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PubMed2006

The Professionalism Mini-evaluation Exercise: a preliminary investigation.

BACKGROUND: As the evaluation of professional behaviors has been identified as an area for development, the Professionalism Mini-Evaluation Exercise (P-MEX) was developed using the mini-Clinical Examination Exercise (mini-CEX) format. METHOD: From a set of 142 observable behaviors reflective of professionalism identified at a McGill workshop, 24 were converted into an evaluation instrument modeled on the mini-CEX. This instrument, designed for use in multiple settings, was tested on clinical clerks in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics. In all, 211 forms were completed on 74 students by 47 evaluators. RESULTS: Results indicate content and construct validity. Exploratory factor analysis yielded 4 factors: doctor-patient relationship skills, reflective skills, time management, and interprofessional relationship skills. A decision study showed confidence intervals sufficiently narrow for many measurement purposes with as few as 8 observations. Four items frequently marked below expectations may be identifiers for "problem" students. CONCLUSION: This preliminary study suggests that the P-MEX is a feasible format for evaluating professionalism in clinical training.

Clinical Clerkship↗

PubMed1987

Specialty choice of medical students in India.

The objectives of this study are to investigate undergraduate medical students' attitudes towards different specialties and to investigate whether there are any differences between the attitudes of students of different sex and different socio-economic background. The sample consisted of 692 final-year students from 11 medical colleges in India. Scale values were worked out to find out the actual distance between students' attitudes. Sex differences were observed in the attitude towards surgery, obstetrics and gynaecology, orthopaedics, microbiology, social and preventive medicine and anatomy. There were no statistically significant differences between the attitudes of students from different socio-economic backgrounds.

Attitude of Health Personnel↗

PubMed1994

Uncertainties and ambiguities: measuring how medical students cope.

To develop psychometric measures specific to the ambiguities encountered in medicine and determine their value in predicting medical students' attitudes towards patients and their choice of residency, we administered to senior and first-year medical students a 25-item Likert-type questionnaire to assess their intolerance of ambiguity (ITA). Factor analysis yielded two dimensions that were converted to scales: 'Aversion to uncertainties in clinical medicine' (ITA1) and 'Preference for highly structured training environs' (ITA2). First-year students scored higher on ITA1 and lower on ITA2 than seniors. An excessive reliance on high-technology medicine, a negative orientation toward psychological problems, and Machiavellianism predicted ITA1. ITA1 was the best predictor of senior medical students' negative attributional style toward hypochondriac, geriatric and chronic pain patients. The following rank order of seniors' career choice was predicted by ITA1 scores: internal medicine, psychiatry and family medicine (lowest); radiology, surgery and anaesthesiology (highest). And by ITA2 scores: surgery, obstetrics and gynaecology, and surgical subspecialties (lowest); radiology, psychiatry and anaesthesiology (highest). We concluded that personality traits and role characteristics which predict 'Aversion to uncertainties in clinical medicine' are maladaptive to managing many primary care patients, and this mismatch is reflected in seniors' residency choice.

Adaptation, Psychological↗

PubMed1998

Puncture technique and postural postdural puncture headache. A randomised, double-blind study comparing transverse and parallel puncture.

BACKGROUND: This clinical study was conducted in order to investigate the effect of two different orientations of the bevel during dural puncture on development of postural postdural puncture headache (PPDPH). METHODS: Two hundred and eighteen patients aged 18 to 50 years scheduled for minor non-obstetric surgery using spinal anaesthesia (SA) were included in this randomised, double-blind study. Dural puncture was performed using a 0.42 mm O.D. (27-g) Quincke spinal needle with the orientation of the bevel parallel or transverse relative to the longitudinal axis of the dural cylinder. All patients were blinded with regard to the puncture technique, and so was the anaesthesiologist performing a telephone interview 5 to 7 days postoperatively. The occurrence and duration of headache, backache and other complaints were recorded. Headache was classified as PPDPH or non-PPDPH, and intensity of the headache was registered using a numerical rating scale (NRS) from 0 to 10. RESULTS: Two hundred and twelve patients with a mean age of 35.3 years completed the study, 106 in each group. The two groups were comparable with regard to mean age, sex, local anaesthetics used and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 4/106 patients (3.8%) in the parallel group and 24/106 (22.6%) in the transverse group (P < 0.0002). Postoperative backache occurred in 31 and 20 patients (parallel compared to transverse) (NS). CONCLUSIONS: Dural puncture with the bevel of the needle transverse to the longitudinal axis of the dural cylinder gave significantly more cases of PPDPH than puncture with the bevel parallel to this axis even when using a 27-g Quincke needle. When using Quincke bevelled needles care must be taken to assure that the orientation of the bevel is parallel to the longitudinal axis of the dural sac.

