[A different look at the quality of psychiatry education: trainee perspective]. / Kwaliteit van de opleiding tot psychiater anders bezien ­ de blik van de aios.

BACKGROUND: The (medical) educational literature does not contain an unequivocal answer to the question 'what is a good quality post-graduate education in psychiatry?'.
AIM: To describe the meaning of 'quality' and the role of psychiatrists in training (residents or trainees) in achieving and monitoring high-quality post-graduate psychiatry education in the Netherlands.
METHOD: Critical consideration of the current system of post-graduate education in psychiatry.
RESULTS: A qualitatively good post-graduate training system offers residents an optimal learning climate in which the individual development plan is central and there is opportunity to acquire a good basis for all competency domains. Possibilities for improvement concern the quality of supervisors, flexibility in internships and curricular education, and extra attention for management and policy skills.
CONCLUSION: Suggestions are made for further development of post-graduate psychiatry training in the Netherlands.

Mental problems among first-year conservatory students compared with medical students.

Musical education and the musical profession can be stressful, which may make musicians vulnerable for stress-related disorders. To determine if music students are particularly at risk for mental problems, we used the Standardised Assessment of Personality-Abbreviated Scale (SAPAS) and the Symptom Questionnaire (SQ48S) to compare symptoms in first-year conservatory students (n=33) and first-year medical students (n=43). On the SAPAS, we found that medical students have significantly more difficulty making and keeping friends (p=0.015). Also, we observed a trend that conservatory students lose their temper more easily (p=0.040). Both student groups showed high scores for the personality trait "perfectionism." On the SQ48, we observed a trend that both conservatory and medical students experience more psychological problems than the general population, but there were no significant differences between conservatory students and medical students in the total scores of both questionnaires.

Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft.

BACKGROUND: The purpose of this study was to evaluate our protocol with the modified skin incision without bone graft in the treatment of intra-articular calcaneal fractures in a consecutive series. METHODS: Thirty-three displaced intra-articular calcaneal fractures operatively treated by a single surgeon were evaluated. Each fracture was managed according to a standardized protocol that included an oblique lateral incision and stable internal fixation, without supplemental bone graft. Fractures were classified according to two accepted criteria. Patients were evaluated with serial clinical and radiographic examinations. Final evaluation was made after at least a 2-year follow-up and was determined by the use of a functional outcome assessment questionnaire. RESULTS: Anatomic or near anatomic reductions were obtained in 97% of cases. All fractures healed without loss of initial reduction or collapse. Excellent or good results were achieved in 88% of non-worker's compensation patients and 27% of worker's compensation patients. Fractures with anatomic reductions were more likely to achieve a good or excellent result. Ninety-two percent of patients returned to the workforce. Complications included one superficial wound infection and five cases of peroneal tendinitis requiring hardware removal. One patient underwent subtalar fusion secondary to painful posttraumatic arthritis. CONCLUSIONS: The open reduction and internal fixation using our standardized protocol is an effective method of treatment for intra-articular calcaneal fractures.

Equivalence of hyperfractionated and continuous brachytherapy in a rat tumor model and remarkable effectiveness when preceded by external irradiation.

PURPOSE: In clinical brachytherapy, there is a tendency to replace continuous low-dose-rate (LDR) irradiation by either single-dose or fractionated high-dose-rate (HDR) irradiation. In this study, the equivalence of LDR treatments and fractionated HDR (2 fractions/day) or pulsed-dose-rate (PDR, 4 fractions/day) schedules in terms of tumor cure was investigated in an experimental tumor model. METHODS AND MATERIALS: Tumors (rat rhabdomyosarcoma R1M) were grown s.c. in the flank of rats and implanted with 4 catheters guided by a template. All interstitial radiation treatment (IRT) schedules were given in the same geometry. HDR was given using an (192)Ir single-stepping source. To investigate small fraction sizes, part of the fractionated HDR and PDR schedules were applied after an external irradiation (ERT) top-up dose. The endpoint was the probability of tumor control at 150 days after treatment. Cell survival was estimated by excision assay. RESULTS: Although there was no fractionation effect for fractionated HDR given in 1 or 2 fractions per day, TCD(50)-values were substantially lower than that for LDR. A PDR schedule with an interfraction interval of 3 h (4 fractions/day), however, was equivalent to LDR. The combination of ERT and IRT resulted in a remarkably increased tumor control probability in all top-up regimens, but no difference was found between 2 or 4 fractions/day. Catheter implantation alone decreased the TCD(50) for single-dose ERT already by 17.4 Gy. Cell viability assessed at 24 h after treatment demonstrated an increased effectiveness of interstitial treatment, but, after 10 Gy ERT followed by 10 Gy IRT (24-h interval), it was not less than that calculated for the combined effect of these treatments given separately. CONCLUSION: In full fractionation schedules employing large fractions and long intervals, the sparing effect of sublethal damage repair may be significantly counteracted by reoxygenation. During 3-h intervals, however, repair may be largely completed with only partial reoxygenation causing PDR schedules to be less effective than fractionated HDR, and equivalent to LDR. Brachytherapy with clinically sized fractions after a large external top-up dose showed a remarkable increase in tumor control rate with no effect of fractionation (up to 4 fractions/day), which could not be fully explained by differences in dose distribution or in the cell viability assessed after treatment. This suggests a longer lasting effect on cell survival or radiosensitivity associated with catheter implantation shortly after the top-up dose.

