Ureteral injury during aortic aneurysm repair by the retroperitoneal approach.

Three ureteral injuries (two proximal, one middle) associated with retroperitoneal repair of aortic abdominal aneurysms are reported. The authors believe these represent traction injuries that are related to the use of stationary retractors and suggest that complete anterior mobilization of the left kidney from its posterior fossa will decrease the odds of such an injury.

Motor vehicle crash involvement and moving violations: convergence of self-report and archival data.

In the crash involvement literature, it is generally assumed that archival and other "objective" criterion data are superior to self-reports of crash involvement. Using 394 participants (mean age = 36.23 years), the present study assessed the convergence of archival and self-report measures of motor vehicle crash involvement and moving violations. We also sought to determine whether predictor/criterion relationships would vary as a function of criterion type (i.e., archival vs. self-report), and if a combination of both criteria would result in better prediction than would either by itself. The degree of agreement between the two criterion sources was low, with participants self-reporting more crashes and tickets than were found in their state records. Different predictor/criterion relationships were also found for the two criterion types; stronger effects were obtained for self-report data. Combining the two criteria did not result in relationships stronger than those obtained for self-reports alone. Our findings suggest that self-report data are not inherently inferior to archival data and, furthermore, that the two sources of data cannot be used interchangeably. Actual or potential applications include choosing the appropriate criterion to use, which, as the finding of this study reveals, may depend on the purpose of the investigation.

Timing of postcarotid complications: a guide to safe discharge planning.

OBJECTIVES: Currently, our standard of practice is that patients undergoing carotid endarterectomy (CEA) may be safely discharged on the first postoperative day. Because many patients do not appear to require overnight observation, we wanted to determine the safety and feasibility of same-evening discharge by establishing the timing of postoperative complications, which may potentially require operative intervention. METHODS: A total of 835 consecutive patients undergoing CEA were retrospectively reviewed. Sixty-two patients had a postoperative wound hematoma or neurologic deficit (ND) (transient ischemic attack or stroke) within 24 hours of their operation, complications potentially requiring a second operation. Excluded were 64 patients not eligible for same-day discharge because of other reasons (eg, heparinization, CEA with coronary artery bypass grafting). RESULTS: Sixty-two patients (8.0%) had ND (26 [3.4%]) or neck hematoma (NH) (36 [4.7%]) within 24 hours of their CEA. Nineteen (73%) of the NDs were diagnosed in the operating room or recovery room, 5 (19%) within 8 hours of the operation, and 2 (7.7%) after 8 hours but in less than 24 hours. Of the NHs, 23 (66%) were diagnosed in the recovery room, 11 (31%) within 8 hours, and 1 (2.7%) after 8 hours. Of the outliers, one patient experienced a blowout of the vein graft occurring on postoperative day 1, one patient had a delayed ipsilateral stroke, and one had a vertebrobasilar stroke. Overall, only three of 773 (0.4%) patients undergoing CEA had a complication occurring more than 8 hours after operation. CONCLUSION: NDs and NHs in post-CEA patients occurred within 8 hours of operation in 95% of those patients experiencing these complications or 99.6% of all CEA patients. These data indicate that same-evening discharge may be safely performed without increasing the adverse effects of stroke or hematoma. This plan has cautiously been initiated at this institution.

How well do third-year medical students learn key objectives in a case-based surgical lecture series?

Faculty members were asked to list major and minor concepts of their case-based session presented during the 12-week 3rd-year surgical clerkship. After each session, students were queried to list the key concepts presented. Data were collected from two groups: one at the end of an academic year and a second at the beginning of the next academic year. Faculty members listed a median of 10 major and 15 minor concepts. The mean number of matched major concepts ranged from 0.2 to 4, and from 0.2 to 3.4 for minor concepts. In a comparative analysis, the end-of-the-year students listed a higher number of matched concepts for 17 of the 20 sessions than the beginning of the year students (8 sessions reached statistical significance, P < 0.05). The current case-based teaching method is not effective in emphasizing key concepts to students. Reformatting cases to better align with key concepts may be one solution to enhance a student's ability to grasp key concepts. Students at the end of the academic year outperformed those at the beginning of the year. This additional variable needs to be considered by faculty and incorporated into their teaching techniques.