Adolescent↗

PubMed1998

Postural post-dural puncture headache after spinal and epidural anaesthesia. A randomised, double-blind study.

BACKGROUND: This study was conducted in order to investigate the effect of patient expectation in the development of postural post-dural puncture headache (PPDPH). METHODS: 224 patients less than 55 years scheduled for minor non-obstetric surgery were randomised to receive single-injection spinal (SA) or epidural (EA) anaesthesia. A 27-g Quinke needle was used for SA and a 18-g Tuohy needle for EA. Patients, operating team and postoperative ward personnel were all blinded to the anaesthetic given and so was an independent observer responsible for follow-up after 5-7 days. The occurrence of headache, backache and other complaints was recorded. Headache was classified as PPDPH or non-PPDPH, and duration and intensity of the headache was registered. The quality of anaesthesia was directly evaluated by the surgeon using a VAS scale from 1 (excellent) to 10 (very poor) and indirectly by the supplemental use of opioid analgesia and general anaesthesia in the two groups. RESULTS: 212 patients, 103 SA and 109 EA, with a mean age of 36.7 years, could be fully evaluated. The groups were comparable with regards to age, sex and surgical procedure performed. Headache occurred in 44 patients postoperatively. PPDPH was diagnosed in 16 patients (15.5%) in the SA group and 2 (1.8%) in the EA group (P = 0.0014). Non-PPDPH occurred in 13 patients in each group. PPDPH had significantly greater mean intensity and duration than non-PPHPH. More patients in the EA group had postoperative backache (31.2%) than in the SA group (22.3%), but this difference was not statistically significant. More patients in the EA received general anaesthesia and opioid analgesia than in the SA group, and the surgeon's rating was on average 1.3 in the SA group compared to 2.5 in the EA group (P = 0.0003). CONCLUSIONS: SA gave more headache but superior quality of surgical anaesthesia compared with EA. Dural puncture, and not expectation, is the major cause of PPDPH.

Adult↗

PubMed1989

Bilateral fetal uropathy: what is the outlook?

OBJECTIVE: To assess the morbidity and mortality associated with a prenatal diagnosis of bilateral fetal uropathy. DESIGN: Retrospective study. SETTING: Departments of radiology, paediatric surgery, obstetrics, and pathology in two teaching hospitals that serve as referral centres for the Yorkshire region. PATIENTS: 126 Cases of fetal uropathy were referred either prenatally or postnatally from hospitals in Yorkshire between August 1982 and December 1987. The disease was bilateral in 54 cases and unilateral in 72 cases. In 14 cases bilateral fetal uropathy was associated with coexistent disease. INTERVENTIONS: All cases were managed individually by an obstetrician after discussion with the radiologists and paediatric surgeons. Babies who survived were treated prophylactically with antibiotics after delivery and were operated on if appropriate. END POINT: Assessment of prognosis for long term renal function for each baby referred between August 1982 and December 1987: follow up ranged from six months to five years. MEASUREMENTS AND MAIN RESULTS: Of the 54 fetuses with bilateral fetal uropathy, 13 were terminated as the prenatal findings of ultrasonography were considered to be incompatible with long term survival. Ten of the liveborn babies died, five of renal or pulmonary insufficiency, or both, and five of associated congenital anomalies. Thirty one infants survived to follow up; four of these had serious coexistent disease and two had impaired renal function. Thus the overall mortality was 43% and the morbidity rate 19%. The renal anomaly was associated with other serious disease in 14 cases (26%) compared with two (3%) of the 72 cases of unilateral fetal uropathy. All but two of the 27 infants with isolated bilateral urinary tract disease had excellent prospects for survival. CONCLUSION: Although bilateral fetal uropathy is associated with a high morbidity rate and mortality, careful prenatal assessment can help to identify fetuses with a poor prognosis. The outlook for a fetus with isolated renal disease if treated promptly after delivery is excellent and compares favourably with that reported after prenatal surgical intervention.

