independent-samples t-tests, adjusted for multiple testing. The items from the 44-item and 60-item BFI were compared between UK and Dutch surgeons and classified accordingly: identical (n = 16), analogous (n = 3), comparable (n = 12). RESULTS: UK (n = 78, 61.5% male) and Dutch (n = 280, 65% male) gastrointestinal surgeons had marked differences in the domains of open-mindedness, extraversion and agreeableness compared with national normative datasets. Moreover, although surgeons had similar levels of emotional stability, country of work influenced differences in specific BFI items. For example, Netherlands-based surgeons scored highly on questions related to sociability and organization versus UK-based surgeons who scored highly on creative imagination (p < 0.0001). CONCLUSION: In a first cross-cultural setting, we identified country-specific personality differences in gastrointestinal surgeon cohorts across domain and facet levels. Given the variation between Dutch and UK surgeons, understanding country-specific data could be useful in guiding personality research in healthcare. Furthermore, we advocate that future work adopts consensus usage of the five factor model.

Prevention of seroma formation after axillary dissection in breast cancer: a systematic review.

BACKGROUND: The most common complication after breast cancer surgery is seroma formation. It is a source of significant morbidity and discomfort. Many articles have been published describing risk factors and preventive measures. The aim of this paper is to provide a systematic review of studies and reports on risk factors and preventive measures. Surgery lies at the core of seroma formation; therefore focus will be placed on surgical ways of reducing seroma. METHODS: A computer assisted medline search was carried out, followed by manual retrieval of relevant articles found in the reference listings of original articles. RESULTS: 136 relevant articles were reviewed. Though the level of evidence remain varied several factors, type of dissection, tools with which dissection is carried out, reduction of dead space, suction drainage, use of fibrin glue and octreotide usage, have been found to correlate with seroma formation and have been shown to significantly reduce seroma rates. CONCLUSION: Seroma formation after breast cancer surgery cannot be avoided at present. There are however several methods to minimize seroma and associated morbidity. Future research should be directed towards the best ways of reducing seroma by combining proven methods.

Handlebar hernia: a case report and literature review on traumatic abdominal wall hernia in children.

A rare case of abdominal trauma, a handlebar hernia, is described, as well as a review of the pertinent literature. A 7-year-old boy presented to our emergency room after sustaining blunt force to the abdomen; he fell on the handlebar of his bicycle. Immediately after the accident, a bulge was noticeable at the point of impact. Handlebar hernia is a diagnosis that is easily missed, which can lead to strangulation and incarceration of the bowel. With this case report, we hope to augment the knowledge on traumatic abdominal wall hernia, hopefully leading to early diagnosis and treatment.

[Widespread preoperative hair removal in the southwest of The Netherlands despite an evidence-based guideline discouraging this practice]. / Wijdverbreide preoperatieve ontharing in Zuidwest-Nederland ondanks evidence-based ontmoediging.

OBJECTIVE: To determine whether the 1993 guideline from the Dutch Institute for Healthcare Improvement (CBO) is followed in the Southwest region of the Netherlands. The guideline states that preoperative hair removal serves no purpose in preventing wound infection. DESIGN: Inventory. METHOD: All surgical short-stay departments in the Southwest region of The Netherlands received a structured questionnaire on their management of preoperative hair removal. Questions included whether or not they had a hair removing protocol, which methods they used for removing hair and the timeframe within which preoperative hair removal usually was carried out. RESULTS: The response was 100% (24/24). The majority of surgical short-stay departments did practice preoperative hair removal (88%). Less than half of the hospitals use a hair removal protocol. Hair clippers were used for preoperative hair removal in most hospitals (86%) and in 71% the procedure was carried out within 2 hours of the planned operation and mostly by nursing staff (71%). No difference was found in hair removal management in hospitals with or without a protocol. CONCLUSION: Despite the existence of a published guideline that states that preoperative hair removal serves no purpose in preventing wound infection, the majority of hospitals in the Southwest region of the Netherlands do still carry out the practice as a routine action. The policy of hair removal management appears to depend on subjective feelings of individual surgeons. The existence ofan evidenced-based guideline does not appear to have much effect on this management.

