Comparison of surgical skill acquisition by UK surgical trainees and Sierra Leonean associate clinicians in a task-sharing programme.

Background: Task-sharing in surgery is well established, with associate clinicians performing successful surgery in many countries. Little is known about the process of surgical skill acquisition by associate clinicians, or whether this differs from that of doctors. Methods: A blinded experimental study compared surgical skill acquisition by Sierra Leonean associate clinicians enrolled in an essential and emergency surgery training programme with that of a matched group of UK surgical trainees. After identical instruction, practice time and with identities disguised, trainees were videoed performing simulated surgery. Trainees were marked on 12 performance parameters and five behaviour characteristics using validated tools and qualitative comment. Results: The Sierra Leonean group comprised 19 associate clinicians and one doctor; the UK group comprised 20 doctors in their first 5 years of training. The UK group had significantly more surgical and postgraduate experience than the Sierra Leonean group. The Sierra Leonean trainees outperformed the UK trainees on three of the 12 performance parameters and four of the five behaviour characteristics. UK trainees did not outperform Sierra Leonean trainees on any parameter or characteristic. Qualitative differences in learning style were observed. Conclusion: Sierra Leonean associate clinicians demonstrated equal or superior skill in all objective parameters tested, despite having less experience than the UK doctors.

Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone.

INTRODUCTION: The mortality and morbidity of Ebola extends far wider than those contracting the disease. Surgical activity in Sierra Leone has been severely disrupted by the epidemic. METHOD: This is a retrospective study examining the effect of the 2014-2015 Ebola virus epidemic on surgical activity in a Sierra Leone's main teaching hospital. RESULTS: The impact of national and local events on surgical provision is illustrated by the experience of Connaught Hospital, Freetown Sierra Leone. Surgical activity fell dramatically in August 2014, the month when the most health care workers died and continued to fall to just 3% of expected activity. Two of eight surgeons at Connaught Hospital died of Ebola. DISCUSSION: The example of Connaught Hospital serves as a graphic and poignant illustration of the difficulties faced by surgeons in low resource settings when dealing with the acute effects of a natural disaster. In any future epidemic, high levels of preparedness, training and protection, in addition to liaison with public health teams early in an epidemic, may allow surgeons to carry out at least some of their duties without the very high levels of personal risk seen here.In a country with so few specialists the loss of 25% is disastrous and will result in long term capacity reduction.

Pancolonic motor response to subsensory and suprasensory sacral nerve stimulation in patients with slow-transit constipation.

BACKGROUND: Sacral nerve stimulation (SNS) is emerging as a potential treatment for patients with constipation. Although SNS can elicit an increase in colonic propagating sequences (PSs), the optimal stimulus parameters for this response remain unknown. This study evaluated the colonic motor response to subsensory and suprasensory SNS in patients with slow-transit constipation. METHODS: Patients with confirmed slow-transit constipation were studied. Either a water-perfused manometry catheter or a high-resolution fibre-optic manometry catheter was positioned colonoscopically to the caecum. A temporary electrode was implanted transcutaneously in the S3 sacral nerve foramen. In the fasted state, three conditions were evaluated in a double-blind randomized fashion: sham, subsensory and suprasensory stimulation. Each 2-h treatment period was preceded by a 2-h basal period. The delta (Δ) value was calculated as the frequency of the event during stimulation minus that during the basal period. RESULTS: Nine patients had readings taken with a water-perfused catheter and six with a fibre-optic catheter. Compared with sham stimulation, suprasensory stimulation caused a significant increase in the frequency of PSs (mean(s.d.) Δ value - 1·1(7·2) versus 6·1(4·0) PSs per 2 h; P = 0·004). No motor response was recorded in response to subsensory stimulation compared with sham stimulation. Compared with subsensory stimulation, stimulation at suprasensory levels caused a significant increase in the frequency of PSs (P = 0·006). CONCLUSION: In patients with slow-transit constipation, suprasensory SNS increased the frequency of colonic PSs, whereas subsensory SNS stimulation did not. This has implications for the design of therapeutic trials and the clinical application of the device.

