Attitudes towards skills examinations for basic surgical trainees

Objective measures of surgical skill and cognition are becoming available. A questionnaire study examining surgeons' beliefs towards a skills-based examination, current standards and possible benefits was devised. Three hundred pairs of standardised anonymous questionnaires were sent to consultants and their basic surgical trainees (BSTs) irrespective of surgical specialty. Responses were requested using a Likert scale (1-5, 3=neutral response). Two-hundred and two replies were received (including 54 pairs). BST experience ranged from 6 to 60 months (mean 24 months). When questioned regarding current training in basic surgical skills, only 34% believed that they were given adequate training at present. Sixty-four per cent of respondents believed the introduction of a skills examination would raise standards and 66% believed it necessary. Eighty-three per cent of respondents believed that they or their BST would practice these skills, if an examination were introduced and 85% wanted or would provide dedicated teaching time for this. However, 68% had no access to a dedicated skills facility, and uptake of these, where available, was variable. When questioned about their ability to perform the six appropriate tasks, there was a poor correlation of scoring between the groups. Consultants and their BSTs do not believe that they are given adequate training in basic skills. The introduction of an examination would lead to practice of these skills and is seen as a positive move.

The Increasing Significance of How to Learn Motor Skills

The training of surgeons has traditionally been an apprenticeship. In recent times it has become increasingly difficult for trainees to acquire operative skills. The acquisition and refinement of these technical skills by the surgical trainee are central to surgical teaching. Much work has been done looking into the theories of motor skill learning, working on the assumptions that if they are understood then tests may be developed to be used as skill predictors. Two schools of thought exist as to the use of neuropsychological factors in learning fine motor skills but all agree that practice and instructional feedback are essential for the correct acquisition of these essential surgical skills. With the current climate of shortened training and new guidelines its even more important to understand skill acquisition and assist in the learning of new surgical skills.

Long-term Outcomes of Brachiobasilic Transposition Fistula for Haemodialysis

OBJECTIVES

The transposed basilic vein to brachial artery arteriovenous fistula provides secondary vascular access for haemodialysis. The long-term results of such fistula are assessed in this retrospective series.

MATERIAL AND METHODS

Over a 5-year period 75 brachiobasilic transposition fistulae were performed in 74 patients. There was a median follow up of 14 months.

RESULTS

Primary patency was achieved in 69 (92%) of the fistulae, and secondary patency in 74 (99%) of the fistulae. Successful interventions included angioplasties in four, and saphenous vein interposition in one, whilst three patients had failed thrombectomies. Dialysis was performed using 69 (92%) of the fistulae while 6 (8%) were never used. Of the 75 fistulae 47 (63%) were patent at follow up. Cumulative secondary patency was 66% at 1 year, 52% at 2 years, and 43% at 3 years. Complications developed in 41 (55%), and included thrombosis, infection, stenosis, arm oedema, bleeding, steal syndrome and microaneurysm formation.

CONCLUSIONS

Brachiobasilic transposition fistulae have good long-term patency rates. The complication rate, although high, is lower than that reported for PTFE grafts. Brachiobasilic fistulae should be used in preference to PTFE grafts for secondary access.

Circadian variation--increased morning incidence of acute myocardial infarction in patients with coronary artery disease

OBJECTIVE

To examine whether a circadian variation exists in the onset of symptoms of Acute Myocardial Infarction (AMI) in patients with Coronary Artery Disease (CAD) and to review the characteristics of such variation.

SETTING

Patients with AMI admitted to the coronary care units of two teaching hospitals in the city of Karachi, Dr. Ziauddin Medical University Hospital and National Institute of Cardiovascular Disease.

METHOD

The study population included patients admitted to the coronary care unit. The diagnosis was based on the onset of AMI signs and symptoms and ECG changes. The inclusion criterion was an age less than 76 years.

RESULTS

The incidence of Myocardial infarction assessed by the onset of clinical symptoms exhibited a marked circadian variation. Myocardial infarction occurred 2.8 times more frequently during morning hours (period of maximum incidence) as compared to evening (period of minimum incidence).

CONCLUSION

This result extends previous observation of the circadian variation in the incidence of AMI onset. This study also helps in searching the potential triggers to physiological changes that may occur during morning hours. Design and timing of cardioprotective medication may play a crucial role in improving circadian variation and prevention of AMI.

