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PubMed2003

US graduate medical education, 2002-2003.

CONTEXT: By selecting a specialty to train in, physicians entering graduate medical education (GME) training provide advance information about the future physician workforce. OBJECTIVE: To determine trends in the residency choices of medical school graduates entering GME training. DESIGN, SETTING, AND PARTICIPANTS: The American Medical Association and Association of American Medical Colleges jointly surveyed active programs as well as combined programs in academic year 2002-2003 about active, transferred, and graduated residents. In 2002 the survey was sent to 8064 program directors; 84.2% of them confirmed the status of all active residents and 82.6% completed the program survey. MAIN OUTCOME MEASURES: In addition to overall trends, the specialty choices of graduates of osteopathic schools (DOs) and international medical graduates (IMGs). Also, where native US citizen resident physicians attended medical school if not in the United States, with a focus on Hispanic ethnicity and Spanish-language facility. RESULTS: The census counted 98 258 resident physicians in GME programs in academic year 2002-2003, similar to 5 years ago and reversing a decline over the past few years. There were 23 443 residents in graduate year 1 (GY1) positions, for which prior GME training is not required, a slight increase from 2001-2002. The proportion of GY1 residents without prior GME increased slightly compared with 2001-2002 (92.3% to 93.3%). In 1996-1997, 624 DOs were GY1 residents without prior GME (2.9%); their numbers increased to 1312 (6.0%) in 2002-2003. The number of IMGs in GY1 positions without prior GME also increased over this period, from 5033 (23.5%) to 5623 (25.7%). Over the past 6 years the number of IMG and DO GY1 residents without prior GME in specialties such as general surgery, obstetrics and gynecology, and emergency medicine has increased disproportionately faster than the overall rate. Hispanic native US citizens are more likely to be IMGs than non-Hispanic native US citizens (9.6% vs 5.0%). One third of Hispanic native US citizen IMGs received their medical education in Spanish vs less than 3% of non-Hispanic native US citizen IMGs. CONCLUSIONS: Nearly 25% of physicians in US allopathic training programs in 2002-2003 were IMGs, and the percentage of DOs continues to increase. The number of residents conversant in Spanish could serve a need for a large US minority population.

Career Choice↗
PubMed1993

Postdural puncture headache: a randomized prospective comparison of the 24 gauge Sprotte and the 27 gauge Quincke needles in young patients.

This study was designed to compare the frequency of postdural puncture headaches (PDPH) using the 24 gauge Sprotte and the 27 gauge Quincke spinal needles in a population of patients less than 45 yr of age undergoing spinal anaesthesia for non-obstetrical surgery. Patients were randomly assigned to receive spinal anaesthesia with either the 24 gauge Sprotte spinal needle (n = 46) or the 27 gauge Quincke spinal needle (n = 47). Patients were interviewed on either postoperative day one or two and on postoperative day three. A PDPH was defined as a headache involving the occipital or frontal areas that is made worse when assuming either the sitting or standing position. Ninety-three patients were included in the analysis of data. The overall incidence of PDPH was 14% (13 of 93), and no difference was found between the Sprotte (15.2%) and Quincke (12.8%) needles. The distribution of the PDPHs by severity was not different between the two groups. None of the 13 patients with PDPHs required on epidural blood patch for relief of symptoms. Both the Sprotte needle and the Quincke needles were judged as easy to use and both required the same number of attempts in order to locate cerebrospinal fluid (first attempt successful: 73.9% versus 66%). Neither patient satisfaction nor the acceptability of spinal anaesthesia for a future procedure was adversely affected by the occurrence of a PDPH. The results of this study suggest that the risk of PDPH after spinal anaesthesia in young patients is similar using either the 24 gauge Sprotte or the 27 gauge Quincke spinal needle.

Adult↗
PubMed2002

The oxygen concentrator is a suitable alternative to oxygen cylinders in Nepal.

PURPOSE: To review the efficacy and reliability of oxygen concentrators used over the last six years in Nepal. The apparatus used was a DeVilbiss(R) oxygen concentrator that provided O(2) for anesthesia supplemented with compressed air to drive a Penlon Manley Multivent Ventilator(R). It remains difficult to supply oxygen in cylinders to peripheral hospitals in Nepal due to lack of proper roads. METHODS: We conducted a retrospective analysis of a sample of 378 cases anesthetized at the Bir Hospital and at a private hospital in Kathmandu from April through October 1999. The Bain circuit or its modification was used in adults, and Bain or Ayre's T piece in children. High flows from the oxygen concentrator used with the Bain and Ayre's T-circuits were reduced to 2 L/min, delivered through the halothane vaporizer, supplemented by room air in the modified Bain circuit. Positive pressure ventilation was provided with an Ambubag, Oxford Inflating Bellows or Penlon Manley Multivent Ventilator. Blood pressure, electrocardiogram, FiO(2) and SpO(2) were monitored in all cases. RESULTS: Surgery included urologic, general surgery, obstetrics and gynecological procedures, neurosurgery and closed mitral valvotomy. Age ranged from six months to 78 yr. The anesthetic time lasted from 45 min to 12 hr. The FiO(2) ranged from 0.5 to 0.6 in the Bain and Ayre's T circuits, and from 0.34 to 0.40 in the modified Bain circuit with a flow of oxygen of 2 L/min from the concentrator. CONCLUSION: With regular maintenance and servicing done locally, the oxygen concentrator can be used safely in adults and children. Use of the oxygen concentrator is a suitable alternative to oxygen cylinders in the developing world.