A critical review of racial/ethnic variables in osteoporosis and bone density research.

UNLABELLED: Racial and ethnic variables are common in research on variation in bone density. This literature review describes some of the common flaws associated with the use of these variables and provides some suggestions for how bone density research may be able to better document and address skeletal health disparities. INTRODUCTION: Racial/ethnic differences in bone density have been commonly documented in the research literature. While effective identification of the specific factors underlying these trends might go a long way in informing treatment and screening for osteoporosis, this would require careful consideration of exactly what these variables are capturing. However, the basis and implications of what racial/ethnic variables represent have not carefully been examined in bone density research. METHODS: For this paper, we systematically reviewed 55 articles that included bone density and race/ethnicity as key variables. Our analysis reveals that racial/ethnic terminology in these articles is highly variable, and discussion of how race/ethnicity is determined is often vague and idiosyncratic. Racial/ethnic variables are being used for a wide range of analytical purposes in statistical tests, which may not be appropriate for such a complex and poorly defined variable. RESULTS: Many articles attribute racial/ethnic differences in bone mass/bone density to genetic causes, although few studies actually examine genetic data. CONCLUSION: This analysis indicates that more rigorous examination of what race/ethnicity actually captures, more careful definitions of group labels and the procedures for assigning them, and attention to the limitations of how such variables can reliably be used in data analyses is needed to help address the problems and issues outlined in this review.

Pancolonic spatiotemporal mapping reveals regional deficiencies in, and disorganization of colonic propagating pressure waves in severe constipation.

BACKGROUND: The morphology, motor responses and spatiotemporal organization among colonic propagating sequences (PS) have never been defined throughout the entire colon of patients with slow transit constipation (STC). Utilizing the technique of spatiotemporal mapping, we aimed to demonstrate 'manometric signatures' that may serve as biomarkers of the disorder. METHODS: In 14 female patients with scintigraphically confirmed STC, and eight healthy female controls, a silicone catheter with 16 recording sites spanning the colon at 7.5 cm intervals was positioned colonoscopically with the tip clipped to the cecum. Intraluminal pressures were recorded for 24 h. KEY RESULTS: Pan-colonic, 24 h, spatiotemporal mapping identified for the first time in STC patients: a marked paucity of propagating pressure waves in the midcolon (P = 0.01), as a consequence of a significant (P < 0.0001) decrease in extent of propagation of PS originating in the proximal colon; an increase in frequency of retrograde PS in the proximal colon; a significant reduction in the spatiotemporal organization among PS (P < 0.001); absence of the normal nocturnal suppression of PS. CONCLUSIONS & INFERENCES: Pancolonic, 24 h, spatiotemporal pressure mapping readily identifies characteristic disorganization among consecutive PS, regions of diminished activity and absent or deficient fundamental motor patterns and responses to physiological stimuli. These features are all likely to be important in the pathophysiology of slow transit constipation.

Genes, race and research ethics: who's minding the store?

BACKGROUND: The search for genetic variants between racial/ethnic groups to explain differential disease susceptibility and drug response has provoked sharp criticisms, challenging the appropriateness of using race/ethnicity as a variable in genetics research, because such categories are social constructs and not biological classifications. OBJECTIVES: To gain insight into how a group of genetic scientists conceptualise and use racial/ethnic variables in their work and their strategies for managing the ethical issues and consequences of this practice. METHODS: In-depth semi-structured interviews were conducted with a purposive sample of 30 genetic researchers who use racial/ethnic variables in their research. Standard qualitative methods of content analysis were used. RESULTS: Most of the genetic researchers viewed racial/ethnic variables as arbitrary and very poorly defined, and in turn as scientifically inadequate. However, most defended their use, describing them as useful proxy variables on a road to "imminent medical progress". None had developed overt strategies for addressing these inadequacies, with many instead asserting that science will inevitably correct itself and saying that meanwhile researchers should "be careful" in the language chosen for reporting findings. CONCLUSIONS: While the legitimacy and consequences of using racial/ethnic variables in genetics research has been widely criticised, ethical oversight is left to genetic researchers themselves. Given the general vagueness and imprecision we found amongst these researchers regarding their use of these variables, they do not seem well equipped for such an undertaking. It would seem imperative that research ethicist move forward to develop specific policies and practices to assure the scientific integrity of genetic research on biological differences between population groups.