Spin-dependent exciton formation in pi-conjugated compounds

The efficiency of light-emitting diodes (LEDs) made from organic semiconductors is determined by the fraction of injected electrons and holes that recombine to form emissive spin-singlet states rather than non-emissive spin-triplet states. If the process by which these states form is spin-independent, the maximum efficiency of organic LEDs will be limited to 25 per cent. But recent reports have indicated fractions of emissive singlet states ranging from 22 to 63 per cent, and the reason for this variation remains unclear. Here we determine the absolute fraction of singlet states generated in a platinum-containing conjugated polymer and its corresponding monomer. The spin-orbit coupling introduced by the platinum atom allows triplet-state emission, so optically and electrically generated luminescence from both singlet and triplet states can be compared directly. We find an average singlet generation fraction of 22 +/- 1 per cent for the monomer, but 57 +/- 4 per cent for the polymer. This suggests that recombination is spin-independent for the monomer, but that a spin-dependent process, favouring singlet formation, is effective in the polymer. We suggest that this process is a consequence of the exchange interaction, which will operate on overlapping electron and hole wavefunctions on the same polymer chain at their capture radius.

The energy gap law for triplet states in Pt-containing conjugated polymers and monomers

The energy gap law established for aromatic hydrocarbons and rare earth ions relates the nonradiative decay rate to the energy gap of a transition through a multiphonon emission process. We show that this energy gap law can be applied to the phosphoresce of a series of conjugated polymers and monomers for which the radiative decay rate has been enhanced through incorporation of a heavy metal. We find that the nonradiative decay rate from the triplet state T(1) increases exponentially with decreasing T(1)-S(0) gap for the polymers and monomers at 300 and 20 K. Comparison of the nonradiative decay of polymers with that of their corresponding monomers highlights the role of electron-lattice coupling.

Synthesis of novel tetrahydroimidazole derivatives and studies for their biological properties

Ethylenediamine was reacted with suitable aromatic aldehydes in order to prepare their respective diSchiff bases. These compounds were then reduced to give the corresponding tetrahydrodiSchiff bases, which were low melting in nature. Finally, these derivatives were condensed with different aromatic aldehydes to give the desired tetrahydroimidazoles. The structures of all these compounds were established on the basis of spectral data. These novel tetrahydroimidazoles showed promising anti-inflammatory and analgesic activity. The compounds were also screened for their anti-bacterial property against Staphylococcus aureus and Escherichia coli.

Rupture of the male membranous urethra

BACKGROUND

Management of traumatic rupture of the male membranous urethra remains controversial. Long-term morbidity can include urinary incontinence, urethral stricture and erectile dysfunction.

AIMS

To review management and outcome of urethral rupture to improve treatment protocols.

METHODS

A retrospective study of 47 patients presenting with traumatic urethral rupture over 25 years was performed.

RESULTS

All patients underwent emergency suprapubic catheterisation, 32 patients had open surgical realignment at 1-2 weeks; 78% of whom developed strictures. Ten patients unsuitable for early repair underwent delayed transabdominal transpubic urethroplasty at three months: 40% of whom developed strictures. Five patients with partial rupture were managed by cystoscopy and urethral catheter. Erectile dysfunction correlated to initial injury rather than treatment.

CONCLUSIONS

If the patient is stable and requires emergency laparotomy for other abdominal injuries, he should have immediate realignment of the urethra. Early realignment of the urethra at laparotomy at 1-2 weeks can be combined with orthopaedic fixation of pelvic fractures. Patients who remain unstable due to associated injuries should have delayed urethroplasty at three months.

Electronic spectra of 1-methyl and 2-methyl phenanthrenes and their radical cations

Electronic spectra of phenanthrene (P), 1-methyl phenanthrene (1-MeP), 2-methyl phenanthrene (2-MeP) and their monopositive ions are investigated experimentally as well as theoretically. The ions were produced by photo-oxidation of the hydrocarbons in boric acid matrix. The electronic absorption spectrum of 2-methyl phenanthrene cation (2-MeP+) is entirely new. For the interpretation of the electronic spectra of neutral and ionized MePs, semi-empirical AM1 (Austin Model 1) calculations are carried out for the first time. The bathochromic shifts in the spectral bands of the neutral and ionized MePs are attributed to 'conjugative' effect. The present experiments reveal that the 448 nm band of 1-methyl phenanthrene cation (1-MeP+) and the 486 nm band of 2-MeP+ show close matching with the respective 450 nm and 488 nm 'diffuse interstellar bands'. This suggests the possibility of the existence of such ionic species in the interstellar matter.

