Accuracy of colon tumor localization: Computed tomography scanning as a complement to colonoscopy.

AIM: To determine the utility of computed tomography (CT) scanning in localizing colon tumors. METHODS: At a single tertiary care teaching hospital, a retrospective chart review was conducted on patients who underwent surgery for colon malignancies between January 2004 and May 2006. One hundred and four charts containing all of the following data were reviewed: preoperative colonoscopy report, preoperative CT report, surgical operative report, tumor pathology report. The colon was divided into five segments from the cecum to the sigmoid and the location of the lesions was categorized into one of these areas. The tumor location was considered "erroneous" if its location determined during surgery differed from the location determined by colonoscopy or CT. RESULTS: Over all, tumor location was accurately determined via colonoscopy in 83/104 cases (79.8%) and erroneously in 21/104 (20.2%) of cases. CT scan accurately localized colon tumors in 52/104 (50.0%) of cases, incorrectly localized tumors in 18/104 (17.3%) of cases, and did not detect known tumors in 34/104 (32.7%) of cases. Of the 21 tumors erroneously located by colonoscopy, 11 (52.4%) were accurately localized by CT scan. The average tumor size for all patients in this study was 5.72 (+/- 3.11) cm. The average size of tumors properly located by colonoscopy and CT was 5.39 (+/- 3.34) cm and 6.79 (+/- 3.48) cm, respectively. The average size of the tumors not detected by CT was 3.98 (+/- 1.75) cm. CONCLUSION: CT scanning may be used in concert with colonoscopy to help localize colon tumors.

Focused versus screening CT scans for evaluation of nontraumatic abdominal pain in the emergency department.

OBJECTIVE: To evaluate the utility of computed tomography (CT) scans in patients with abdominal pain in the emergency department. We compared focused scans (having a single diagnosis in mind) and screening scans (having no diagnosis or more than one diagnosis in mind) with the hypothesis that focused scans will reveal pathology more often than screening scans. Treatment plans and patient outcomes were also compared between the two populations. METHODS: This is a prospective study in which 100 patients who presented to an academic medical center with abdominal pain and underwent an abdominal CT were enrolled in the study. A chart review was later completed to gather ultimate outcome data for each of the enrolled subjects. RESULTS: Of the 61 patients having a focused CT, pathology was identified on 63.9% of the scans, which did not differ significantly from the 65.4% of scans that revealed pathology in the screening group. In the focused group, anticipated admissions were reduced, but the reduction was not significant. The screening group did show a significant difference, with eight fewer patients being admitted than initially planned. The total number of patients deemed to require admission was significantly reduced by 15% following all CT scans. CONCLUSION: While there was no difference between the focused and screening groups in the rate of identifying pathology, there was a significant decline in number of patients requiring admission to the hospital in the "screening" CT group (when comparing emergency physicians' pre- and post-CT treatment plans).

Improving surgical residents' performance on written assessments of cultural competency.

CONTEXT: The pressure to implement cultural-competency training at the level of GME is high. The rapidly diversifying American population and the ACGME demand it, and cultural competency is recognized as a core competency under "Professionalism." OBJECTIVES: The objectives for this study were (1) to assess residents' baseline levels of cultural competence, (2) define barriers to skill-acquisition, and (3) examine efficacy of educational programs in improving cultural competence. SETTING & PARTICIPANTS: In all, 43 residents from the University of Connecticut School of Medicine participated in a prospective, Institutional Review Board (IRB)-approved study. DESIGN: During Step 1 (pretest), baseline performance was recorded using 3 assessments: (1) Healthcare Cultural Competency Test (HCCT), (2) Cultural skills acquisition (CSA), and (3) Clinical Scenarios Test (CSE). During Step 2 (Educational Intervention), a 2-part lecture that focused on principles of cultural competency and continued self-learning was presented. Last, for Step 3 (posttest), the post-program evaluation was administered as in Step 1. MAIN OUTCOME MEASURES: Answers for Step 1 (pretest) and Step 3 (posttest) were compared using a paired t-test for HCCT and CSE and the chi-square test for CSA. RESULTS: Thirty-five replies were evaluated. Every resident performed better on the posttest than the pretest. Specifically, participants showed 88% improvement in their scores on the HCCT (pretest: 360, posttest: 696; p < 0.01), 2-fold improvement on the CSA (pretest: 6, posttest: 12; p < 0.009), and 40% improvement in CSE (pretest mean score = 23.3, posttest = 34.6; p < 0.01). Commonly identified barriers to learning included inadequate teaching tools and absence of formal training. CONCLUSIONS: Surgery residents tested for 3 aspects of cultural competence prior to and after teaching sessions showed marked improvement on all 3 assessment measures after this brief intervention.

