摘要:

ObjectiveTo determine the impact of work hour limitations imposed by the 405 (Bell) Regulations as perceived by general surgery residents in New York State.Summary Background DataNew Accreditation Council for Graduate Medical Education (ACGME) requirements on resident duty hours are scheduled to undergo nationwide implementation in July 2003. State regulations stipulating similar resident work hour limitations have already been enacted in New York.MethodsA statewide survey of residents enrolled in general surgery residencies in New York was administered.ResultsMost respondents reported general compliance with 405 Regulations in their residency programs, a finding corroborated by reported work hours and call schedules. Whereas a majority of residents reported improved quality of life as a result of the work hour limitations, a substantial portion reported negative impacts on surgical training and quality and continuity of patient care. Negative perceptions of the impact of duty hour restrictions were more prevalent among senior residents and residents at academic medical centers than among junior residents and residents at community hospitals.ConclusionsImplementation of resident work hour limitations in general surgery residencies may have negative consequences for patient care and resident education. As surgical residency programs develop strategies for complying with ACGME requirements, these negative consequences must be addressed.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury.Summary Background DataPowerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error.MethodsThe authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations.ResultsThe primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot.ConclusionsThese data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo update and summarize evidence of risk factors for breast cancer.Summary Background DataWomen who are at high risk for breast cancer have a variety of options available to them, including watchful waiting, prophylactic surgery, and chemoprevention. It is increasingly important to accurately assess a patient’s risk profile to ensure that the cost/benefit ratio of the selected treatment is favorable.MethodsEstimates of relative risk for documented risk factors were obtained from seminal papers identified in previous reviews. These estimates were updated where appropriate with data from more recent reports using large sample sizes or presenting meta-analyses of previous studies. These reports were identified from a review of the Medline database from 1992 to 2002.ResultsRisk factors that have received a great deal of publicity (hormone use, alcohol consumption, obesity, nulliparity) present a relatively modest relative risk for breast cancer (<2). Factors associated with a prior history of neoplastic disease or atypical hyperplasia and factors associated with a genetic predisposition significantly affect the risk of breast cancer, with relative risks ranging from 3 (for some cases of positive family history) to 200 (for premenopausal women positive for aBRCAmutation).ConclusionsMore precise tools, based on techniques of molecular biology such as microarray analysis, will be needed to assess individual risk for breast cancer.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.Summary Background DataIatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors’ experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.MethodsA retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions.ResultsEleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients.ConclusionsGracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess whether the presence of Barrett’s esophagus (BE) modifies the results of Nissen fundoplication.Summary Background DataSome authors consider that BE, whether or not there is associated stricture, significantly increases the failure rate of standard antireflux surgery; they recommend using different and more aggressive surgical procedures in all patients with BE.MethodsOne hundred seventy-seven patients with gastroesophageal reflux disease, without esophageal stricture, were included in a retrospective study. Patients were divided into two groups: those with BE (n = 57) and those without BE (n = 120). Nissen fundoplication was performed in all patients by the same surgical team. Clinical, endoscopic, and functional (manometry and 24-hour pH monitoring) results in the two study groups were compared.ResultsAfter a median follow-up of 5 years (range 1–18) in the BE group and 6 years (range 1–18) in the non-BE group, the rate of clinical recurrence was 8% in the BE group and 10% in the non-BE group, with no statistically significant difference. The rate of pH-metric recurrence was the same in both groups (15%).ConclusionsThe presence of BE without esophageal stricture does not increase the rate of failure of Nissen fundoplication.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo determine if NF-&kgr;B regulates intestinal epithelial cell migration and if it has a role during bile salt-induced migration.Summary Background DataMucosal restitution is an important repair modality in the gastrointestinal tract. The authors have shown that taurodeoxycholate (TDCA) increases intestinal epithelial cell migration. NF-&kgr;B regulates activation of a number of genes involved in inflammatory responses.MethodsStudies were conducted in IEC-6 cells. I&kgr;B protein expression was determined by Western blot analysis. Sequence-specific NF-&kgr;B binding activity was measured by EMSA shift assays and nuclear localization by immunohistochemistry. Cell migration was examined by using an in vitro model that mimics the early cell division-independent stages of epithelial restitution.ResultsThe process of cell migration over the wounded area was associated with a significant increase in NF-&kgr;B binding activity in IEC-6 cells. Immunohistochemistry revealed translocation of NF-&kgr;B into the nucleus. Western blot analysis showed that injury decreased I&kgr;B protein expression. Inhibition of the binding activity by treatment with a specific NF-&kgr;B inhibitor, MG-132, inhibited cell migration during restitution. Further, exposure to TDCA at the physiologic concentration that induces intestinal epithelial cell migration increased NF-&kgr;B binding activity, induced NF-&kgr;B translocation into the nucleus, and decreased I&kgr;B protein expression. MG-132 also inhibits bile salt-induced cell migration.ConclusionsNF-&kgr;B regulates intestinal epithelial cell migration. Bile salts at physiologic concentrations increase cell migration by activation of NF-&kgr;B. These data show that bile salts may have a role in the maintenance of intestinal mucosal integrity.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID