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Biomedical subjects

W E Strodel

Publications and source records attributed to W E Strodel.

At least 37 records · Page 2Linked to original sources
PubMed1995

The structured clinical instruction module: a novel strategy for improving the instruction of clinical skills.

We have previously shown that both medical students and residents demonstrate numerous important deficits when evaluating patients with abdominal complaints. To address these deficits, we implemented a pilot instructional program derived from the Objective Structured Clinical Examination. Fifty third-year medical students were presented with a 1-hr Structured Clinical Instruction Module (SCIM) of five stations, each station addressing a different aspect of the surgical evaluation of the abdomen. Simulated patients were present at two of the stations. Faculty from appropriate disciplines were present at the stations to provide standardized instruction according to predetermined curricular objectives. The medical students evaluated the SCIM for its specific characteristics, and they evaluated each of the five stations for its efficacy in increasing their clinical skills. All the specific aspects of the SCIM were given a rating significantly higher than neutral (P < 0.0001). Students agreed most strongly that the faculty were well prepared for the SCIM and that the faculty were enthusiastic. All of the SCIM stations were given a rating significantly higher than average (P < 0.0001). When compared to a conventional workshop, the SCIM scored significantly higher on all three common evaluation items. The SCIM was very well received by medical students as a format for clinical instruction. This unique modification of the Objective Structured Clinical Examination has potential for teaching important clinical skills that are not consistently mastered within current surgical curricula.

Adult↗
PubMed1995

Expression of p53 protein in pancreatic adenocarcinoma. Relationship to cigaret smoking.

We studied the expression of p53 gene product in pancreatic adenocarcinomas of the usual ductal type to determine its relationship to cigarette smoking and its usefulness as an independent prognostic indicator. Twenty-six resection specimens of pancreatic adenocarcinoma were examined by immunohistochemistry using an antigen retrieval solution and monoclonal PAb1801 and polyclonal CM1 antibodies on paraffin-embedded material. Specific nuclear p53 expression for both PAb1801 and CM1 was identified in seven cases (27%). In all cases immunoreaction was confined to neoplastic cells. Three of four (75%) tumors from patients who had never smoked showed immunoreaction, whereas only three of 14 (21%) tumors from smokers showed positive staining. Cases with positive staining had shorter mean survival (6.3 mo) than cases that failed to stain (9.8 mo), but the difference was not statistically significant in this small study. There was no statistically significant association between p53 immunoreactivity and other clinicopathologic parameters. Our findings indicate that abnormalities of p53 gene in pancreatic adenocarcinomas may not be directly related to cigarette smoking. Those patients who survived the longest tended to have tumors negative for p53 immunostaining. p53 immunoreaction may be a useful feature in distinguishing adenocarcinoma from chronic pancreatitis in small biopsies.

Adenocarcinoma↗
PubMed1995

The relationship between faculty ward evaluations, OSCE, and ABSITE as measures of surgical intern performance.

BACKGROUND: This study determined the degree to which ward evaluations, the American Board of Surgery In-Training Examination (ABSITE), and an Objective Structured Clinical Examination (OSCE) provide equivalent information about intern performance. METHODS: Twenty-two general surgery interns completed both the ABSITE and a 17-problem, 35-station OSCE. Faculty members completed several 12-item ward evaluations for each intern. Pearson product-moment correlations were employed to determine the degree of association among the various evaluation measures. RESULTS: The total OSCE score correlated with both the total ABSITE score and the overall ward evaluations, but the latter two measures did not correlate with each other. The ward evaluations identified the performance of 1 of the 22 interns (5%) as deficient, the ABSITE identified 9 (41%) as deficient in knowledge, and the OSCE 8 (36%). CONCLUSIONS: In the future, performance-based testing methods such as the OSCE should become more important as an evaluative parameter in assessing the clinical performance of postgraduate surgical trainees.

Attitude of Health Personnel↗
PubMed1995

The Objective Structured Clinical Examination. The new gold standard for evaluating postgraduate clinical performance.

OBJECTIVE: The authors determine the reliability, validity, and usefulness of the Objective Structured Clinical Examination (OSCE) in the evaluation of surgical residents. SUMMARY BACKGROUND DATA: Interest is increasing in using the OSCE as a measurement of clinical competence and as a certification tool. However, concerns exist about the reliability, feasibility, and cost of the OSCE. Experience with the OSCE in postgraduate training programs is limited. METHODS: A comprehensive 38-station OSCE was administered to 56 surgical residents. Residents were grouped into three levels of training; interns, junior residents, and senior residents. The reliability of the examination was assessed by coefficient alpha; its validity, by the construct of experience. Differences between training levels and in performance on the various OSCE problems were determined by a three-way analysis of variance with two repeated measures and the Student-Newman-Keuls post hoc test. Pearson correlations were used to determine the relationship between OSCE and American Board of Surgery In-Training Examination (ABSITE) scores. RESULTS: The reliability of the OSCE was very high (0.91). Performance varied significantly according to level of training (postgraduate year; p < 0.0001). Senior residents performed best, and interns performed worst. The OSCE problems differed significantly in difficulty (p , 0.0001). Overall scores were poor. Important and specific performance deficits were identified at all levels of training. The ABSITE clinical scores, unlike the basic science scores, correlated modestly with the OSCE scores when level of training was held constant. CONCLUSION: The OSCE is a highly reliable and valid clinical examination that provides unique information about the performance of individual residents and the quality of postgraduate training programs.