Abnormalities, Multiple↗

PubMed2005

Deaths associated with anaesthesia in Togo, West Africa.

This study attempts to determine the anaesthetic death rate, the causes of deaths and the avoidable mortality rate (AMR) in consecutive cases. The number of anaesthetics given was 1464: 30 cases died within 24 h. The incidence of 24-h perioperative deaths per 100 anaesthetics was 2.57. In all, 50% of deaths were observed in obstetric surgery; 47% of deaths were associated with cardiovascular management, 30% with respiratory management; 93% of deaths were identified as avoidable. The AMR was 1.5% (anaesthetic AMR: 0.75%, administrative AMR: 0.68%, surgical AMR: 0.07%). Insufficient or no blood available is the only factor for administrative AMR.

Adolescent↗

PubMed2005

Rural health care in the U.K.: a rapidly changing scene.

Delivery of medical, nursing, and other health-related services in remote and rural areas is challenging. Historically, in the U.K., rural health care delivery has focused on medically qualified general practitioners or family physicians providing primary care services, together with isolated small hospitals providing limited specialist services such as surgery, obstetrics, and internal medicine. However, three recent developments in Europe and the U.K. will change these traditional practices. These are implementation of the European Working Time Directive, constraints related to "clinical governance", and a new contract for general medical practitioners. Delivery of services in rural areas currently faces potential conflict between national standard setters and local practicalities, and re-design of services is required. Public engagement with redesign is essential, but the outcome may be dependent on the methods used. Evaluation of new services is essential. This article gives brief examples of: two public engagement processes (a survey and a discrete choice experiment), two redesign experiments related to screening for aortic aneurysm and consultant-supported care in an island hospital, and some issues concerning the use of new technologies (telemedicine and telephone triage) in remote communities. Future implications are discussed.

Contracts↗

PubMed1994

Videoendoscopic removal of a mediastinal cyst.

A 41-year-old woman was admitted to the hospital for obstetric surgery. A preoperative chest x-ray film showed a mediastinal mass. After examinations with echocardiography, computed tomography, and magnetic resonance imaging, we removed a cyst that was 2.7 x 3.5 cm in size by thoracoscopic means. The patient left the hospital 3 days after the operation.

Adult↗

PubMed2000

Ropivacaine.

Ropivacaine (Naropin, AstraZeneca) is a long-acting amide local anaesthetic released for clinical use in 1996. Similar to bupivacaine, ropivacaine is equally effective for s.c. infiltration, epidural and peripheral nerve block for surgery, obstetric and post-operative analgesia. Ropivacaine differs from most other amide-type local anaesthetics in that it is marketed as a pure S-enantiomer, instead of as a racemate. This feature improves the safety of ropivacaine, and, indeed, studies have shown ropivacaine to have less cardiovascular and CNS toxicity than bupivacaine. Ropivacaine is nearly identical to bupivacaine in onset, quality and duration of sensory block, but it produces less motor block. Whether or not the motor sparing effect of ropivacaine is due to a lower relative potency compared to bupivacaine is a matter of intense debate. Despite a better safety profile, the increased cost of ropivacaine may limit its clinical utility.

Amides↗

PubMed1998

Dissociation of adrenomedullin concentrations in plasma and cerebrospinal fluid in pregnant and non-pregnant women.