Adolescent↗
PubMed2005

[Airways and respiratory function in obese patients. Anaesthetic and intensive care aspects and recommendations].

In obese patients, perioperative pulmonary complications have an increased frequency and are associated with higher morbidity and mortality compared with non-obese patients. The management of surgical procedures in these patients is a challenge for the anaesthetist. Knowledge of pathophysiological and pharmacological aspects of the obese patients' condition is essential for their care during preoperative assessment, intra-operative management and, if necessary, postoperative intensive care. Special information on airway and lung protection as well as cases involving laparoscopic surgery, obstetric and paediatric anaesthesia in obese patients are also discussed.

Adult↗
PubMed1989

Variations in resource utilization--the role of medical practice and its economic impact.

Several studies have indicated that differences in medical practice are often an important factor behind variations in resource utilization. 'Practice', in medical contexts, is used as a comprehensive expression for what is regarded to be adequate care, considering science and proven experience, as well as present resources, demography, organization, and other given conditions. However, experience shows that routines and practice, even under similar conditions (resources, organization, etc.) often vary significantly among departments within the same medical discipline. In this more restricted sense, variations in practice might depend on different--more or less well-founded--opinions among physicians concerning what constitutes appropriate length of stay, level of care, and technology. With examples from some specialties (e.g. general surgery, obstetrics and gynecology), we demonstrate this 'model' and the economic impact of practice variations. Our conclusion is that there are opportunities for achieving greater benefit from existing resources, i.e. increasing efficiency, through reallocation and alternative utilization of resources, altered practice.

Cesarean Section↗
PubMed2006

Non-obstetrical acute abdomen during pregnancy.

Acute abdomen in pregnancy remains one of the most challenging diagnostic and therapeutic dilemmas today. The incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies. Despite advancements in medical technology, preoperative diagnosis of acute abdominal conditions is still inaccurate. Laboratory parameters are not specific and often altered as a physiologic consequence of pregnancy. Use of laparoscopic procedures as diagnostic tools makes diagnosis of such conditions earlier, more accurate, and safer. Appendicitis is the most common cause of the acute abdomen during pregnancy, occurring with a usual frequency of 1 in 500-2000 pregnancies, which amounts to 25% of operative indications for non-obstetric surgery during pregnancy. Surgical treatment is indicated in most cases, as in nonpregnant women. Laparoscopic procedures in the treatment of acute abdomen in pregnancy proved safe and accurate, and in selected groups of patients are becoming the procedures of choice with a perspective for the widening of such indications with more frequent use and subsequent optimal results. Despite these advances, laparotomy still remains the procedure of choice in complicated and uncertain cases.

Abdomen, Acute↗
PubMed2006

Endoscopic retrograde cholangiopancreatography during pregnancy.

Physiologic changes of pregnancy leave women at increased risk for gallstone complications. Endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy was first reported in 1990 for the treatment of complicated gallstone disease. Since then, numerous reports have shown that if certain precautionary measures are taken, therapeutic ERCP can be safely performed during pregnancy. A multidisciplinary approach that involves obstetrics, surgery, and gastroenterology is necessary to help ensure maternal and fetal safety. This article addresses the physiologic changes that increase a women's risk for gallstone complications, the indications for ERCP, the safety of ERCP, and its use within the last 15 years.

Animals↗
PubMed2006

Anaphylactic reactions during cesarean section.

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.

Adult↗
PubMed2006

Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis.

BACKGROUND: Little is known about socioeconomic differences in access to life-saving obstetric surgery, yet access to a caesarean for women is essential to achieve low levels of maternal mortality. We examined population-based caesarean rates by socioeconomic groups in various developing countries. METHODS: We used data from 42 Demographic and Health Surveys in sub-Saharan Africa, south and southeast Asia, and Latin America and the Caribbean. We report caesarean rates by wealth quintile and the absolute and relative difference between the richest and poorest quintiles. We also categorise the sample into richer and poorer halves and examine caesarean rates within rural areas. FINDINGS: Caesarean rates were extremely low among the very poor: they were below 1% for the poorest 20% of the population in 20 countries and were below 1% for 80% of the population in six countries. Only in five countries did the very poor have caesarean rates exceeding 5%. At the other extreme are seven countries, mostly in Latin America, where caesareans are far in excess of the suggested maximum threshold of 15% for at least 40% of the population. INTERPRETATION: In the poorest countries-mostly in sub-Saharan Africa-large segments of the population have almost no access to potentially life-saving caesareans, whereas in some mid-income countries more than half the population has rates in excess of medical need. These data deserve the immediate attention of policymakers at national and international levels.

