Complications in laparoscopic intestinal surgery: prevention and management.

Laparoscopic surgery is rapidly becoming the standard of care for many intestinal disorders. Intraoperative complications of laparoscopic intestinal surgery have been described to occur in 4-16% of procedures, although definitions vary widely across reports. Complications associated with first trocar insertion, although rare, can be fatal. The use of an open insertion technique is strongly recommended. Other intraoperative complications associated with laparoscopic intestinal surgery include cautery injuries, vascular injuries and hemorrhage, bowel injuries, bladder and ureteric injuries as well as missed or delayed injuries. Physiolo-gical complications of laparoscopy include pneumoperitoneum-specific complications, cardiopulmonary complications, and position-related complications. Finally, injury to the surgeon can occur, from which the field of surgical ergonomics has been derived.

Broad-based fellowships: a cornerstone of minimally invasive surgery education and dissemination.

Aware of the trends in surgery and of public demand, many residents completing a 5-year training program seek fellowships in minimally invasive surgery (MIS) because of inadequate exposure to advanced MIS during their residency. A survey was designed to evaluate the effectiveness of a broad-based fellowship in advanced laparoscopic surgery offered in an academic health science center. The questionnaire was mailed to all graduates. Data on demographics, comfort level with specific laparoscopic procedures, and opinions regarding the best methods of acquiring these skills were collected. Most of the surgeons entered the fellowship directly after residency. The majority of these surgeons are academic surgeons. Fellows performed a median of 187 cases by the end of their training and felt comfortable operating on foregut, hindgut, and end organ. A full year of training was found to be the best format for appropriate skill transfer. A broad-based MIS fellowship meets the needs of both academic and community surgeons desiring to perform advanced laparoscopic procedures.

Initial validation of a computer-administered Addiction Severity Index: the ASI-MV.

The Addiction Severity Index--Multimedia Version (ASI-MV) is a CD-ROM-based simulation of the interviewer-administered Addiction Severity Index (ASI). Clients in treatment (N = 202) self-administered the ASI-MV to examine the test-retest reliability, criterion validity, and convergent-discriminant validity of the ASI-MV. Excellent test-retest reliability was observed for composite scores and severity ratings. Criterion validity, tested against the interviewer-administered ASI, was good for the composite scores. For severity ratings, variable agreement was observed between the ASI-MV and each interviewer, suggesting poor interrater reliability among interviewers. This conclusion was bolstered by a finding of superior convergent-discriminant validity for both composite scores and severity ratings compared to the standard ASI. The ASI-MV is a viable alternative to the expensive and potentially unreliable interviewer-administered version.

Female condom reuse in Lusaka, Zambia: evidence from 12 cases.

Female condom reuse could address one of the principal barriers to use, namely, cost; however, the safety of reuse has not been established. Recent reports have provided information related to reuse safety under carefully specified research study conditions. Still, little is known about reuse outside a research study context, and there are outstanding questions related to feasibility of reuse among general populations. This study reports on naturally occurring reuse from a small, purposive sample of self-identified women who, prior to the study, had reused the female condom of their own volition without reuse instruction. Three types of reuse were identified. Most women attempted to clean devices between removal and reinsertion. A number of agents, including water (only), bath soap, laundry detergent, Dettol, and beer were used for cleaning. A number of agents were used for relubrication, including Reality((R)) lubricant, various kinds of cooking oil, and Vaseline((TM)). Perception of the strength and integrity of female condoms making them suitable for reuse were influenced by both provider advice and product packaging. Most participants reported no problems with reuse. Some women, faced with barriers to single use of a female condom or use of an acceptable alternative, will resort to reuse and rely on their own "common sense" notions to implement reuse. Providers and purveyors have opportunities to shape responses to reuse for the better, and the research community is obligated to provide a solid scientific base regarding reuse safety.

The importance of field-workers in Bangladesh's family planning programme.

PIP: This study explored the importance of field-workers in Bangladesh's Family Planning Programme. Three separate sources of data were used to develop the analysis. The first data set provides information that was collected as part of a study to calculate the costs of both clinic and home service delivery program of the government. The second data set provided information on the perspective of the field-workers' clients to determine the level of knowledge, attitudes and practices concerning specific issues of oral contraceptive compliance. The third source of data provided information on the willingness and ability to pay for doorstep delivery of contraceptives in two rural areas. Using the three independent studies, it was shown that the length of client-provider interactions was short, and that the percentage of visits in which various family planning, and maternal and child health topic discussion was low. Furthermore, clients lack important information on contraceptives and do not put a high value on interactions with field-workers. The vast majority of clients view the field-worker program as a convenience and not as an important source of information. Furthermore, the studies show even poorer quality of care services, and the reported visits of the field-workers often do not involve discussions on family planning methods. The results indicated that field-workers are not doing a good job in motivating women to adopt contraceptive use. In addition, the high cost and low quality of services indicate that other models of service delivery need to be considered.^ieng

Is a health promotion campaign successful in retail pharmacies?

