From the AACE president--perseverance, innovation, and progress.
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Education, Medical↗
Biomedical subjects
A K Sachdeva
Publications and source records attributed to A K Sachdeva.
Surgical educators and the contemporary training of generalists.
The national agenda calling for an increase in the number of generalists has resulted in several curricular recommendations, ones which might seriously compromise the training of medical students in surgery. Review of the curricular needs of family physicians reveals that substantial and broad education in surgery is necessary to achieve full competency. Currently, many such curricular objectives are met through special surgical courses and rotations during postgraduate training in family medicine. The argument suggesting that close student interaction with surgeons is unnecessary, and will discourage students from entering generalist disciplines, does not take into account a number of important factors. With appropriate modifications in the core third-year surgery clerkship and inclusion of an appropriately designed fourth-year surgery subinternship, it is possible for surgical educators to provide students with the experience in surgery that is essential for the training of generalists.
Career Choice↗
Redesigning the surgical teaching of fourth-year medical students to meet the training needs of generalists.
The fourth year of the medical student curriculum remains of questionable educational value at most medical schools. The training needs of generalists include the acquisition of knowledge and skills in broad areas of general surgery and the surgical subspecialties. By appropriately tailoring the educational objectives to the learning needs of individual students and implementing teaching models based on principles of adult education, a special surgical experience may be provided to each fourth-year medical student, building on the previously acquired knowledge and skills. Rotations may be offered in a number of surgical disciplines, with heavy emphasis on teaching in the ambulatory setting. One such model was recently implemented at The Medical College of Pennsylvania. Advantages of this type of program include support of the training of generalists using contemporary teaching strategies and provision of a meaningful educational experience to medical students during the fourth year.
Ambulatory Surgical Procedures↗
A model for teaching medical students in an ambulatory surgery setting.
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Ambulatory Surgical Procedures↗
Technique of ultrasonic detection and mapping of abdominal wall adhesions.
A technique for noninvasive ultrasound examination to detect and map abdominal wall adhesions is described. The examination is based on the demonstration of movement of abdominal viscera during real-time imaging. This movement is called viscera slide and either occurs spontaneously as a result of respiratory movement or may be induced by manual compression. Abdominal wall adhesions produce a restriction of viscera slide. Ultrasonic demonstration of restricted viscera slide has been used for the precise localization and mapping of abdominal wall adhesions prior to abdominal surgery. The technique may be particularly useful in providing safe initial access in patients undergoing laparoscopy who are at increased risk for trocar injury of viscera due to abdominal wall adhesions resulting from previous surgery or peritonitis.
Abdominal Muscles↗
Surgical treatment of peptic ulcer disease.
Elective surgery for peptic ulcer disease has diminished significantly over the past 15 years. However, emergency surgery has not shown a decline. Some series have even reported an increase in hospitalizations and operations for hemorrhage. The appropriate surgical procedure for peptic ulcer disease must be tailored to the specific needs of the individual patient. During emergency operations for hemorrhage from duodenal ulcer, we recommend suture ligature of the bleeding vessel and vagotomy-pyloroplasty for high-risk patients, or vagotomy-antrectomy for the lower-risk patient. Bleeding gastric ulcers should be resected, if possible. For massive hemorrhage from stress ulceration requiring surgery, near-total or total gastrectomy should be performed. Perforated duodenal ulcers are best managed by closure and a definitive ulcer operation, such as vagotomy-pyloroplasty. Perforated gastric ulcers are best excised but may be simply closed if conditions do not favor resection. In these situations, biopsy should be performed. We recommend truncal vagotomy-antrectomy for patients presenting with obstruction. Vagotomy (truncal or proximal gastric) with drainage is an acceptable alternative in this situation. For patients with intractable ulcer disease or for those who are noncompliant, proximal gastric vagotomy is the preferred operation. However, other operations may need to be considered, depending on the specific situation. Recurrent ulceration needs appropriate work-up to determine the possible cause. Although patients with ulcer recurrence initially may be placed on medical treatment, about 50% will require reoperation. The most effective procedure for peptic ulcer disease is truncal vagotomy-antrectomy, which has a recurrence rate of less than 1%. The procedure with the least morbidity and the fewest undesirable side effects is proximal gastric vagotomy. Ulcer recurrence after proximal gastric vagotomy or truncal vagotomy-pyloroplasty is in the range of 10% to 15%.
Gastrectomy↗
Identification of human appendicitis by in vitro nuclear magnetic resonance.
The spin-lattice relaxation time, T1 as determined by nuclear magnetic resonance techniques, correlates positively with tissue water content. The latter relationship has been observed in rabbits with experimentally induced appendicitis whose inflamed appendiceal tissues had significantly higher T1's and water contents than tissue from normal controls. The present experiment studied these relationships in humans. Tissue water content and T1 were measured on appendiceal tissue from 10 patients with documented appendicitis and from 6 controls without the disease. All T1's were determined within 30-60 min of removal of the appendix at operation. The mean in vitro T1 of appendiceal tissue from patients with appendicitis was significantly higher than that of controls (527 +/- 15 msec versus 430 +/- 17 msec, mean +/- SEM, P less than 0.002). In addition, a strong positive correlation was noted between T1 and tissue water content (r = 0.70, P less than 0.01). Based on these findings, the use of in vivo magnetic resonance imaging techniques to detect human appendicitis noninvasively warrants investigation.