Adult↗
PubMed2003

The direct depressant effects of desflurane and sevoflurane on spontaneous contractions of isolated gravid rat myometrium.

Our purpose was to investigate the direct depressant effects of desflurane and sevoflurane at 0.5, 1 and 2 minimum alveolar concentrations (MAC) on spontaneous contractions of isolated gravid rat myometrium. Ten gravid, albino Wistar rats, weighing 240-310 g and at 19-20 days' gestation were used. Sixty myometrial strips were obtained from 10 rats, and randomly assigned into six groups of 10. After obtaining spontaneous myometrial contractions in de Jalon solution for 45 min, 0.5, 1 or 2 MAC of desflurane or sevoflurane were continuously bubbled in the bath for 15 min and myometrial contractions evaluated during the last 10 min. Desflurane 0.5 MAC did not affect duration or amplitude of spontaneous contractions, but frequency was significantly decreased (P < 0.05). Duration, amplitude and frequency were all significantly decreased by desflurane 1 and 2 MAC (P < 0.05). Sevoflurane did not affect duration, amplitude or frequency at 0.5 MAC, but amplitude and frequency were significantly decreased at 1 MAC and all were significantly decreased at 2 MAC (P < 0.05). The frequency of contractions was decreased 21.2% with 1 MAC desflurane versus 17.1% with 1 MAC sevoflurane. The amplitude and frequency of contractions were decreased 48.2% and 48.7% with 2 MAC desflurane versus 58.9% and 49.3% with 2 MAC sevoflurane, respectively. We suggest that due to tocolytic activity, desflurane and sevoflurane can be useful in non-obstetric surgery during pregnancy.

Journal Article↗
PubMed2003

Nurses' knowledge regarding patients with intravenous catheters and phlebitis interventions.

This study was planned and applied in 2 stages. Stage I was applied to determine the knowledge of nurses working in the internal medicine, surgery, obstetrics and gynecology, pediatrics, and other services in Celal Bayar University Hospital about using intravenous catheter and intravenous fluid treatment, and the symptoms and treatment procedure for phlebitis. Stage II consisted of observation of all patients who had intravenous catheters for symptoms of phlebitis for 5 days and the interventions the nurses used for the patients who had phlebitis. In stage I, questionnaires were used to determine the knowledge of the nurses; in stage II, 2 investigators observed the patients. Results were evaluated using SPSS software with chi(2) statistical analysis. Nurses were found to have high knowledge levels, but their practices were not suitable to their knowledge levels. Of the patients who participated in the study, 67.24% showed symptoms of phlebitis. We found that there was a significant relationship (P <.05) between the selection of the vein and the occurrence of phlebitis in patients who had an intravenous catheter. We also found that the relationships between the age groups of the patients and phlebitis and the relationships between the diagnosis and phlebitis were statistically significant (P <.05).

Adolescent↗
PubMed1987

[Comparison between prostaglandin E2 gel and oxytocin in medically indicated labor induction].

The use of prostaglandins (PG) increasingly replaces the "classical" method of induction of labour by means of oxytocin and amniotomy, the last-named method being associated, especially in women with an unripe cervix, with side effects like prolonged labour and a higher rate of obstetric surgery. In this study the point of interest was whether prostaglandins offer any advantages over the classical method in respect of efficacy and maternal and foetal tolerance. 99 patients subdivided into primiparae and multiparae were randomly assigned to group A or B. In group A labour was induced with 1 mg resp. 2 mg PGE2 intravaginally at an interval of 6 hours. In group B the method of induction consisted of intravenous oxytocin and amniotomy. The success rate of induction was almost equal in both groups. However, in those patients where PGE2 induction did not succeed and who could not be delivered within 12 hours the cervical score was significantly improved in comparison to the oxytocin group. Based on the experience reported in the literature, one might speculate that an increased dosage could still improve the results of vaginally administered PGE2 gel.

Administration, Intravaginal↗
PubMed1983

[Caesarean hysterectomy or tubal coagulation following caesarean section--a comparison].