Efficient library synthesis of imidazoles using a multicomponent reaction and microwave irradiation.

Optimization of Radziszewski's four-component reaction employing a microwave-assisted protocol, led to a small library of 48 imidazoles with a success rate of 65% (conversion > 45%). All three diversity points of the four-component reaction were varied. Aromatic and aliphatic inputs were successfully implemented and mono-, di-, tri- and tetrasubstituted imidazoles with various substitution patterns were synthesized. Furthermore, unsymmetrical diketones could successfully be used which improved the intrinsic diversity of the method significantly. If the unsymmetrical diketone 1,2-phenylpropanedione (R1 and R2) was used two regioisomers were formed. Depending on the type of amine (R4) and aldehyde (R3) applied, regioselectivity was modest to good. Based on these results, a reaction mechanism is proposed.

Long-term results of fasciotomy of the anterior compartment in patients with exercise-induced pain in the lower leg.

This prospective study aims to describe the results of fasciotomy in patients with exercise-induced pain in the lower leg with suspected (chronic) exertional compartment syndrome. The diagnosis of (chronic) exertional compartment syndrome was made if pain in the lateral side of the lower leg after a standard physical load was accompanied by elevated tissue pressures in the anterior muscle compartment. Tissue measurements were performed in 114 patients. In 56 patients (106 compartments) increased tissue pressure was found (> 50 mmHg measured immediately after exercise, or > 30 mmHg if the pressure before exercise > 20 mmHg, or if the pressure five minutes after exercise is still > 30 mmHg). Two years after fasciotomy, (remaining) complaints were evaluated on the basis of a questionnaire: 87 % of the patients had significant reduction in complaints. Patients who were not found to have increased tissue pressure were also asked to report developments through the questionnaire. In 18 patients a fasciotomy was performed on the basis of the typical history, despite normal or slightly increased intramuscular pressures. Twelve of these patients (24 compartments) were asymptomatic after surgery. Fasciotomy in patients with a (chronic) exercise-induced compartment syndrome in the anterior compartment of the lower leg, based on our criteria, gave a marked reduction in symptoms in 87 % of the patients. Further research has to be done for the minimum tissue pressures above which fasciotomy may be successful in terms of reducing complaints.

Religious circumcision under local anaesthesia with a new disposable clamp.

OBJECTIVE: To compare the results using a new disposable clamp (the Taraklamp Circumcision Device, TCD, Taramedic Europe BV, Bilthoven, The Netherlands), used since 1998 in one clinic, and the conventional dissection technique (CDT) in another clinic, for religious circumcision in infants. SUBJECTS AND METHODS: The TCD and CDT were compared prospectively; the duration of the procedure, complications and postoperative pain were recorded. The cosmetic result and the degree to which the parents were satisfied were evaluated after 6 weeks. After obtaining informed consent, 275 boys were included in the study (median age 3 years). RESULTS: The median operative duration was 8 min less for the TCD (15 vs 7 min; P < 0.001). There was no difference in complication rate (bleeding in one vs two; infection in two vs three) and postoperative pain was comparable in both groups. The cosmetic results were better for the TCD group (P < 0.001). The parents' satisfaction score for the procedure was equal in the groups, at 8, on a scale of 1 (very bad) to 10 (extremely good). CONCLUSION: A religious circumcision outside the hospital with the TCD is quicker and leads to a better cosmetic result than with the CDT, without increasing morbidity.

Results of group-circumcision of Muslim boys in Malaysia with a new type of disposable clamp.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

[Ambulatory laparoscopic cholecystectomy is as effective as hospitalization and from a social perspective less expensive: a randomized study]. / Laparoscopische cholecystectomie in dagbehandeling even effectief als tijdens klinische opname en vanuit maatschappelijk perspectief goedkoper; een gerandomiseerd onderzoek.