Adrenomedullin (AM), a potent vasodilator peptide, has been shown to act within the central nervous system to modulate fluid and electrolyte balance. AM-immunoreactive cells have been found in the anterior pituitary gland and the choroid plexus of humans. In addition, AM activity has been implicated in the regulation of maternal circulation during pregnancy. To determine the relationship between AM concentration in the cerebrospinal fluid (CSF) and plasma, we measured AM levels in CSF and plasma of pregnant (group P, n = 12) and non-pregnant (group NP, n = 10) women scheduled to undergo gynecologic or obstetric surgery. In both groups, the concentration of AM in the plasma exceeded that in the CSF. Plasma AM concentration was significantly higher in pregnant than non-pregnant women (17.3+/-5.8 vs 5.1+/-1.4 pmol/l, mean +/- S.D.; P<0.01), whereas CSF AM concentration did not differ between the two groups (1.3+/-0.9 and 0.9+/-0.4 pmol/l in groups P and NP respectively). No significant correlation was found between AM concentrations in the CSF and plasma. The present findings suggest that AM is present in the CSF and that its concentration in the CSF is regulated independently from that in the plasma.

Adrenomedullin↗

PubMedDate not supplied

Agreement between Medline searches using the Medline-CD-Rom and Internet Pubmed, BioMedNet, Medscape and Gateway search-engines.

OBJECTIVE: To compare the information obtained from the Medline database using Internet commercial search engines with that obtained from a compact disc (Medline-CD). METHODS: An agreement study was carried out based on 101 clinical scenarios provided by specialists in internal medicine, pharmacy, gynaecology-obstetrics, surgery and paediatrics. 175 search strategies were employed using the connector AND plus text within quotation marks. The search was limited to 1991-1999. Internet search-engines were selected by common criteria. Identical search strategies were independently applied to and masked from Internet search engines, as well as the Medline-CD. RESULTS: 3,488 articles were obtained using 129 search strategies. Agreement with the Medline-CD was 54% for PubMed, 57% for Gateway, 54% for Medscape and 65% for BioMedNet. The highest agreement rate for a given speciality (paediatrics) was 78.1% for BioMedNet, having greater -/- than +/+ agreement. CONCLUSIONS: Even though free access to Medline has encouraged the boom and growth of evidence-based medicine, these results must be considered within the context of which search engine was selected for doing the searches. The Internet search engines studied showed a poor agreement with the Medline-CD, the rate of agreement differing according to speciality, thus significantly affecting searches and their reproducibility. Software designed for conducting Medline database searches, including the Medline-CD, must be standardised and validated.

Databases as Topic↗

PubMed1980

Air embolism during caesarean section.

Air embolism is an uncommon cause of cardiovascular collapse in obstetric surgery. A case is presented in which air was introduced through the open venous sinuses of a partially separated placenta during a delivery by caesarean section. The mechanism of death, methods of monitoring for air embolus, and treatment of embolism are discussed.

Adult↗

PubMed1997

Nursing process documentation--effects on workload and quality when using a computer program and a key word model for nursing documentation.

In 1993 the federation of County Councils commissioned Spri to carry out a broadly based study aimed at investigating individualised patient care as described in the notes kept at various care units using computers to support documentation of the nursing process. The wards involved in the study represented various disciplines such as surgery, obstetrics, internal medicine, geriatrics and psychiatry. During the study period certain measures designed to improve the documentation were implemented i.e. a special computer program and structured nursing documentation following the VIPS-model. Interviews with staff at the units confirm that the introduction of computers, in combination with the structure of the VIPS-model and training in nursing documentation, has made changes possible to working procedures and brought greater goal orientation to the activity of care. The overall examination of the nursing entries in the patients' notes showed that the language has improved. The entries were to a greater extent expressed clearly and distinctly.

Computer User Training↗

PubMedDate not supplied

New options regenerate interest in diagnostic ultrasound.

New technical developments in diagnostic ultrasound have won many converts to this modality. Once plagued with a reputation for producing blotchy black and white images, ultrasound today uses intracavitary probes and moving pictures with brilliant color to provide accurate, finely detailed images that are widely accepted in the fields of cardiology, vascular surgery, abdominal surgery, obstetrics, and gynecology.