An epidemiological study of myopathies in Warmblood horses.

REASON FOR PERFORMING STUDY: There are few detailed reports describing muscular disorders in Warmblood horses. OBJECTIVES: To determine the types of muscular disorders that occur in Warmblood horses, along with presenting clinical signs, associated risk factors and response to diet and exercise recommendations, and to compare these characteristics between horses diagnosed with polysaccharide storage myopathy (PSSM), those diagnosed with a neuromuscular disorder other than PSSM (non-PSSM) and control horses. METHODS: Subject details, muscle biopsy diagnosis and clinical history were compiled for Warmblood horses identified from records of biopsy submissions to the University of Minnesota Neuromuscular Diagnostic Laboratory. A standardised questionnaire was answered by owners at least 6 months after receiving the muscle biopsy report for an affected and a control horse. RESULTS: Polysaccharide storage myopathy (72/132 horses) was the most common myopathy identified followed by recurrent exertional rhabdomyolysis (RER) (7/132), neurogenic or myogenic atrophy (7/132), and nonspecific myopathic changes (14/132). Thirty-two biopsies were normal. Gait abnormality, 'tying-up', Shivers, muscle fasciculations and atrophy were common presenting clinical signs. Forty-five owners completed questionnaires. There were no differences in sex, age, breed, history or management between control, PSSM and non-PSSM horses. Owners that provided the recommended low starch fat supplemented diet and regular daily exercise reported improvement in clinical signs in 68% (19/28) of horses with a biopsy submission and 71% of horses diagnosed with PSSM (15/21). CONCLUSIONS: Muscle biopsy evaluation was a valuable tool to identify a variety of myopathies in Warmblood breeds including PSSM and RER. These myopathies often presented as gait abnormalities or overt exertional rhabdomyolysis and both a low starch fat supplemented diet and regular exercise appeared to be important in their successful management. POTENTIAL RELEVANCE: Warmbloods are affected by a variety of muscle disorders, which, following muscle biopsy diagnosis can be improved through changes in diet and exercise regimes.

Spinal-injured neuropathic bladder antisepsis (SINBA) trial.

OBJECTIVE: To determine whether Methenamine Hippurate (MH) or cranberry tablets prevent urinary tract infections (UTI) in people with neuropathic bladder following spinal cord injury (SCI). STUDY DESIGN: Double-blind factorial-design randomized controlled trial (RCT) with 2 year recruitment period from November 2000 and 6 month follow-up. SETTING: In total, 543 eligible predominantly community dwelling patients were invited to participate in the study, of whom 305 (56%) agreed. METHODS: Eligible participants were people with SCI with neurogenic bladder and stable bladder management. All regimens were indistinguishable in appearance and taste. The dose of MH used was 1 g twice-daily. The dose of cranberry used was 800 mg twice-daily. The main outcome measure was the time to occurrence of a symptomatic UTI. RESULTS: Multivariate analysis revealed that patients randomized to MH did not have a significantly longer UTI-free period compared to placebo (HR 0.96, 95% CI: 0.68-1.35, P=0.75). Patients randomized to cranberry likewise did not have significantly longer UTI-free period compared to placebo (HR 0.93, 95% CI: 0.67-1.31, P=0.70). CONCLUSION: There is no benefit in the prevention of UTI from the addition of MH or cranberry tablets to the usual regimen of patients with neuropathic bladder following SCI.