OBJECTIVE: To compare the effects and costs of an ambulatory treatment versus an overnight stay for laparoscopic cholecystectomy. DESIGN: Prospective, randomised. METHOD: In the St Antonius hospital, Nieuwegein, the Netherlands, 86 patients with symptomatic cholelithiasis without comorbidity underwent either ambulatory (AM: 42 patients: 8 men and 36 women; mean age: 48.9 years (SD: 11.9)) or overnight stay (OS: 44 patients: 10 men and 32 women; mean age: 44.9 years (SD: 11.8)) laparoscopic cholecystectomy in the period 1 November 1997-30 September 1999. The following were registered: operative time, complications, hospital stay and readmissions, as well as reported pain, nausea, activity resumption, quality of life and patient satisfaction. The cost analysis was performed from a societal and hospital perspective. RESULTS: In the OS group one laparoscopic procedure was converted to open cholecystectomy, two relaparotomies were performed due to intra-abdominal haemorrhage and 1 patient had a catheter inserted due to urine retention. Two patients were readmitted, one for postoperative pancreatitis and the other for a retained bile duct stone. In the AM group one laparoscopic procedure was converted to open cholecystectomy, in 1 patient a wound abscess was treated with drainage in the outpatient clinic, in 1 patient there was peroperative stone loss without further complications and in 1 patient a catheter was placed to drain peroperative bile and blood loss. In the AM group 11 (26%) patients were kept overnight due to nausea and/or pain (n = 7) or one of the aforementioned complications (n = 4). Two patients were readmitted within 24 hours of being discharged due to abdominal pain. The average hospital stay was 3.1 (OS) versus 1.7 (AM) days. The quality of life, pain, nausea and activity resumption were comparable for both groups. Due to the difference in hospital stay, costs for the ambulatory procedure were lower. CONCLUSION: Laparoscopic cholecystectomy was successfully performed as an ambulatory surgery procedure in 69% of the patients. The quality of life, patient satisfaction and resumption of activities in both groups were comparable. The ambulatory treatment was less expensive.

[Assessment of day surgery in a district training hospital: safety, efficacy and patient's satisfaction]. / Evaluatie van de heelkundige dagverpleging in een regionaal opleidingsziekenhuis: veiligheid, doelmatigheid en tevredenheid van de patiënt.

OBJECTIVE: To assess the quality of day surgery in the St. Antonius Hospital in Nieuwegein, the Netherlands. DESIGN: Prospective and descriptive. METHODS: During one year all patients treated by general surgeons in ambulatory surgery of the St. Antonius Hospital, Nieuwegein, the Netherlands (breast surgery (n = 232), hernia repair (n = 143), varicose vein surgery (n = 137), lymph node or lump excision (n = 85), (peri-)anal surgery (n = 70), ganglion surgery (n = 41), removal of bone implants (n = 41), laparoscopic cholecystectomy (n = 23), miscellaneous (n = 82); total 854) were evaluated by telephone questionnaires six weeks after surgery, to measure the following three aspects of quality of care: safety, efficacy and patient's satisfaction. Questions were asked about complications, visits to the emergency room, the outpatient clinic and the general practitioner and extra care at home. Unplanned clinical admissions following day surgery and re-admissions were registered. All outpatient clinic charts were also checked for complications. Whenever the registration of complications was incomplete the patient's general practitioner was contacted. All patients gave informed consent. RESULTS: After 854 planned day cases 823 patients (96.4%) returned home the same day. Reasons for clinical admission following day surgery were pain and/or nausea (n = 8), an operation late in the afternoon (n = 7), haemorrhage (n = 6), more extensive surgery than expected (n = 3), others (n = 7). Of all patients who returned home the same day and about whom the interview yielded adequate information (n = 656; 80%) 54 (7%) suffered from a complication (wound infection (n = 28), haemorrhage (n = 7), haematoma (n = 5), seroma (n = 3), phlebitis (n = 2), infection skin (n = 2), wound dehiscence (n = 2), others (n = 5)). Six patients were re-admitted. In the hospital and outpatient clinic 40 patients were seen without an appointment (6%) and 91 patients visited their general practitioner (14%). After surgery 84 (13%) patients were helped at home by friends or family. Of the group of patients who were successfully treated in day care 14% would have preferred an overnight stay.