Clinical Competence↗
PubMed1995

Biliary sludging in critically ill trauma patients.

We used serial weekly ultrasonography to prospectively screen 19 critically ill trauma victims for the development of biliary sludge. Fourteen patients had sludge formation during their hospitalization. Sludge development was positively associated with increased transfusion requirements, but not with any other laboratory or clinical findings, including injury severity scores. The enteral feedings administered to most patients did not prevent sludge formation in the majority of cases; all five patients receiving total parenteral nutrition had sludge. Three patients had complications that could possibly be attributed to the sludge (one case of acalculous cholecystitis and two cases of mild pancreatitis). No such problems occurred in the five patients who did not have sludge. No long-term clinical problems related to sludge have occurred. We conclude that gallbladder sludge frequently develops in critically ill trauma patients and that sludge may be associated with pancreatobiliary complications.

Adolescent↗
PubMed1995

Preincubation of endotoxin with monoclonal anti-lipid A (E5), but not in vivo treatment, inhibits circulatory dysfunction.

Monoclonal antibodies (mAb) directed against the toxic lipid A portion of lipopolysaccharide (LPS) have been shown to bind lipid A in vitro, but clinical trials of such mAbs have yielded mixed results. In 53 rats instrumented for macrocirculatory and cremaster muscle microcirculatory measurements, we examined whether E5, a murine-derived anti-lipid A mAb, could inhibit LPS-induced circulatory dysfunction when incubated with LPS in vitro or given separately in vivo prior to LPS administration. Compared with Control rats (Group I), rats infused with 10 mg/kg Escherichia coli LPS (Group II) displayed marked decreases in arterial pressure and cardiac output and marked decreases in erythrocyte velocity in second, third, and fourth order skeletal muscle arterioles. Infusion of 2 mg/kg E5 90 min prior to LPS infusion (Group III) did not improve cardiovascular performance. In contrast, incubation of LPS with either 2 mg/kg (Group IV) or 10 mg/kg (Group V) E5 prior to infusion significantly attenuated LPS-induced changes in both macrocirculatory and microcirculatory function. Further investigation of the disparity between the in vitro and in vivo neutralizing capacity of anti-lipid A mAbs may aid interpretation of the variable clinical results achieved with these preparations.

Analysis of Variance↗
PubMed1994

Small intestinal microcirculatory effects of octreotide.

Somatostatin and its analogue, octreotide acetate, are thought to decrease mesenteric blood flow; however, it is unknown whether the decrease occurs at the central, regional, or microvascular level. We hypothesized that the circulatory effects of octreotide are regulated at the microvascular level. Changes in superior mesentery artery (SMA) flow in response to octreotide were measured with a perivascular ultrasonic flow probe. In separate experiments, the jejunal microcirculatory effects of octreotide were studied using in vivo videomicroscopy. After accrual of baseline hemodynamic and microcirculatory data, animals were randomized to control or treatment (10 micrograms/kg octreotide) iv groups. Measurements were made every 15 min during the infusion and for 90 min after the completion of the infusion. Results are expressed as means +/- SEM. Intravenous infusion of octreotide caused no significant change in arterial pressure, cardiac index, or systemic vascular resistance index in either group in either set of experiments. A statistically significant decrease in heart rate (9%) occurred in the control group of animals undergoing SMA flow measurement. SMA flow did not change significantly with infusion of octreotide. In contrast, jejunal first-order arteriole flow increased to 117.9 +/- 9.7% of baseline (P < 0.05) in the absence of significant changes in microvessel diameters. This was due to an increase in centerline red cell velocity (116 +/- 5% of baseline, P < 0.05). We conclude that octreotide increases jejunal first order arteriole flow by mechanisms that are regulated at the microcirculatory level.

Animals↗
PubMed1994

Assessing surgical residents' and medical students' interpersonal skills.