An analytical framework for contrasting patient and provider views of the process of chronic disease management.

Medical anthropologists involved in clinical research are often asked to help explain patients' "noncompliance" with treatment recommendations. The clinical literature on "noncompliance" tends to problematize only the patient's perspective, treating the provider's perspective as an uncontroversial point of departure. Explicating the articulation between provider and patient assumptions, expectations, and perceptions in managing chronic illness is an area well suited to the unique perspective of medical anthropologists. In this article we present an analytical framework for contrasting patient and provider goals, strategies, and evaluation criteria in chronic illness management, using examples from research on type 2 diabetes care in South Texas. This approach goes beyond contrasting patient and provider concepts and explanations of the illness itself and examines their contrasting views within the dynamic process of long-term care. This approach may prove especially useful for research aimed at a clinical audience, since it maintains a clinically relevant focus while giving serious consideration to the patient's perspective.

Development of a life events/icon calendar questionnaire to ascertain occupational histories and other characteristics of migrant farmworkers.

BACKGROUND: Specialized methods are necessary to collect data from migrant farmworkers for epidemiologic research. METHODS: We developed a questionnaire that collected lifetime occupational histories and other lifestyle risk factors via a life events/icon calendar, and administered the questionnaire to a convenience sample of 162 migrant farmworkers in nine areas of the U.S. RESULTS: The average duration of the interviews was about 1 h 30 min, with an average of 45 min for the work history section. The occupational histories covered a median of 27.6 years per person for men and 20.8 years per person for women. The median number of years spent in farm jobs was 11.3 for men and 5.8 for women. The median number of farm jobs (crop/task combination) per person was 59 among men and 27 among women. Many farmworkers performed the same crop/task combinations at multiple times throughout their lives, yielding a median of 13 unique farm jobs and 8 unique crops among men and 7 jobs and 5 crops among women. CONCLUSIONS: The project demonstrated that it is feasible to collect detailed work histories and other risk factor data from farmworkers, documented the complexity of work histories encountered among farmworkers, and yielded recommendations for refining a questionnaire that will facilitate future epidemiologic research on farmworkers.

Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators.

PURPOSE: This study assessed the extent to which community-dwelling rural older adults mismanage their prescription medication regimens and predicted mismanagement of medications from selected socioeconomic, health status, and medication profile characteristics. DESIGN AND METHODS: Personal interviews with 499 community-dwelling adults aged 66 and over taking at least one prescription medication and living in a rural region of the Southeast. With approximately equal numbers of African American and white men and women, the SUDAAN multiple logistic regression procedure was used to predict the mismanagement of prescription medications. RESULTS: The mismanagement of prescribed medication regimens is relatively common among older adults. Those more likely than others to mismanage their regimens are African American, younger, in poorer mental health, with more acute care physician visits, and those who find payment for their medications to be problematic. IMPLICATIONS: The implications of the findings for what is known about the self-modification of drug regimens, targeting prescription drug cost benefits or interventions, and the limitations of the study are discussed.

Herbs, prayer, and insulin. Use of medical and alternative treatments by a group of Mexican American diabetes patients.