Reactivity of ether- and amine-complexed dimers and tetramers of alkyllithiums towards triphenylmethane.

Kinetics of Lewis base (LB) complexed primary and secondary sigma-alkyllithiums (RLi) with triphenylmethane (TPMH) are reported. RLis in which one or two LB groups (-OMe, -NMe, -NMeR) are part of the molecule form, in benzene, intramolecularly complexed tetramers, for example, 2(4), or dimers, for example, 4(2). They are used as models for their intermolecular congeners R4Li4 x 4LB and R2Li2 x 4LB (LB = NR'3, OR'2). Nonunity reaction orders in [RLi] are in line with reactions via as yet unidentified 1:1 complexes formed in an equilibrium (K(stat. corr.) approximately = 1) between aggregated RLi and TPMH. In some cases, a tetramer/dimer equilibrium mixture undergoes complexation/reaction. Reaction rates correlate linearly with calculated concentrations of the complexes. Relative rates of complexes range from 1 [prim-R4Li4 x 3LB x TPMH (presumed)] to 4250 [sec-R2Li2 x 3LB x TPMH (presumed)]. A major role in the reactivity enhancement owing to LB-induced conversion of tetramers into dimers is ascribed to increased LB participation in LB-richer dimer transition states. Amine and ether complexes have practically equal reactivities. Lithiation of TPMH by dimeric RCH2Li is retarded by a factor of 24000 if a silyl group is linked to the alpha-carbon.

[Analysis and treatment of pancreatic cystic diseases]. / Analyse en behandeling van cysteuze aandoeningen van het pancreas.

Owing to the spectacular progress in imaging techniques, cystic lesions of the pancreas are detected more often than previously, and this leads to therapeutic dilemmas. Of the cystic lesions of the pancreas, 80% are found to be pseudocysts and 10-15%, neoplastic cysts. The definition of a pseudocyst is: 'an accumulation of pancreatic juice surrounded by a wall of connective tissue or granulation tissue, developed as the result of acute pancreatitis, pancreatic injury or chronic pancreatitis'. In cases of asymptomatic pseudocyst, an expectative policy suffices; growth and symptomatic pseudocysts justify intervention. In addition to surgical internal drainage (cystojejunostomy) there are new therapeutic techniques: external drainage guided by ultrasonography or CT, and internal drainage guided by endoscopy. Endoscopic drainage is the treatment of choice, but it requires experienced hands. The cystic tumours are subdivided into two groups: serous and mucinous cystadenomas. The group of mucinous tumours is subdivided into mucinous cystadenomas and intraductal papillary mucinous tumours. The mucinous or macrocystic adenoma is potentially malignant and should be treated as a malignancy.

[Good results from circumcisions of Muslim boys performed outside the hospital]. / Gunstige resultaten bij circumcisie van moslimjongens buiten het ziekenhuis.

OBJECTIVE: To describe the experience with circumcision of Moslem boys under local anaesthesia outside the hospital. DESIGN: Prospective, descriptive. METHOD: A total of 94 circumcisions under local anaesthesia were performed from April through November 1997 in a Health Centre of the Municipal Health Service, Utrecht, the Netherlands. Pain and unrest of the boys were scored on a scale from 1 to 10 by the operating surgeon (1 = no pain/patient fully calm; 10 = unbearable pain/patient in panic). Postoperative follow-up was only done on request of the parents/fosterers. The reasons for these follow-ups were recorded. One week after the circumcision the parents/fosterers were asked if there were any complications and whether they were satisfied with this method. RESULTS: The median age was 3 years (range: 2-24). The pain during the operation was scored by the surgeon with a median of 1 (1-6) while unrest scored a median of 3 (1-9). Thirteen children were seen again because of bleeding (n = 4), haematoma (n = 2), swelling (n = 7). One week after the operation 89% of 70 parents/fosterers interviewed by telephone were content with the treatment. The social aspect of this way of circumcision was much appreciated. CONCLUSION: Circumcisions under local anaesthesia outside the hospital are feasible. Complications were according to published figures and most parents were content. With this procedure a cost reduction of 70% may be achieved in comparison with clinically performed circumcision under general anaesthesia.