Tumor hypoxia--a confounding or exploitable factor in interstitial brachytherapy? Effects of tissue trauma in an experimental rat tumor model.

PURPOSE: To evaluate the potential effects of tumor hypoxia induced by afterloading catheter implantation on the effectiveness of brachytherapy in a rat tumor model. METHODS AND MATERIALS: Afterloading catheters (4) were implanted in subcutaneously growing R1M rhabdomyosarcoma in female Wag/Rij rats. A MicroSelectron (Nucletron) was used for interstitial high-dose-rate irradiation ((192)Ir). Tumor oxygenation, perfusion, and cell survival were assessed by pO(2) histography (Eppendorf), Tc-99m injection, and excision assay, respectively. RESULTS: Tumor perfusion was markedly reduced at 1 h after catheter implantation (33.9 +/- 6.0% (SEM, n = 9) of control) and partly recovered after 5 h (61.5 +/- 12.2%). At 24 h, the perfusion level reached control values (100.6 +/- 25.7%), but was highly variable with some of the tumors showing hardly any recovery at all. Tumor oxygenation showed a similar pattern, but with less recovery. Median pO(2) readings were 13.5, 1.2, and 5.3 mm Hg before and at 1 and 24 h after implantation, respectively (7 tumors). The percentages of pO(2) readings

Humeral blade plate fixation of intercalary allografts and segmentally comminuted proximal humeral fractures: a preliminary report.

The AO 90 degrees humeral blade plate is a relatively new device, whose primary indication and previously described use is for proximal humeral fracture non-union. This study describes the use of the humeral blade plate for extended indications-fixation of segmentally comminuted proximal humeral fractures in two patients and fixation of humeral intercalary allografts after primary humeral neoplasm resection in three patients. A mean follow-up of 20 months revealed union in both fractures and five of the six allograft-host junctions. One patient required subsequent bone grafting for non-union at a proximal allograft-host junction. Functional results were excellent in three patients, good in one, and fair in one. Problems encountered intraoperatively were directly related to the limited array of implants. The long plates which were needed had blades which were too long and required intra-operative trimming in three cases. In four cases, additional plates were used to supplement the blade plate for distal fixation. In conclusion, the humeral blade plate is a useful device for fixation in these extended indications, but longer plates with 30.0 and 40.0-mm blade lengths should be made available.

Bone growth after osteotomy and internal fixation in young rabbits.

The factors leading to overgrowth following fixation of long-bone fractures in children have never been clearly understood. The amount of trauma and the type of fixation may play a role. A rabbit model was used to investigate the influence of a femoral osteotomy and plate fixation on subsequent growth. Unilateral midshaft femoral osteotomy was performed in 6-week-old rabbits, and the bone was fixed internally with a plate and screws. End-to-end reduction was performed either at full length or with a segment removed. Bone length measurements at the end of growth revealed no significant difference in growth between the control femur and the femur that had undergone osteotomy and plate fixation. Shortened plated femora also showed no tendency to grow longer or faster than full-length fixed femora or controls. Interestingly, in the ipsilateral tibia a small but statistically significant length increase, equivalent to about 2% increase in additional growth, was observed, whereas technetium-99 methylene diphosphonate uptake was reduced in the tibial physes. In the context of the rabbit experimental model chosen, these results suggest that significant femoral over-growth does not occur following femoral osteotomy and plate fixation.

Indirect reduction and internal fixation of supracondylar femur fractures without bone graft.

Thirty supracondylar-intercondylar fractures of the distal femur were treated in a prospective series using an indirect reduction technique. From January 1988 to July 1993, patients who entered into this protocol had undergone fixation with a distal lateral plate without stripping of the medial soft tissues and without bone graft. With this technique, 86.6% excellent and satisfactory results were achieved using the Neer rating system. Of the three failures, two were in elderly, osteoporotic women with comminuted intraarticular fractures, and one failure occurred in a renal transplant patient with bilateral quadriceps ruptures despite a good result from her femur fracture. Only one patient with a grade 2 open fracture and comminution developed a nonunion, which eventually healed after bone grafting. The results of this technique compare favorably with other series of osteosynthesis of supracondylar femur fractures in the orthopaedic literature without the added morbidity associated with autogenous bone grafting. The surgical technique is demanding and may not be suitable for patients with severe open fractures with devascularized bony fragments or marked osteoporosis.