From 1973 to 1982 a total of 99 Caesarean hysterectomies and 105 Caesarean sections with subsequent tubal coagulation were performed. This represents 6.5% and 6.9%, respectively, of all Caesarean sections. After excluding the emergency cases, 86 planned Caesarean hysterectomies and 99 Caesarean sections combined with tubal coagulation remained. Statistical evaluation showed that the postoperative course was more favourable and less febrile with Caesarean hysterectomy than with tubal coagulation after Caesarean section. The somewhat greater loss of blood after hysterectomy is practically without any sequel. Hysterectomy saves the patient from subsequent uterine diseases, ascending infections, menstrual anaemias, problems of hygiene, etc. Caesarean hysterectomy appears to be the method of choice if surgical sterilisation is deemed appropriate besides performing the Caesarean section; if the patient has been informed of the operation in detail; if the patient feels no emotional ties towards the uterus; if there has been ample opportunity to think things over calmly; and if the surgeon is really skilled in performing hysterectomy.

Cesarean Section↗
PubMed2007

Risk factors for abdominal scar endometriosis after obstetric hysterotomies: a case-control study.

OBJECTIVE: To identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. METHODS: The authors conducted a case-control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. RESULTS: In the multivariate analysis, positive associations were observed between scar endometriosis and hysterotomy type (early versus late: OR = 42.99; CI 8.77-210.81), amount of the menstrual blood flow (heavy versus light/normal: OR = 11.97; CI 2.35-60.82), and alcoholic consumption (yes versus no: OR = 5.31; CI 1.22-23.11). Negative association was observed between scar endometriosis and parity (OR = 0.61; CI 0.31-1.23), however it was not statistically significant (p>0.05). CONCLUSIONS: Early hysterotomy in pregnancy is the main risk factor for scar endometriosis. Increased menstrual flow and alcohol consumption are also risk factors, while high parity may be a protecting factor.

Abdomen↗
PubMed2005

Use of interaction cards to evaluate clinical performance.

Currently in-training evaluation in Kuwait depends on the use of the global rating scale at the end of clinical rotation clerkships. Such a scale is inconsistent, subjective, and suffers from deficiencies such as positive skewness of the distribution of ratings and poor reliability. The aim of the study was to assess the inter-rater variation and the reliability of the recently introduced Interaction Card (IC) method for evaluating clinical performance and to measure the agreement between trainees' overall performance evaluation by the currently used global rating scale and the IC summative evaluation. In the study, 370 evaluators encountered 50 trainees during their basic clinical training rotations (internal medicine, surgery, obstetrics and gynecology, and pediatrics) at six hospitals. A total of 9146 encounters were conducted focusing on six clinical performance domains: clinical skills (taking history, case sheet, and physical examination), professional behaviour, case presentation, diagnosis, therapy and handling of emergencies. The method demonstrated significant inter-rater variation in the overall IC ratings according to specialty, rank of evaluator and hospital (p < 0.001). The Interaction Card was found to be reliable, as shown by the internal consistency between the six domains (Cronbach's alpha = 0.914). There was low correlation (Spearman rank correlation coefficient, rs = 0.337), and low agreement (Kappa = 0.131) between the global rating scale and Interaction Cards summative evaluations. The IC method provided instantaneous formative feedback and summative evaluation for clinical performance to trainees. The method can be generalized to encompass training and examinations programmes for all categories of trainees in most clinical specialties.

Clinical Competence↗
PubMed1983

Predicting performance during clinical years from the new Medical College Admission Test.

The results of a predictive validity study of the new Medical College Admission Test (MCAT) using criteria from the clinical years of undergraduate medical education are presented and discussed. The criteria included course grades and faculty ratings of clerks in internal medicine, surgery, obstetrics and gynecology, pediatrics, and psychiatry; scores on a comprehensive test of clinical knowledge (including patient management type examinations); and scores on Part II of the examinations of the National Board of Medical Examiners (NBME). While the validity coefficients of the MCAT with the Part II examinations ranged from .03 to .47, they were higher than those of undergraduate grade-point averages with the same criteria. The implications of the small-to-medium size validity coefficients for admissions are discussed.

Achievement↗
PubMed1991

National curricular guidelines for third-year family medicine clerkships. The Society of Teachers of Family Medicine (STFM) Working Committee to Develop Curricular Guidelines for a Third-Year Family Medicine Clerkship.

In most U.S. medical schools, required clerkships in internal medicine, pediatrics, surgery, obstetrics and gynecology, and psychiatry are considered the core components of a student's clinical education. Because the specialty of family practice is not as well established in the medical school curriculum, the federal government is interested in promoting the specialty as part of its continuing efforts to increase the number of primary care physicians. Therefore, in August 1989 the Division of Medicine, Bureau of Health Professions, United States Department of Health and Human Services, awarded a purchase order to the Society of Teachers of Family Medicine to develop curricular guidelines for third-year family medicine clerkships. The authors represent the working committee that developed these guidelines. This paper describes the process used to develop the core curricular guidelines, presents the product of the curriculum development activities, and discusses dissemination, implementation, and further development activities.

Clinical Clerkship↗