[Increase of surgical day treatment in the Netherlands]. / Toename van chirurgische dagverpleging in Nederland.

OBJECTIVE: To assess the quantitative development of day surgery in the Netherlands. DESIGN: Descriptive. SETTING: St. Antonius Hospital, Nieuwegein, the Netherlands. METHOD: Numbers of admissions in the period 1984-1995 were obtained from Dutch data bases of the National Hospital Institution (NZi). From SIG Health Care Information numbers were obtained with regard to seven specified interventions in the years 1991 to 1995, i.e. breast tumour excision, inguinal hernia repair, varicose vein operation, laparoscopic sterilisation, knee arthroscopy, cataract operation and tonsillectomy. The increase if any of the number of interventions in day care was determined by placing the hospitals in the order of decreasing proportions of day care, and subsequently applying the proportions of the 5th and 10th hospitals, respectively, to the whole group. RESULTS: The number of day care admissions rose from 172,000 (9.9% of all admissions) to 649,000 (29.1%). Of all interventions studied, the percentage carried out in day care increased; the percentages varied greatly from one hospital to another. In 1995, the mean number of interventions in daytime was 115,000 (57% of all 201,000 interventions). The shift from interventions during hospitalization to day care would be 42,000 and 51,000 (21% and 25% respectively, of 201,000), respectively; operations performed in day care would then amount to 166,000 (83% of the total number of interventions) and 157,000 (78%). CONCLUSION: Of the interventions studied, the proportion carried out in day care increased to 57%. In view of the intra- and interhospital differences, a considerable increase of day care in the near future is possible.

[Towards safer and parenchyma-conserving liver resections: experience with three-dimensional reconstructions of spiral CT scan]. / Naar veiliger en parenchymsparende leverresecties; ervaringen met driedimensionale reconstructies van de spiraal-CT-scan.

New techniques are available for the diagnosis and treatment of liver metastases. Three patients, a male aged 52 and two females aged 70 and 47, developed liver metastases after resection of a colorectal carcinoma. Spiral CT scanning made possible detailed three dimensional imaging of the liver to determine the extension of the metastases and the site of the metastasis in relation to blood vessels and bile ducts. This enabled the surgeon preoperatively to arrive at a balanced operation strategy, with the objectives of radical resection of the metastasis and conservation of sufficient residual liver tissue with minimal morbidity and mortality. In addition, use was made of peroperative clamping of blood vessels to determine the possibility of resecting along anatomical borders. This offers the advantages that less blood is lost and a smaller resection often suffices. In the 3 patients followed respectively a wedge excision of the tumour, a wedge excision combined with a hemihepatectomy and a resection of two segments.

Electroantennograms by mountain pine beetles,Dendroctonus ponderosae Hopkins, exposed to selected chiral semiochemicals.

Electroantennograms (EAGs) were recorded fromD. ponderosae to the enantiomers of the terpenoid bark-beetle pheromonestrans-verbenol,cis-verbenol, verbenone, and the bicyclic ketals frontalin,exo-brevicomin, andendo-brevicomin. Male and female responses to enantiomers of the terpenoids differed significantly only at the two highest concentrations. No sex differences were seen in response to the bicyclic ketals. Significantly different responses to the enantiomers of all the chemicals, except frontalin, were noted over at least part of the dosage-response ranges tested. The negative antipode for all of the terpenoids elicited higher responses, while for the bicyclic ketals, the positive antipode effected the largest responses except for the two highest concentrations ofexo-brevicomin.