Fine-needle aspiration diagnosis of Kaposi's sarcoma in a developing country

Fine-needle aspiration (FNA) cytology was performed on 15 patients with peripheral lymphadenopathy and/or skin lesions referred to the Department of Pathology of the Hospital Central of Maputo, Maputo, Mozambique. Epitrochlear lymph nodes were the most frequently aspirated site. All aspirates allowed diagnoses of Kaposi's sarcoma (KS). Smears contained loosely cohesive clusters of bland spindle cells, with a radial arrangement and nuclear crush artifacts. These diagnostic clues have not been described in other spindle-cell intranodal lesions that should be considered in differential diagnoses. Taking into consideration the high prevalence of AIDS and limited resources for diagnosis in Africa, FNA cytology appears to be a useful method for the diagnosis of KS in developing countries, reducing the necessity for surgical lymph node excision.

An evaluation of pharmacokinetics and pharmacodynamics of leuprorelin acetate 3M-depot in patients with advanced and metastatic carcinoma of the prostate

OBJECTIVES

The investigational objectives of this open, noncomparative phase I study were to determine the pharmacokinetic profile of a single dose of 11.25 mg leuprorelin acetate, the effective duration of the chemical castration (serum testosterone < or = 1.73 nmol/l) and safety in patients with locally advanced and/or metastatic carcinoma of the prostate foreseen for chemical castration, in the hope that such a dose of leuprorelin acetate may be suitable as a depot formulation to be administered 3-monthly to these patients.

METHODS

A total of 24 males up to 85 years old with histologically proven advanced carcinoma of the prostate were enrolled in the study to obtain 18 eligible patients. Each patient was given 11.25 mg of leuprorelin acetate in a depot formulation subcutaneously after reconstitution in 2 ml of a special suspension vehicle. The study period lasted 24 weeks. Patients whose serum testosterone levels reincreased prior to the end of the observation period of 24 weeks were withdrawn from the study and received the monthly depot formulation of 3.75 mg of leuprorelin acetate.

RESULTS

The 3M-depot formulation of leuprorelin acetate ensured continuous and constant drug release and effective suppression of testosterone serum levels to castration range for at least 13 weeks. After an initial rise, 5 alpha-dihydrotestosterone as well as the gonadotropin serum levels of luteinizing hormone and follicular stimulating hormone reflected the testosterone serum pattern.

CONCLUSION

The results of this study show that the 3M-depot preparation of leuprorelin acetate is effective in suppressing the serum testosterone levels to the castration range for a targeted period of at least 13 weeks.

Development of a blocking enzyme-linked immunosorbent assay for the detection of avian polyomavirus-specific antibodies

Avian polyomavirus, described originally as budgerigar fledgling disease virus, has been associated with devastating contagious disease outbreaks in budgerigar aviaries. At present, this virus affects a wide range of psittacine and non-psittacine birds worldwide, and the serum neutralisation test is used for the serodiagnosis of avian polyomavirus infections. A blocking enzyme-linked immunosorbent assay was developed for the screening of large numbers of sera collected from various avian species. The assay employs a monoclonal antibody directed against the major structural protein VP1 as a blocking antibody in a sandwich blocking procedure. Either purified avian polyomavirus particles or avian polyomavirus VP1 expressed in recombinant baculovirus-infected Sf9 cells were used as antigen. The specificity of the blocking enzyme-linked immunosorbent assay was evaluated by testing sera directed against mammalian polyomaviruses. Using sera obtained from chicken infected experimentally with avian polyomavirus and a collection of psittacine field-origin sera, a good correlation was observed between the results of the blocking enzyme-linked immunosorbent assay and the serum neutralisation test. However, the blocking enzyme-linked immunosorbent assay is more rapid and more economic. Both, avian polyomavirus particles and VP1 produced by recombinant DNA technology proved to be suitable antigens.

Treatment of abdominal aortic pseudoaneurysm with covered stents in a pediatric patient

An occasional complication of redilating stents placed in children is false aneurysm. We report the use of covered stents to treat a false aneurysm of the abdominal aorta in an adolescent girl with neurofibromatosis and abdominal coarctation of the aorta.

Renal transplantation in patients with an augmentation cystoplasty

OBJECTIVE

To retrospectively review our experience over a 10-year period of renal transplantation in patients with augmented bladders and thus assess the safety of this procedure.

PATIENTS AND METHODS

Ten transplant recipients who had previously undergone augmentation cystoplasty were reviewed; a cadaveric kidney was transplant in each case. The donor ureter was anastomosed to the augment bladder in six patients, in three to the native ureter and in one the donor renal pelvis was anastomosed to the native ureter.