Effective physician-patient interaction is an important part of surgical practice. This study had three goals: (1) to measure the interpersonal skills (IS) of surgical students and residents in structured clinical settings and to determine the reliability of such measurements; (2) to determine the relationship of IS to clinical performance; and (3) to determine the impact of level of training on IS. Twenty third-year medical students and 30 junior-level interns (23 PGY-1s, 7 PGY-2s) interacted with nine actual or simulated patients as part of an objective structured clinical examination. Using a global rating scale, faculty graded both the IS and the organizational skills of the candidates. A two-way analysis of variance indicated significant differences among the three groups of trainees (P = 0.0002) and among the IS scores for each of the nine patient problems (P < 0.0001). Both the PGY-2s and the medical students exhibited significantly better interpersonal skills than did the PGY-1s. The IS scores correlated significantly with the data gathering scores, the data interpretation scores, and the organizational scores. We conclude that faculty measurement of IS is moderately reliable even when a simple global rating scale is used. Overall IS scores were rather poor, particularly in the PGY-1 group. IS were highly correlated with overall objective clinical performance.

Clinical Competence↗
PubMed1994

Assessing medical students' and surgery residents' clinical competence in problem solving in surgical oncology.

BACKGROUND: We sought to determine the competence of medical students and surgery residents in evaluating clinical problems (using both real and simulated patients) in surgical oncology. METHODS: Forty-five third-year medical students, 23 first postgraduate year (PGY-1) residents, and seven second postgraduate year (PGY-2) residents were presented with the same four clinical problems (breast evaluation, prostate nodule, colon cancer, and mole evaluation). The two resident groups were presented with two additional patients (breast cancer options and thyroid mass). RESULTS: Mean performance scores for the problems were generally poor (32-72%); most students and residents failed almost all of the problems. Level of training was of some importance; the overall mean scores of the PGY-2 residents were superior to those of the medical students and the PGY-1 residents (p = 0.049). However, in many areas of information gathering, diagnosis, and management, training level appeared to have no impact. Numerous important performance deficits were identified in all groups. CONCLUSION: Medical students and surgery residents are not receiving adequate training in diagnosing and treating important problems in surgical oncology.

Analysis of Variance↗
PubMed1994

One-stage gastrostomy button: an assessment.

Several types of gastrostomy tube are available. The gastrostomy button (GB) is a skin-level device that is easily used and acceptable to ambulatory patients. Previously, GB required the presence of a mature gastrocutaneous tract, necessitating a two-stage procedure for placement. We report our experience with one-stage GB placed in 24 patients. No difficulties with placement and no periprocedural complications occurred. GBs remained in place from 14 to 148 days (mean 71 days). Thirteen GBs were in place at follow-up. Four patients died from primary disease. Seven GBs were no longer needed, and were removed. No stomal infections occurred; no GBs were inadvertently removed; all GBs were convenient to use. Four complications occurred (17%): two tubes clogged, one colocutaneous fistula developed, and one tube migrated from the stomach into the abdominal wall. Complications were corrected without sequelae. One-stage GB is safe and feasible with comparable complication rates to standard PEG.

Abdominal Muscles↗
PubMed1994

Comparison of cefoperazone plus sulbactam with clindamycin plus gentamicin as treatment for intra-abdominal infections.

This study compared the safety and efficacy of cefoperazone plus sulbactam with that of clindamycin plus gentamicin in the treatment of intra-abdominal infection. Seventy-six patients were included in the analysis of an open, randomized, comparative, single-site trial. Forty-seven patients received cefoperazone-sulbactam, and 29 patients received clindamycin plus gentamicin. Thirty-three patients (70%) who received cefoperazone-sulbactam and 15 patients (52%) who received clindamycin plus gentamicin were cured of infection, did not suffer a relapse within one month after the end of treatment, and did not receive any other antibiotics during the follow-up period (P = 0.17). In patients treated with cefoperazone-sulbactam there were four cases of superinfection, one patient had a prolonged prothrombin time, six patients had a poor response, two patients received antibiotics during follow-up, and one patient died during follow-up because of cancer. Treatment with clindamycin plus gentamicin was associated with five cases of superinfection, four patients had a poor response, four patients had a drug reaction, and one patient required antibiotics in the follow-up period. Serum levels of cefoperazone-sulbactam measured at one and three hours after dosing were consistent with earlier findings in normal volunteers. Two hundred and one pathogens were isolated, and 17 of 122 aerobic isolates (14%) were resistant to cefoperazone-sulbactam, and 17 of 122 (14%) were resistant to both clindamycin and gentamicin. Eleven of 79 (14%) anaerobic isolates were resistant to cefoperazone, none was resistant to cefoperazone-sulbactam, and 10 of 79 (13%) were resistant to clindamycin. The results of this study show that cefoperazone-sulbactam is an effective and safe alternative to clindamycin plus gentamicin in the treatment of intra-abdominal infections.

Abdomen↗
PubMed1994

Effect of cardiogenic shock on pharmacokinetics and tissue distribution of ampicillin-sulbactam.