Interstitial hyperthermia and interstitial radiotherapy of a rat rhabdomyosarcoma; effects of sequential treatment and consequences for clonogenic repopulation.

Animal tumour experiments have been performed to elucidate the interactions between interstitial hyperthermia (IHT) and interstitial radiotherapy (IRT), and to obtain information about the most effective sequence of these treatment modalities. Experimental tumours, transplanted in the flank of Wag/Rij rats, were treated with IHT for 0.5 h at 44 degrees C, and with IRT using low dose-rate (LDR) iridium-192 sources. Both tumour cure probability and the fraction of clonogenic cells in vitro after different IHT and IRT treatments in vivo, were used as endpoints. The sequence of a short (0.5 h) IHT treatment followed by an extended LDR-IRT treatment lasting up to 10 days appeared to be very effective, and resulted in a significant thermal enhancement ratio of 1.34 at the 50% tumour cure probability level. A not significantly increased thermal enhancement of 1.06 was found when the same IHT treatment followed IRT. The level of clonogenic cell survival after IHT alone is high (0.24 +/- 0.08) compared with that after an IRT dose of 20 Gy (0.017 +/- 0.004). Clonogenic cell repopulation started 2-4 days after the in vivo treatment irrespective of the type of treatment. The in vivo combination of IHT and LDR-IRT resulted in lower surviving fractions compared with IRT alone, regardless of the time interval between the end of treatment and in vitro clonogenic assay. IHT followed by LDR-IRT appeared to be the most effective treatment in terms of tumour cure. The in vivo/in vitro studies indicated that the effect of hyperthermia is mainly attributed to radiosensitization, possibly by partial inhibition of sublethal damage repair processes during the subsequent irradiation. The hyperthermia-induced cytotoxicity was of minor importance as estimated from the surviving clonogenic fraction.

Radial head fractures and their effect on the distal radioulnar joint. A rationale for treatment.

Nineteen patients were treated with open reduction and internal fixation for radial head fractures. Open reduction and internal fixation was performed to avoid radial head excision and the possible development of distal radioulnar joint dysfunction. Follow-up observation, which averaged 11.7 months, revealed that no patient developed wrist pain. Range of motion of the elbow and forearm was found to be complete in 14 patients and minimally restricted in four. Fourteen patients were pain free with full activity, and four had mild to moderate pain after heavy labor. One patient subsequently required radial head excision. Based on these findings and the authors continued disappointment with treatment of distal radioulnar joint dysfunction caused by proximal radial migration after radial head excision, the authors recommend early open reduction and internal fixation of all displaced or angulated radial head fractures.

Lack of therapeutic gain when low dose rate interstitial radiotherapy is combined with cisplatin in an animal tumour model.

The interaction of cisplatin with low dose rate interstitial radiotherapy was studied in an animal tumour model with a range of dose rats commonly used in clinical low dose rate brachytherapy. Small pieces of R1-rhabdomyosarcoma were implanted subcutaneously in the flanks of female Wag/Rij rats. When the tumour had grown to the desired treatment volume, four afterloading catheters were inserted in the tumour in a square geometry, and a fixed spacing was attained by means of a template. Subsequently, four 2 cm Ir192 wires were inserted. A range of tumour doses of 20-120 Gy at a mean dose rate of 48 cGy/h was applied; 15 mins before the implant an intraperitoneal bolus injection of 3 mg/kg cisplatin was given. For growth delay and cure rate, no modification of the effects of low dose rate brachytherapy by the addition of cisplatin was observed. The observed effects of the combination of cisplatin with low dose rate interstitial radiation in relation to the animal tumour are discussed.

Application of a capacitive-coupling interstitial hyperthermia system at 27 MHz: study of different applicator configurations.

A 27 MHz capacitive-coupling interstitial hyperthermia system has been developed. It uses thin flexible applicators which can easily be inserted in standard brachytherapy catheters. The system can be operated in two different configurations. In the external ground return configuration tissue is heated by currents passing from the catheters to external ground returns; in the balanced configuration, by currents passing between applicators with a phase difference of 180 degrees. The purpose of this study was to find out which configuration is preferable, in terms of temperature homogeneity and clinical usefulness. Model calculations show that, due to the high impedance associated with capacitive coupling, the applicators can be represented as current sources, in contrast to local current field electrodes which are voltage sources. SAR measurements in muscle-equivalent phantoms illustrate that homogeneous heating patterns along the catheters can be expected in both configurations in regular as well as in irregular implants. Using the external ground return configuration the power of each applicator can be controlled individually. Calculations and measurements show that cross-talk cannot be avoided completely in this configuration, but that it can be minimized by using applicators operating in phase.