Adolescent↗
University-based postresidency training programs in surgical oncology.
The issue of postresidency training in surgical oncology engenders much debate, particularly as it impacts on general surgery training. With the goal of enhancing instruction in surgical oncology in the future, a survey was conducted to assess the role of surgical oncology programs and educational activities within university-based surgery training programs. The results of the study demonstrate an increased emphasis on surgical oncology training over the past five years. The findings also indicate that education activity in surgical oncology in all departments of surgery has increased greatly, as demonstrated by an increased number of specific teaching rounds and conferences. The impact of this increased awareness on the future of surgical oncology training is discussed.
Curriculum↗
The identification of experimentally induced appendicitis using in vitro nuclear magnetic resonance.
Appendicitis was induced in six New Zealand white rabbits. The appendices from these animals had significantly higher spin-lattice relaxation times, T1, as determined in vitro by nuclear magnetic resonance (NMR) (10 controls vs 6 experimentals, 413 +/- 23 vs 455 +/- 41, X +/- SD, P less than (0.02). T1 correlated significantly with the water content of the appendiceal tissue (P less than 0.001). These findings suggest that in vivo NMR imaging techniques weighted on T1 might be able to identify human appendicitis noninvasively by detecting localized edema.
Animals↗
Metronidazole in prevention and treatment of bacteroides infections in elective colonic surgery.
A double-blind randomised trial was carried out among 46 patients undergoing elective colonic surgery; 27 patients received prophylactic metronidazole and 19 received placebo. Anaerobic infections did not develop in any of the metronidazole-treated patients, but did develop in 11 (58%) of 19 controls who were subsequently successfully treated with metronidazole.
Bacterial Infections↗
Axillary artery occlusion and pulmonary tuberculosis.
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Anti-Bacterial Agents↗
Ultrasonic detection of viscera slide as an indicator of abdominal wall adhesions.
Real-time ultrasonography can detect the movement of viscera immediately deep to the abdominal wall. This motion of abdominal contents is called viscera slide, and is produced by the force of respiratory motion (spontaneous viscera slide) or by manual ballottement of the abdomen (induced viscera slide). Viscera slide was observed in 18 "normal" subjects (no history of previous abdominal surgery or peritonitis) and in 24 subjects at "risk" for abdominal wall adhesions because of previous abdominal operations or past history of peritonitis. In 14 of the 24 "risk" group subjects, spontaneous and induced viscera slide was restricted to excursions of less than 1 cm (58.3%). Operations were performed on 18 patients, which confirmed the fact that restriction of ultrasonically detected viscera slide identified abdominal wall adhesions in all cases, but no adhesions were found in patients with normal viscera slide. This ultrasonic finding of restricted viscera slide may be useful in the preoperative discovery and localization of abdominal wall adhesions prior to laparoscopy or laparotomy.
Abdomen↗
Paraganglionoma of extrahepatic biliary tract causing obstructive jaundice.
We report a young woman with paraganglionoma arising from the extrahepatic bile duct presenting with acute obstructive jaundice. The patient underwent excision of the gall bladder and extrahepatic bile duct with the tumor, and Roux-en-Y hepaticojejunostomy. She is asymptomatic 9 months later, with normal biochemical investigations and imaging.
Adult↗
Evaluation of parallel pelvic/breast and male genital/rectal teaching programs.
Pelvic/breast (PB) and male genital/rectal (GR) programs were evaluated to learn if male and female students differed in their reactions to the programs and if observations of the programs confirmed students' reactions. In-depth interviews were conducted with male and female teaching associates to uncover the need for program improvements beyond those suggested by observation and student reactions. Participating in the PB program were 74 men and 85 women; 79 men and 90 women took part in the GR program. Sex differences were found in the GR program: Female students admitted to greater anxiety about examining male genitalia prior to the program (p = .009) and expressed more dissatisfaction with the timing (too late in the curriculum p = .006). Male students were less likely than females to improve their ability to communicate as a result of the GR program (p = .009). Observations and interviews indicated that the programs were successful in teaching technical skills but that they needed further work in integrating technical and communication training, especially during GR examination training.
Breast↗
von Hippel Lindau syndrome presenting as obstructive jaundice with involvement of pancreas in two siblings.
Von Hippel Lindau disease is rare autosomal dominant disorder. In our patient's family, 4 out of 7 siblings had manifestations of the disease; 3 of those affected had pancreatic lesions with obstructive jaundice in 2 siblings caused by pancreatic cysts is reported for the first time.
Adult↗
Course of severe ulcerative colitis in northern India.
Thirty patients with severe ulcerative colitis were studied prospectively. Sixty percent (18/30) of severe ulcerative colitis were in remission after mean duration of 9.2 days (range 2-20 days) of intensive intravenous therapy without major side effects of steroids. Factors predicting poor response to medical therapy on admission are: stool frequency > or = 9 per day, pulse rate > or = 120/minute, temperature > or = 38 degrees C, Albumin < or = 2 gm, mucosal tags on plain x-ray abdomen and pancolitis.
Adult↗