BACKGROUND: Clinicians are often concerned that use of alternative treatments by Mexican American patients with diabetes competes with medical treatment. We examined the use and evaluation of alternative treatments for diabetes by a sample of these patients. METHODS: Following a descriptive qualitative design, a convenience sample of 43 low-income Mexican Americans with type 2 diabetes were interviewed. We analyzed interview transcripts for alternative treatments named, patterns of use, evaluation of those treatments, and the use of biomedical approaches. We crosschecked the results for interrater reliability. RESULTS: Herbs were mentioned as possible alternative treatments for diabetes by 84% of the patients interviewed. However, most had never or rarely tried herbs and viewed them as supplemental to medical treatments. Most said prayer influences health by reducing stress and bringing healing power to medicines. None used curanderos (traditional healers) for diabetes. Most actively used biomedical treatments and were less actively involved in alternative approaches. Statistical tests of association showed no competition between biomedical and alternative treatments, and alternative treatment activity tended to be significantly lower than biomedical. Most study participants emphasized medical treatment and only used alternative treatments as secondary strategies. Those patients very actively using alternative approaches also tended to be very actively using biomedical methods; they were using all resources they encountered. CONCLUSIONS: Traditional attitudes and beliefs were not especially important to the patients in this study and presented no barriers to medical care. For these patients, it also cannot be assumed that belief in alternative treatments and God's intervention indicate fatalism or noncompliance but instead require consideration of individual treatment behaviors.

Contrasting patient and practitioner perspectives in type 2 diabetes management.

Studies of self-care behaviors in the management of type 2 diabetes often focus on patient knowledge and motivation, without considering the role of practitioner orientations. Using an exploratory descriptive design, we conducted open-ended interviews with 51 type 2 diabetes patients and 35 practitioners from clinics in San Antonio and Laredo, Texas. We found critical differences between patient and practitioner goals, evaluations, and strategies in diabetes management, especially regarding such key concepts as "control" and "taking care of self". Practitioners' perspectives are rooted in a clinical context, emphasizing technical considerations, whereas patients' perspectives exist within a life-world context and foreground practical and experiential considerations. These result in very different approaches to treatment. Practitioners, presuming failed treatment indicates uncooperativeness, try to inform and motivate patients. The patients we interviewed, however, understood and were committed to type 2 diabetes self-care, but lacked full access to behavioral options due to their poverty and limited social power.

Management of sexually transmitted disease by surgeons.

The management of 63 patients diagnosed by surgeons as having sexually transmitted disease (STD) was audited. A diagnosis of STD was made in 51 (81%) of patients without taking a sexual history. Only 2 (3%) patients were referred to genitourinary medicine (GUM). Appropriate microbiological specimens were obtained from only two of 52 (4%) patients diagnosed with either pelvic inflammatory disease (PID) or epididymo-orchitis. Reliance was placed on inappropriate specimens in 22 (42%). There was widespread use of inappropriate antibiotics. The management of sexually transmitted disease by surgeons was very poor. These patients should all be referred to genito-urinary medicine.

Abnormal Pap screening among Mexican-American women: impediments to receiving and reporting follow-up care.

PURPOSE/OBJECTIVES: To understand impediments to receiving and reporting timely follow-up care for abnormal Pap tests among Hispanic women. DESIGN: Descriptive, qualitative. SETTING: A federally funded cancer screening clinic in urban South Texas. SAMPLE: 11 Mexican/Mexican-American women over 40 years old who appear in clinic records as "lapsed" in follow-up and 5 clinic staff members. METHODS: Semistructured, qualitative interviews regarding staff and patient concepts about cancer, cancer screening, and follow-up. Abstraction of patients' clinic charts. MAIN RESEARCH VARIABLES: Factors associated with women being classified as "lapsed" in follow-up care for abnormal Pap tests. FINDINGS: Only two patients had no follow-up, while nine eventually had follow-up, either elsewhere or after several missed appointments. Contrary to expectations, poor knowledge, lack of social support, and lack of availability of care were not factors impeding follow-up. Reluctance to be examined by a male practitioner, lack of flexibility in scheduling clinic appointments, and poor staff communication regarding appointments and the seriousness of the condition were all influences negatively affecting follow-up behavior. Nevertheless, these women went to significant lengths to comply with follow-up recommendations. CONCLUSIONS: The classification of patients' follow-up behavior as "lapsed" was not attributable to culturally based beliefs and attitudes, nor lack of knowledge and motivation, but was primarily the result of institutional features such as scheduling and record-keeping practices and policies. IMPLICATIONS FOR NURSING PRACTICE: More thorough evaluation of actual behaviors would ensure more accurate assessment of follow-up behavior in this group. More female practitioners, better communication of appointments and of the seriousness of the condition, and more flexible scheduling options would reduce the difficulty these Hispanic patients encountered in having timely follow-up care.