RESULTS

No patients died and nine of the 10 grafts were functioning at a mean follow-up of 27 months. The mean (SD) serum creatinine level at the follow-up was 100.8 (27.25) mmol/L. Four patients had 10 episodes of urosepsis requiring hospital admission, with only one graft lost.

CONCLUSION

Renal transplantation can be performed safely in patients with an augmentation cystoplasty.

Estradiol causes a dose-dependent stimulation of prostate growth in castrated beagle dogs

BACKGROUND

Previous studies have shown that chronic treatment of castrate dogs with androgen and estrogen results in significant prostate growth. Estrogen treatment of castrate dogs in the absence of androgen has resulted in conflicting data as reported by several authors. The purpose of this experiment was to evaluate the effect of a physiological dose of estradiol on prostate growth in dogs, using ultrasound to study size changes over time.

METHODS

Dogs (n = 25) were randomly divided into groups (n = 5) and treated as follows: castration alone (CC), castration plus low dose estradiol (E(2) low), castration plus high estradiol (E(2) high), castration plus estradiol and androstanediol (E(2)A), or no treatment (normal controls, NC). Silastic implants containing 5alpha-androstan-3alpha-17beta-diol (3alphadiol), and/or 17beta-estradiol were used for continous delivery of steroids. Prostate volume was measured by transrectal ultrasonography, and blood was drawn for hormone and sex hormone binding globulin (SHBG) determinations.

RESULTS

Results show that serum estradiol and SHBG levels were fairly constant over 12 weeks in all groups. Estradiol-treated groups had mean serum estradiol values of approximately 40 and 60 pg/ml, respectively. Initially, all groups had similar prostate volumes. Over 12 weeks the castrate dogs had a decline in prostate volume, whereas the intact dogs and those treated with E(2) and 3alpha-diol maintained a constant prostate volume. Estradiol treatment caused a large, late onset (week 7), dose-dependent increase in prostate volume relative to the intact group (P < 0.01). At 12 weeks, animals were euthanized and prostates weighed. The mean prostate weights in each group were: NC 14.8 +/- 2. 9, CC 2.4 +/- 0.5, E(2)A 9.7 +/- 2.0, E(2) low 21.7 +/- 4.3, and E(2) high 63.6 +/- 12.6 g (geometric mean +/- SEM). Histologically, prostates of estrogen-treated dogs showed metaplastic squamous epithelium.

CONCLUSIONS

These results demonstrate that estradiol causes marked dose-dependent stimulation of prostate growth in the castrate dog.

An immunohistochemical study of the rete ovarii and epoophoron

A study to compare the immuno-histochemical profile of the human rete ovarii, and epoophoron, with the Fallopian tube and ovarian surface epithelium was performed with 31 antibodies and antisera. A reaction was present in the epithelial cytoplasm of the rete ovarii and epoophoron of mesonephric origin, for vimentin, GFAP, cytokeratin markers, (AE1/AE3, MNF116; Cam 5.2, 34 beta E12 and for the monospecific antibodies to cytokeratins 7 and 19), heat shock protein 27, in the cell membrane for HBME-1, EMA and in the subepithelial collagen for collagen IV. Reactions were present only in the epithelium in the rete ovarii for EGFR (one case) and CA-125 (four cases). A reaction was present in the epithelium of the epoophoron only for Ber-EP-4 and S100. There was no reaction with antibodies for desmin, neurofilament protein, cytokeratins 20 or 14, actin, calretinin, E-cadherin, C-erb-B2, or CEA (monoclonal and polyclonal reagents). The immuno-histochemical profile of the Fallopian tube was consistent with its para-mesonephric origin and that in the ovarian surface epithelium was consistent with a proposed modified mesothelial origin. This study provides an immunohistochemical profile of these structures with a large panel of commonly available antibodies and antisera, confirming and extending the findings described in previous studies.

Incidence of urinary tract infection during pregnancy

Incidence of urinary tract infection (UTI) during pregnancy among Pakistani women was examined. Midstream urine was collected from 250 pregnant and 100 control women and streaked on blood agar and incubated. Growth was considered significant if > or = 10(5)/mL bacteria were present. Among the pregnant women, 28.5% had UTI; 30.0% of controls had UTI. Among the pregnant and control women, 24.4% and 20.0% respectively had UTI symptoms, such as incontinence, nocturia and urgency. Symptoms did not correlate with incidence. Socioeconomic status, personal hygiene, education level, pregnancy duration, postcoital washing, contraceptive use and use of underclothing had no significant association with UTI occurrence. A history of past urological problems was associated with an increased incidence of UTI in pregnancy.