Assessing professionalism in surgeons.

Professionalism has been identified as one of four domains of competency for surgical trainees in the UK. This implies that professionalism can be learned and assessed. The priorities of different professions and healthcare systems influence the value placed on different components of professionalism and UK surgeons need to identify the characteristics they would most value as part of an effective assessment process. The success of developing a taxonomy of non-technical skills for surgeons (NOTSS) can guide a similar process for a taxonomy for professionalism assessment. A multitude of assessment instruments for professionalism have been described in the literature but very few are valid, reliable or practical. For surgical trainees a number of assessment tools should be considered. A quantifiable tool using multi-source feedback could be the most practical for clinical surgeons to use. It is important, however, that it is not used to assess isolated behaviours but assess conduct within a surgical community of practice, and that the thinking process behind (un)professional behaviour is also understood, especially in stressful situations.

Coccidioidal meningitis. An analysis of thirty-one cases and review of the literature.

Clinical and laboratory features of 31 patients with coccidioidal meningitis seen from January 1964 through December 1976 with follow-up through 1979 are reported and data on 114 patients from the literature reviewed. History of exposure to C. immitis, a wide age range, and, in about one third, underlying conditions are noteworthy. Dissemination to the meninges usually occurs within the first few months although diagnosis is frequently delayed. Presenting symptoms and signs of coccidioidal meningitis are varied but signs of chronic meningitis or suggestion of hydrocephalus are prominent. Evidence of acute infection is unusual even with widespread disease. Diagnosis is usually made by demonstration of coccidioidal CF antibodies in the CSF although they are not found in all patients. Some show other direct evidence of C. immitis. Special diagnostic techniques such as CAT scanning for evidence of basilar meningitis or hydrocephalus are valuable. Amphotericin B remains the drug of choice despite the need for long-term therapy and the problems with intrathecal administration. Reservoirs are only occasionally useful but shunts are frequently lifesaving despite complications. Factors associated with a bad prognosis are hydrocephalus, non-Caucasian race, or presence of an underlying disease.

Effect of pili on susceptibility of Escherichia coli to phagocytosis.

The degree of piliation of 20 clinical isolates of Escherichia coli was correlated with their susceptibility to phagocytosis by human polymorphonuclear leukocytes. Piliation was quantitated by negative staining, and phagocytosis was quantitated by a monolayer technique. Ingestion was confirmed by electron microscopy. In the absence of source of opsonins, there was a positive correlation between the degree of piliation and susceptibility to phagocytosis (y = 0.83x + 19.58; correlation coefficient = 0.65; P < 0.01). Heavily piliated strains were no longer phagocytized after their pili were removed by ultraviolet irradiation. Phagocytosis was reduced 75% in the presence of 0.1 M d-mannose, an agent which competitively inhibits binding of pili to cell surfaces. l-Mannose, d-glucose, and d-galactose were much less inhibitory. The viability of piliated organisms was reduced by 1 log after 1 h of incubation with polymorphonuclear leukocytes. Addition of 10% fresh human serum increased both the rate and completeness of killing. These observations suggest that polymorphonuclear leukocytes may interact with the pili of E. coli to promote phagocytosis. This phenomenon may have clinical relevance in situations where normal opsonic activity is poor, such as the renal medulla.