A language for effective communication between surgeons and radiographers in trauma theatre.

INTRODUCTION: The advent of the image intensifier has revolutionised trauma surgery since its development in 1955. The manufacturers have given names to various movements of the machine in the operating manual but it has not been popular among orthopaedic surgeons or radiographers. Lack of knowledge of names of various movements and ambiguity in command often leads to confusion between the surgeon and the radiographer regarding which way to move the image intensifier. A questionnaire-based study was conducted to assess the efficacy of communication between orthopaedic surgeons and radiographers while using the image intensifier intra-operatively. SUBJECTS AND METHODS: Diagrams depicting the movements of the image intensifier were used in the questionnaire. Fifty questionnaires were given to orthopaedic surgeons and 50 to radiographers to name the various movements. RESULTS: Ninety questionnaires were returned, 45 from surgeons and 45 from radiographers. Five questionnaires from surgeons and five from radiographers were returned blank. Of those responding, 97% could name the vertical movement, 68% the horizontal movement, 12% the swivel and 29% the angulation movement. None could name the orbital movement. CONCLUSIONS: Even though orthopaedic surgeons do not operate the image intensifier themselves, knowledge of the movements of the image intensifier and their names can improve the efficacy of communication between surgeons and radiographers. A common language and precision in command can avoid confusion and has the potential to improve theatre time utilisation. The nomenclature of various movements of the image intensifier has been described and possible precise commands for various movements have been postulated.

Objective functional assessment of total hip arthroplasty following two common surgical approaches: the posterior and direct lateral approaches.

Despite the high number of total hip arthroplasty (THA) procedures performed each year, there is no common consensus on the best surgical approach. Gait is known to improve following THA although it does not return to what is typically quantified as normal, and surgical approach is believed to be a contributing factor. The current study evaluates postoperative hip function and provides an objective assessment following two common surgical approaches: the McFarland-Osborne direct lateral and the southern posterior. Faced with the common problem of providing an objective comparison from the wealth of data collected using motion analysis techniques, the current study investigates the application of an objective classification tool to provide information on the effectiveness of each surgery and to differentiate between the characteristics of hip function following the two approaches. Seven inputs for the classifier were determined through statistical analysis of the biomechanical data. The posterior approach group exhibited greater characteristics of non-pathological gait and displayed a greater range of functional ability as compared with the lateral approach cohort. The classification tool has proved to be successful in characterizing non-pathological and THA function but was insufficient in distinguishing between the two surgical cohorts.

Carbon fibre plates in the treatment of femoral periprosthetic fractures.

A retrospective review of fractures occurring around the femoral component of total hip replacements was performed using patient notes and X rays. Between 1996 and 2002, 12 patients with total hip replacement had fixation of their periprosthetic femoral shaft fracture with carbon fibre plates. The mean patient age was 76 years (range 57-94). With regard to fracture type (Johansson Classification), three were Type 2 and nine were Type 3. In 11 cases the average time to union was 4 months (range 3-6). There was one non-union leading to implant failure. This was subsequently treated with a revision arthroplasty. There were no other significant complications. Although designed to fit the supracondylar region of the femur, we had no difficulty in applying the plate over the trochanteric region. Our results indicate that carbon fibre plates are effective in the management of femoral periprosthetic fractures in the elderly and this may be related to the unique properties of the plate.

What do students actually do on an internal medicine clerkship? A log diary study.

BACKGROUND: There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear. AIM: To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities. METHODS: Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching. RESULTS: The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03). CONCLUSIONS: Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.

Standard incision or no-scalpel vasectomy?