Moral reasoning and the meaning of cancer: causal explanations of oncologists and patients in southern Mexico.

Moral themes were a striking feature of the causal explanations for female cancers discussed by oncologists and patients in an ethnographic study of hospital-based cancer care in southern Mexico. These explanations integrate general biomedical explanations with everyday expectations and experiences, giving meaning to otherwise arbitrary events. Analysis of case examples shows that causal models incorporate local constructs about what constitutes a virtuous life, especially in terms of class-and gender-based values. Although patients and physicians draw on similar concepts of moral order, they apply these constructs in distinct ways. Because physicians' explanations are necessarily framed in terms of object, their causal stories employ generalized presumptions about how categories of persons behave (e.g., women, the lower class). In contrast, patients' explanations are framed in terms of subject; they are based on the specific details of their personal history. The article examines the distinct perspectives of physicians and patients, and provides an illustration of how biomedical culture articulates with the local moral constructs of a particular community.

Porque me tocó a mi? Mexican American diabetes patients' causal stories and their relationship to treatment behaviors.

This paper reports findings from an ethnographic study of self-care behaviors and illness concepts among Mexican-American non-insulin dependent diabetes mellitus (NIDDM) patients. Open-ended interviews were conducted with 49 NIDDM patients from two public hospital outpatient clinics in South Texas. They are self-identified Mexican-Americans who have had NIDDM for at least 1 yr, and have no major impairment due to NIDDM. Interviews focused on their concepts and experiences in managing their illness and their self-care behaviors. Clinical assessment of their glucose control was also extracted from their medical records. The texts of patient interviews were content analyzed through building and refining thematic matrixes focusing on their causal explanations and treatment behaviors. We found patients' causal explanations of their illness often are driven by an effort to connect the illness in a direct and specific way to their personal history and their past experience with treatments. While most cite biomedically accepted causes such as heredity and diet, they elaborate these concepts into personally relevant constructs by citing Provoking Factors, such as behaviors or events. Their causal models are thus both specific to their personal history and consistent with their experiences with treatment success or failure. Based on these findings, we raise a critique of the Locus of Control Model of treatment behavior prevalent in the diabetes education literature. Our analysis suggests that a sense that one's own behavior is important to the disease onset may reflect patients' evaluation of their experience with treatment outcomes, rather than determining their level of activity in treatment.

Endoscopic screening of relatives of patients with colorectal cancer.

BACKGROUND: The risk of colorectal cancer is higher among relatives of those affected. The neoplastic yield reported from screening such individuals varies enormously between studies and depends on the age and strength of the family history of those screened. AIMS: To ascertain the neoplastic yield of endoscopic screening of first degree relatives of patients with colorectal cancer by age and familial risk. SUBJECTS: A total of 330 individuals with a family history of colorectal cancer. METHOD: Endoscopic screening conducted according to a protocol. RESULTS: Adenomas were found in 12%, and adenomas larger than 1 cm in 8%, of "high risk" individuals screened primarily by colonoscopy. Of those with neoplasia, 26% had lesions at or proximal to the splenic flexure. Neoplasia was found in 9.5% of individuals at lower familial risk, screened primarily by 60 cm flexible sigmoidoscopy, 4% of whom had neoplasia larger than 1 cm in size or cancer. Neoplastic yield was greatest in the fourth and fifth decades in those at highest risk, but increased with age in those at lower risk. CONCLUSIONS: For individuals with two or more first degree relatives, or relatives who have developed colorectal cancer at a young age, colonoscopy appears to be the only satisfactory method of screening, but 60 cm flexible sigmoidoscopy may be useful in those at lower levels of risk.