A look-back investigation of patients of an HIV-infected physician. Public health implications.

BACKGROUND: Transmission of the human immunodeficiency virus (HIV) to five patients receiving care from an HIV-infected dentist in Florida has recently been reported. Current data indicate that the risk of HIV transmission from health care workers to patients is low. Despite this low risk, programs to notify patients of past exposure to an HIV-infected health care worker are being conducted with increasing frequency. METHODS: We recently conducted an investigation of all the patients cared for by an HIV-infected family physician during a period when he had severe dermatitis caused by Mycobacterium marinum on his hands and forearms. After reviewing the patients' records, we notified 336 patients who had undergone one or more procedures (digital examination of a body cavity or vaginal delivery) placing them at potentially increased risk of HIV infection. The patients were offered tests for HIV infection and counseling. RESULTS: Of the 336 patients, 325 (97 percent) had negative tests for HIV antibody, 3 (1 percent) refused testing, 1 (less than 1 percent) died of a cause unrelated to HIV infection before notification, and the HIV-antibody status of 7 (2 percent) remained unknown. The direct and indirect public health costs of this investigation were approximately $130,000. CONCLUSIONS: The results of this investigation raise important questions about the risk of HIV transmission from health care workers to patients and the usefulness of HIV look-back programs, particularly in the light of recently published recommendations from the Centers for Disease Control. We propose that before a look-back investigation is undertaken, there should be a clearly identifiable risk of transmission of the infection, substantially higher than the risk requiring limitation of an HIV-infected health care worker's practice prospectively.

Perceptions of sexual responsibility: do young men and women agree?

PIP: A nonprobability, convenience sample of 248 subjects of a large midwestern university agreed to participate in this study designed to investigate the perception of responsibility for contraception among late adolescents (over age 17), to determine whether age, gender, or sexual activity influences perceptions of responsibility, and to explore the relationship between perceived contraceptive responsibility and subsequent contraceptive choice among late adolescent males and females. The students were enrolled in an undergraduate public health class during the 1984 spring quarter. After initial data examination, 28 married subjects were eliminated from analysis. Of the final sample size of 220 students, 131 were female and 89 were male. The majority of the students, 57.5%, were between the ages of 20-22; 19% were between the ages of 17-19; and the remaining 23% were older than 22. The students completed a questionnaire anonymously as part of the development of a slide-tape program entitled "Young Men's Sexual Responsibility." Contraceptive responsibility was defined as perceived responsibility for pregnancy control, perceived responsibility to initiate conversation about contraception in a dating relationship, and perceived responsibility for who should pay for contraceptives. 63% of the students indicated that they had engaged in sexual intercourse at least once. Male students were significantly more likely to have had sexual intercourse than female students. Only 7% of the entire sample reported having had intercourse before the age of 15, but this sample consisted primarily of white, middle-class college students who may not represent students in inner-city school districts reported to have had 1st intercourse at earlier ages. 91% of the students perceived contraceptive responsibility as a shared responsibility. Of the small number of students who perceived 1 sex or the other responsible for pregnancy control, most (7%) perceived that it was the woman's responsibility. No relationship was found between age or intercourse experience and perceived contraceptive responsibility. 52.3% of the students reported using effective birth control methods at 1st intercourse, but 37.2% reported not using contraceptives. The remaining students used 2 of the least effective methods for adolescents (withdrawal, 7.2%; rhythm, 3.5%). No relationship was found between the students' perception of responsibility for pregnancy control or responsibility for initiating a conversation about contraception and the type of contraceptive used at most recent intercourse. If the concept of shared responsibility is in fact an emerging value, health professionals and educators must reconsider sex education curricula for adolescents.^ieng