BACKGROUND: For more than a decade a new method of vas deferens access, the no-scalpel vasectomy (NSV), has been promoted and publicized in the United States, Canada, and other countries and has gained remarkable acceptance. Supporters of NSVs claim fewer hematomas, less bleeding, fewer infections, shorter operating times, less pain, and an enhanced acceptance of vasectomy. METHODS: The records of a series of 619 consecutive vasectomies performed by the same surgeon using both NSV and standard incision techniques were analyzed to compare the incidence of early complications in each. RESULTS: The incidence of complications in the series of vasectomies was virtually the same whether NSV or a conventional method was used. Infections occurred in 0.7% of conventional procedures, compared with 0.6% in NSVs; hematomas occurred in 0.3% of both; and no incisional bleeding was seen after either procedure. CONCLUSIONS: The claims made for NSV remain unsubstantiated. This study indicates that either a standard incision or the NSV method of accessing the vas deferens can yield similarly good results.

Complications in a series of 1224 vasectomies.

BACKGROUND: The assessment of a vasectomy technique should be based on the incidence of complications resulting from the procedure. Differing diagnostic criteria for defining complications and the belated occurrence of some adverse events, however, have made such appraisals difficult. The purpose of this paper is to suggest criteria for defining vasectomy-related problems and to present the results of a long-term study of 1224 vasectomies. METHODS: The records of 1224 men who had a vasectomy performed by the same technique during a 4-year period were reviewed, and documented complications were tabulated and evaluated. Patients were referred residents of the lower mainland of British Columbia, and the majority were married. The group included a wide spectrum of ages, races, and occupations. Twelve categories of potential complications were defined, of which 10 were actually encountered in the study group. Infection was defined as having had antimicrobial drugs prescribed, and regret as having returned to discuss a reversal; all other complications were diagnosed based on a documented clinical diagnosis. RESULTS: Complications had been documented in 124 cases (10.6%) and included 46 minor infections (3.8%), 2 serious infections (0.16%), 23 instances of epididymitis (1.9%), 16 cases of sperm granuloma (1.3%), and 4 minor hemorrhages (0.33%). Of 3 failures, only one (0.08%) was due to recanalization. No serious hemorrhages or late failures were seen. CONCLUSIONS: Satisfactory results were believed to be related to surgical technique and the liberal use of antimicrobial drugs. The low recanalization rate was attributed to the treatment of the ends of the vas with multiple loops of polyglycolic acid ligature.

PIP: The assessment of a vasectomy technique should be based on the incidence of complications resulting from the procedure. Differing diagnostic criteria for defining complications and the belated occurrence of some adverse events, however, have made such appraisals difficult. This paper offers criteria for defining vasectomy-related problems and presents the results of a longterm study of 1224 vasectomies. The records of 1224 men who had undergone vasectomies by the same technique over a 4-year period were reviewed, and documented complications were tabulated and evaluated. Patients were referred residents of the lower mainland of British Columbia, and the majority were married. The group spanned many ages, races, and occupations. 12 Categories of potential complications were defined, of which 10 were actually encountered in the study group. Infection was defined as having had antimicrobial drugs prescribed, and regret was defined as having returned to discuss a reversal; all other complications were diagnosed based on a documented clinical diagnosis. Complications were documented in 124 cases (10.6%) an included 46 minor infections (3.8%), 2 serious infections (0.16%), 23 instances of epididymitis (1.9%), 16 cases of sperm granulomas (1.3%), and 4 minor hemorrhages (0.33%). Of 3 failures, only 1 (0.08%) was the result of recanalization. No serious hemorrhages or late failures were seen. Satisfactory results were believed to be related to surgical technique and the liberal use of antimicrobial drugs. The low recanalization rate was the result of treatment of the ends of the vas with multiple loops of polyglycolic acid ligature.

General and anomalous sperm disappearance characteristics found in a large vasectomy series.

There is no accepted standard for the time after vasectomy before infertility is achieved. To help address this question, the records of 5,233 vasectomy patients who had had at least 12 ejaculations and had completed semen tests were reviewed. Seventy-five percent were able to fulfill a designated criterion for success by 4 months postoperatively, nearly 90% by 6 months, and nearly 99% by 1 year. Also found were a number of individual anomalies, including five instances of transient reappearance of sperm, four late spontaneous reversals after proof of success, and one late "delayed success" after evidence of failure. Patients can be reassured by the overall efficacy of male sterilization, but physicians also may wish to be aware of the possibility of capriciously intermittent-fitful-sperm.