A sun awareness campaign with the theme "Be Sun Smart" was initiated by the Alberta Pharmaceutical Association in collaboration with the Alberta Cancer Board, Alberta Health and the Canadian Cancer Society. The campaign aimed to increase awareness and knowledge on the part of pharmacists and their staff and customers of adequate protection from the sun. The evaluation consisted of a precampaign questionnaire focusing on pharmacists' attitudes and knowledge, followed by a post-campaign questionnaire evaluating the campaign and assessing changes in pharmacists' knowledge. Questionnaires were sent to all 697 retail pharmacies in Alberta. The data indicated that responding pharmacists' knowledge was high before the campaign. However, knowledge of skin protection and magnitude of the problem did improve from the pre- to postcampaign survey. Pharmacists' precampaign attitudes varied, 49% agreeing that a tanned person looks healthier, and 96% agreeing that skin cancer is a dangerous disease. There was a high degree of acceptance for educational campaigns within retail pharmacies.

Sequential monotherapy of hypertension.

In most cases, the antihypertensive therapy for an individual patient is selected through a process of trial and error. This study determined if, by treating each hypertensive patient sequentially, with six antihypertensive drugs, one from each of the major classes, one could decide on the best possible drug for control of hypertension. In a randomized open-label crossover study, 19 patients (16 male and 3 female), 28-70 years of age with a sitting diastolic blood pressure of 95-110 mm Hg were given atenolol, captopril, clonidine, indapamide, prazosin, and verapamil in a sequential manner. Each drug was started at the minimum recommended or lower dose and titrated upwards every 2 weeks, if well tolerated, until blood pressure was controlled (diastolic BP < 90 mm Hg). If blood pressure was controlled, the drug was continued for another 2 weeks. A washout period of at least 2 weeks was allowed between drugs. Both systolic and diastolic blood pressures were reduced significantly with all of the six drugs. In 18 of the 19 patients, blood pressure was controlled with at least one of six drugs, frequently with the lowest dose. The authors conclude that if hypertension is not controlled with the lowest recommended dose of a drug, other antihypertensive drugs should be tried sequentially rather than increasing the dose or adding a second drug.

User characteristics and oral contraceptive compliance in Egypt.

Results from the 1988 Egypt Demographic and Health Survey show that many women are not taking oral contraceptives in a manner that ensures full protection by the method. Reports from 1,258 current pill users show a range of incorrect use; 63 percent of women surveyed reported an interruption in their use of the pill in the past month, and of those women, only 40 percent took the correct action when they missed a pill. The majority (89 percent) did not wait the correct number of days between packs. Multivariate analysis revealed that rural women were more likely to take pills out of sequence, compared with their urban counterparts. Failure to take a pill within the previous month was strongly associated with the experience of side effects. The younger women surveyed were more likely to know the correct interval between pill packs than were older women; and women who wanted more children were more likely to know the correct interval than those who did not. The use patterns exhibited by the pill users may be the result of their receiving confusing, incorrect, or incomplete information, and highlight the need to provide women with accurate, updated, and comprehensible information about oral contraceptives.

PIP: The results of the 1988 Egypt Demographic and Health Survey showed that misuse of oral contraceptives was higher by four times when the source was the government. Users took pills out of sequence. Further follow-up is needed because of the small sample sizes and lack of information on differences in packaging, counseling, knowledge, or other psychosocial factors. Results also indicated that women who were uneducated were more likely than educated women to take pills out of sequence. Confounding beliefs that the pill need only be used when sperm were present may have been responsible. Support was given to prior findings that there was a strong association between occurrence of side effects and discontinuation of use. This practice was explained as possibly related to the belief that the body needed a "rest" and the misunderstanding that breakthrough bleeding was a resumption of menses, which would necessitate stopping pill taking. Women reported having missed taking pills without becoming pregnant, which reinforced the idea that pills need not be taken sequentially. Findings also indicated that pills were taken more consistently and correctly, when husbands or some else secured the product for the client. An important finding was that almost all had poor knowledge of the correct interval to wait before resuming pill use between cycles. A study by Abou-Bakr found that family planning training was variable, and counseling was not directed to the level of knowledge, understanding, or concerns of clients. Clients also relied heavily on the printed instructions/inserts provided with the supplies. The sample included 8911 ever married women aged 15-49 years, and a subsample of 1258 current oral contraceptive users. Oral contraceptive users were 59% urban and had a mean number of 4 children. 44% had no education. 28% of husbands had no education. Pill use averaged 2 years and ranged from 2 months to 22 years. 91% used 21 day cycle pills. Logistic regression models were used to analyze incorrect pill use.