Pain clinic #15. Treatment of sciatic nerve causalgia following pelvic fracture.

Direct injury to the sciatic nerve may occur in patients who sustain acetabular/pelvic fractures. Sciatic nerve causalgia has been noted in patients who suffer posterior wall acetabular fracture with or without ipsilateral hip dislocation. Sympathetic nervous system dysfunction is considered the primary cause for this syndrome, although some investigators suggest central nervous system involvement. This report documents the treatment results of three patients suffering from sciatic nerve causalgia who were referred to the Pain Treatment Center during the past year. In each case, diagnosis was confirmed by sympathetic blockade. Treatment regimens varied and included nerve blocks, cryoanalgesia techniques, and transcutaneous electrical nerve stimulation therapy. The syndrome was relieved in these patients within four to six weeks. Patients were followed for six months after initial treatment.

The effect of age on the oxidative metabolism of antipyrine by uninduced microsomal fractions of rat liver.

The influence of ageing on the metabolism of antipyrine by different forms of cytochrome P-450 was studied in vitro, by measuring the formation of antipyrine metabolites by microsomes isolated from untreated rats, which were grouped into 5 different ages. Km, Vmax and Vmax/Km values were determined for the metabolites: 3-hydroxymethylantipyrine (HMA), norantipyrine (NORA) and 4-hydroxyantipyrine (OHA). Km values for all metabolites ranged from 2.0 to 5.0 mM and Vmax values from 1.84 to 3.66 nmol/min per mg. The Vmax/Km ratios varied from 0.65 to 1.73 microliters/min per mg. With respect to the Km values, a decrease for HMA from 12 to 24 months, no change for OHA and an increase for NORA from 3 to 30 months, was observed. The Vmax values showed an increase for HMA from 3 to 24 months, a decrease for OHA from 12 to 30 months and no change for NORA. The absolute Vmax/Km ratios for all metabolites showed no significant changes during ageing. However, regarding the relative Vmax/Km ratios, an increase for HMA from 3 to 24 months, a decrease for OHA from 12 to 35 months and also a decrease for NORA from 3 to 24 months, was observed. It is concluded that ageing influenced the Km, Vmax and Km/Vmax ratio of the different P-450 isoenzymes involved in antipyrine metabolism, in different ways. However, the age-related changes are modest (10-100%), especially for the Vmax/Km ratio.

Tips of the trade #21. Simplified starting technique for femoral intramedullary rodding.

A simplified method for determining the position of and creating the proximal starting hole for a femoral intramedullary rod is presented. The method, which uses the combination reamer from the DHS hip screw set and other equipment found in most operating rooms, increases the certainty of correct placement of the proximal starting hole. The difficulties and risks inherent in the use of the starting awl are eliminated.

Internal fixation of proximal radial head fractures.

The treatment of choice for proximal radial head fractures remains controversial. The goal of any treatment for an intra-articular fracture must be the complete restoration of the joint and its function. Nonoperative treatment leads to full motion in cases of less than 1-2 mm of fracture displacement. Resection of the radial head can be recommended only for very comminuted fractures. All other fracture types should be treated by open reduction and internal fixation. Our own personal follow-up observation of 19 patients who had surgical intervention demonstrated restoration of elbow function after an average follow-up time of 11.7 months. Five patients had a slightly restricted range of motion of less than 10 degrees extension and flexion as well as less than 8 degrees pronation and supination, without signs of arthritis. Because complications were minimal, we recommend internal fixation of displaced proximal radial head fractures to restore the anatomic function of the elbow. This is especially true in cases with accompanying proximal ulna fractures and/or ruptured collateral ligaments of the elbow joint and/or disruption of the distal radio-ulnar joint.

Irrigation drainage with intracatheter in severe infections of the hand.

Severe infections of the hand and fingers still challenge the surgeon's skill in spite of modern antibiotics. Very often patients are referred too late, with inadequate incisions and insufficient drainage. In addition, wound edges tend to seal up rapidly, even if no sutures are inserted. In the management of such infections we have successfully introduced an irrigation drainage system, using a common intracather (I-Cath). The method described here is simple, atraumatic and shortens the time of treatment.

[17-year results following vagotomy and pyloroplasty]. / 17-Jahres-Resultate nach Vagotomie und Pyloroplastik.

Report on 51 patients who underwent surgery for peptic ulcer between 1964 and 1966 by truncular vagotomy and pyloroplasty. The recurrence rate was 6.6% for duodenal ulcer and 19.9% for gastric ulcer. Two carcinomas were detected in the latter group. In neither group were dumping or diarrhea symptoms observed.