PIP: The records of 5233 vasectomy patients who had had at least 12 ejaculations and had completed semen tests were reviewed to help address the issue of no accepted standard for the time after vasectomy before infertility is achieved. Patients were requested to start semen tests at 3 months postoperatively, after which monthly tests were requested until at least 2 consecutive azoospermic specimens were obtained. This constituted proof of success. If sperm had persisted for more than 6 months after vasectomy, a 3rd such test was requested. patient records provided for up to 10 tests. 4197 (80% of the study group's initial specimens, performed at a median 98 days after surgery, were azoospermic, but 188 of these (45% revealed sperm in the following specimen. At a median 137 days postoperative, 4640 (88.7%) of tests were azoospermic. Azoospermia was not regarded as synonymous with success, for which the criterion was a minimum of 2 negative and consecutive monthly samples. For the study group as a whole, there was a rapid increase with time in the proportion of successful vasectomies, with, for example, 76% of men achieving success at 137 days, 93.3% at the 215th days, and 97.2% by the 301st day. The records of the 8879 men were screened for manifestations of individual anomalous sperm persistence, disappearance, or reappearance. In 8 men, small numbers of sperm appeared intermittently over prolonged periods. These 8 individuals each had 7 or more sequential specimens reported as either "occasional sperm" or azoospermic, with the last appearances of sperm ranging from 297 to 448 days after vasectomy. 5 cases demonstrated either azoospermia or just an occasional nonmotile sperm at the initial semen test, toe be followed in 2 or 3 by substantial concentrations of sperm and then by 1 or more azoospermic tests. 4 men who had had 2 negative and consecutive semen tests, and therefore "successful" operations, were later found to have pregnant partners and significant sperm in their semen. These 4 failures followed their vasectomies by an average of 5.5 years. While for the study group as a whole, sperm disappearance rates were a function of time, the total group contained instances of considerably individual variability. The cause of these variations is unclear.

Sterilization: Canadian choices.

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.

The lurking sperm. A review of failures in 8879 vasectomies performed by one physician.

Vasectomy techniques and failure rates vary among surgeons, and the criteria for failure are not often clearly defined. To help establish a yardstick for comparative purposes, a series of 8879 consecutive vasectomies performed with uniform technique over 24 years was reviewed. A subgroup of 5331 men who had returned for at least two postoperative semen tests--the study group--was used for follow-up analysis. Failures were defined as early or late and also were categorized as overt or technical according to the numbers, motility, or persistence of the remaining spermatozoa. There were 97 failures of all types, including 32 (0.60%) early and overt failures and 61 (1.14%) technical failures that involved the persistence of small numbers of spermatozoa, possibly of no significance. Four (0.08%) late overt failures were also seen; each of these was discovered as a result of a pregnancy, and each occurred at least four years after two azoospermic test results. Of the 97 failures, four were recognized as due to missed vasa deferentia, and the remainder were attributed to recanalization. Whether improved and reproducible failure rates can be consistently obtained by other techniques is not yet clear.

Vasectomies: Motivations and Attitude of Physicians-as-Patients.

Vasectomies have not been as widely favoured as have techniques of sterilization in Canada for some years, in spite of having a better morbidity and mortality record than tubal sterilizations. Physicians or others who themselves have had the procedure seem to be in an especially favourable position to describe accurately the advantages and risks of this surgery, as well as its alternatives. Questionnaires inquiring about reasons for choosing vasectomy were sent to 42 medical doctors who had undergone the procedure. Counsellors can usefully proffer to inquiring patients the same advantages that reportedly motivated the medical doctors: convenience, economy, and safety.