Hospitals↗

PubMed1999

The use of sevoflurane anesthesia during early pregnancy.

Sevoflurane has favorable pharmacodynamic properties such as a rapid, smooth induction and emergence from anesthesia. However, there is only one report of sevoflurane anesthesia during early pregnancy. We report the use of sevoflurane for maintenance of general anesthesia in a pregnant patient undergoing non-obstetric surgery. A 25-year-old, female patient, at 13 weeks gestation, was diagnosed as having a strangulated ileus. General anesthesia was performed and maintained with oxygen, nitrous oxide, and sevoflurane. Six months later a healthy infant without abnormalities was delivered.

Adult↗

PubMed2000

[A homozygous quantitative defect of alpha 2-antiplasmin in a family from central Slovakia].

Alpha2-antiplasmin is the main inhibitor of plasma fibrinolytic system. An inborn defect of alpha2-antiplasmin was first described by Koie et al. in 1978 in connection with severe haemorrhage syndrome. The authors present a case report of 45 years old woman living in middle Slovakia with severe haemorrhagic syndrome started in childhood (epistaxis, skin and muscle hematomas, appendectomy with 6 weeks recovery, hardly manageable haemorrhage after teeth extractions, menorrhage, metrorrhage). Laboratory tests were negative for platelet function defects and coagulation system defects. Low level of alpha2-antiplasmin activity (10%) was detected with use of synthetic chromogenic substrate method and low amount (2%) with ELISA method. In asymptomatic daughter was decreased level of alpha2-antiplasmin (activity 51%, quantity 32%) detected. On the basis of patient history, laboratory investigations and comparison with published cases the haemorrhagic syndrome is considered to be an inborn homozygous quantitative defect of alpha2-antiplasmin. Detection of the defect in further haemorrhagic and risk situations (including laparotomy, multiple teeth extractions, obstetric surgery) led to following therapeutic measures: careful local care [by procedures], tranexamic acid in sufficient dose [4 g/day in continual i.v. infusion, or 4 x 1 g in 1/hour infusions, 4 x 1 g perorally], in sufficient duration [14 days by procedures]. Therapeutic approach after detection of the defect is efficient. (Tab. 2, Ref. 13.)

Female↗

PubMed2000

Hospital morbidity of alcohol use disorders in the center of France.

BACKGROUND: The Auvergne region of central France has the third highest mortality rate in the country for alcohol-related disorders and the highest level of alcohol consumption among young people. METHODS: An exhaustive cross-sectional study of regional hospital morbidity related to alcohol was undertaken on a single day in May 1998, including 9,552 hospital beds. All inpatients age 16 and older in the Departments of Medicine, Surgery, Obstetrics and Gynecology, Psychiatry, and Medium-Stay Services were studied. The aim was to define alcohol-related behavior patterns (by using the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] criteria of abuse and dependence and the CAGE questionnaire) and to measure the proportion of nonsomatic alcohol-related care dispensed in hospital. RESULTS AND CONCLUSIONS: The prevalence of alcohol use disorders in all wards was 20%. Half of these patients were alcohol dependent, a quarter were diagnosed as alcohol abusers, and a quarter had an alcohol-related problem that was not identified during the stay. Alcohol use disorders were more common in male inpatients (34% vs. 8% in female inpatients) and in certain age groups. One male subject in two and one female subject in five between 34 and 45 years had an alcohol-related problem. Almost 25% of male inpatients studied between the ages of 16 and 20 years had an alcohol-related problem, but only half had been diagnosed previously. Hospital care for alcohol-related health problems was seriously inadequate. On average, 38% of patients diagnosed with an alcohol use disorder received relevant nonsomatic alcohol care, of which 13% were alcohol abusers and 50% were alcohol-dependent patients. SIGNIFICANCE: This exhaustive study demonstrates the degree of alcohol-related morbidity among hospitalized patients, which is particularly high in men, in the Auvergne region of France. The study emphasizes the lack of diagnosis, particularly for the young, and the apparent deficiencies in the hospital management of these patients.

Adolescent↗