Cost-aware care: critical core competency.

HYPOTHESIS: Resident core competence can be improved by learning to accurately estimate the costs of postoperative complications. DESIGN: Prospective, institutional review board-approved study. In step 1, residents were provided 3 clinical vignettes detailing specific treatment measures for postsurgical complications and asked to assign total cost estimates for the treatment for each vignette; in step 2 they were given a pocket-sized cost card listing hospital costs, and in step 3, after 2 weeks, they were retested using the same clinical vignettes as in step 1. SETTING: University of Connecticut, Farmington, and the Yale University School of Medicine, New Haven. PARTICIPANTS: Fifty-three general surgery residents. MAIN OUTCOME MEASURES: Cost estimates for steps 1 and 3 were compared using the paired t test and analysis of variance to examine whether there is a difference between the baseline cost estimates and the actual cost; whether introduction of the cost card improves performance; and whether responses correlate to postgraduate year level or to the clinical vignette. RESULTS: There was a statistically significant difference between the baseline cost estimates (before introduction of the cost card) and the actual cost of the treatment (P = .03). Introduction of the cost card resulted in a statistically significant improvement between the cost estimates before and after the intervention (P = .002), with a drop in average percentage error by 35% (range, 32%-38%). Level of postgraduate training or type of test vignette (at analysis of variance) did not seem to be a significant factor. CONCLUSIONS: There is a lack of awareness among surgical residents of the cost of treatment of postoperative complications. Introduction of a simple educational tool such as a cost card measurably improves their overall understanding of the cost of care and can be easily incorporated into the residency curriculum.

The value of videotape in mock oral board examinations.

OBJECTIVE: To determine the impact on self-perception, of having residents view their own performance (taped) on mock oral board examinations. DESIGN: Self-evaluation-intervention-self-evaluation design. Third-, fourth-, and fifth-year residents evaluated themselves after each examination(room) during mock oral examinations. Residents reviewed the examination on videotape and re-evaluated themselves. SETTING: University Medical Center. PARTICIPANTS: Twenty surgical residents from the third, fourth, and fifth years of training. MAIN OUTCOME MEASURES: Mean scores in 6 categories based on a 5-point Likert scale. Scores by examiners plus pre- and post-video viewing self-scores were compared. RESULTS: We found that residents consistently underestimated their performance on the examination. Viewing their videotapes resulted in revised self-scores, which were more consistent with scores of the examiners. All scores will be presented in sequence as follows: Mean score by examiners, mean self-score pre-tape viewing and mean self-score post-tape viewing. For professionalism, scores were 4.63, 4.15, and 4.43, p = 0.047. For organization, 3.91, 3.27, and 3.63, p = 0.007. For decision making, 4.02, 3.42, and 3.72, p = 0.033. P-values reflect the comparison of resident self-scores pre- and post-tape viewing. Analysis of variance comparison of scores in various rooms (different examiners) revealed no significant difference in scores based on rooms (different examiners). Evaluations according to rooms (different examiners) were not statistically different, supporting inter-rater reliability. There was consistent improvement in knowledge and decision making with advanced years of training, supporting internal validity of the examination. CONCLUSIONS: Videotape viewing results in revised resident self-scores, which are more consistent with scores given by the examiners. Tape viewing significantly affected resident self-scores in professionalism, organization, and decision-making.

Has the pendulum swung too far in postoperative pain control?

BACKGROUND: The Joint Commission on Accreditation of Health Care Organizations declared pain level to be the "fifth vital sign." This has led to increased efforts to reduce patients' pain scores. Current postoperative analgesic modalities may not be entirely safe. We prospectively studied pain and sedation scores to determine whether postoperative patients were reaching sedation levels similar to patients undergoing "conscious sedation" (eg, colonoscopy cases). "Conscious sedation" patients have been shown to achieve states of sedation, which at time result in oxygen desaturation. METHODS: Fifty-three patients within three groups were compared in an observational study. Group 1 included "conscious sedation" patients undergoing colonoscopy. Group 2 included postoperative patients using patient-controlled analgesia (PCA). Group 3 included postoperative patients under nurse-controlled analgesia (NCA). Levels of sedation were monitored using the 6-point Ramsay sedation scale. Pain and oxygen saturation were monitored using an 11-point verbal scale and finger pulse oximetry, respectively. Patients were monitored for up to 12 hours in the postoperative period or for the length of their colonoscopy procedure. RESULTS: Patients in groups 1 and 2 reached similar sedation levels. CONCLUSIONS: Patients may reach dangerous levels of sedation during the first 24 hours postoperatively. Patients using PCA devices warrant close observation during this time period.