A reversible cardiogenic shock model in pigs investigated shock-induced changes in the pharmacokinetics and tissue distribution of ampicillin-sulbactam and the efficacy of this antibiotic regimen in eliminating enteric bacterial translocation. Sixteen pigs were randomly allocated to 3 groups: group I (shock, ampicillin-sulbactam, n = 6), group II (no shock, ampicillin-sulbactam, n = 6), and group III (shock, no ampicillin-sulbactam, n = 4). Nalidixic acid-resistant E. coli (60 x 10(6) CFU) were instilled into a jejunal loop created in each pig, and bacterial cultures were taken from thoracic duct lymph, periportal, and mesenteric lymph nodes. Ampicillin-sulbactam was administered intravenously at a standard dose of 3 g. Results showed that 1) ampicillin and sulbactam concentrations generally increase during cardiogenic shock; 2) cardiogenic shock does not increase ampicillin concentrations in jejunum and liver; 3) during resuscitation, thoracic duct lymph ampicillin concentrations decrease; and 4) during and immediately after cardiogenic shock, standard doses of ampicillin-sulbactam appear efficacious in eliminating translocated bacteria.

Ampicillin↗
PubMed1994

Expression of HER-2/neu oncoprotein and epidermal growth factor receptor and prognosis in gastric carcinoma.

Fifty-six specimens of gastric carcinoma were examined for the localization of HER-2/neu oncoprotein (HER-2/neu) and epidermal growth factor receptor (EGFR) by immunohistochemistry using polyclonal antibodies on paraffin-embedded material. Strong membrane staining for HER-2/neu was noted in 14 cases (25%), all of which were of the intestinal type. Only cytoplasmic staining was found in an additional 21 cases (37.5%), including seven diffuse tumors. Twenty-four cases (nine diffuse and 15 intestinal) showed cytoplasmic staining with accentuation on the cell membrane for EGFR. Patchy staining was common for HER-2/neu, while EGFR immunoreactivity was always diffuse. Twenty cases (35.7%) showed positive staining for both, 15 cases (26.8%) for HER-2/neu only, four cases (7.1%) for EGFR only, and 17 cases (30.4%) for neither. Expression of HER-2/neu was more commonly associated with intermediate-grade and high-stage tumors. Cases with positive (either membrane or cytoplasmic) staining for HER-2/neu showed poorer overall mean survival (308 days) than cases that failed to stain (763 days). The EGFR-positive cases showed shorter mean survival (387 days) than the negative cases (547 days), but this difference did not reach statistical significance. The EGFR positivity did not further reduce survival in HER-2/neu-positive cases (362 days). The results of this study support the hypothesis that the expression of HER-2/neu may be a significant predictor of prognosis in patients with gastric carcinoma. Our findings also suggest that expression of these two closely related protooncogenes in malignant and benign gastric tissues is independent of each other and that EGFR does not potentiate the oncogenic effect of HER-2/neu.

Adult↗
PubMed1994

Assessing senior residents' knowledge and performance: an integrated evaluation program.

BACKGROUND: Surgical residents have traditionally been evaluated by ward evaluations and multiple-choice testing; overall resident performance has seldom been objectively evaluated. We developed a comprehensive evaluation program for senior residents. The purpose of this study was to determine whether the several different assessment methods included in this program provide similar information about senior residents' clinical knowledge and performance. METHODS: Sixteen senior general surgery residents were evaluated by subjective faculty ward evaluations, a structured oral examination, the American Board of Surgery In-Training Examination, and an objective structured clinical examination (OSCE). The OSCE was divided into two parts: part A required the resident to obtain a directed history or to perform a physical examination; part B required the resident to answer questions about the patient seen in part A. RESULTS: The various evaluation methods differed in their estimates of clinical competence (ward evaluations rated residents highest; the OSCE, lowest). The American Board of Surgery In-Training Examination correlated with both the structured oral examination and OSCE part B, indicating that all are adequate measures of knowledge. Neither the total OSCE score nor OSCE part A correlated with other measures, but the fact that both are highly reliable suggests that they evaluate different clinical skills. Faculty ward evaluations are inflated and do not correlate with other measures. CONCLUSIONS: We conclude that developing a comprehensive program for evaluating resident competence is desirable and feasible.

Employee Performance Appraisal↗
PubMed1994

Hepatocellular carcinoma embolus to the common hepatic duct with no detectable primary hepatic tumor.

Obstruction of the common bile duct (CBD) by direct extension of tumor is occasionally found in patients with hepatic neoplasms. Tumor embolus to the CBD is very rare, however, when no primary hepatic tumor is found. The patient described herein was a 74-year-old man who presented with a new onset of jaundice, nausea, anorexia, and epigastric pain. There was a history of dark urine and clay-colored stools, but no fever. Endoscopic retrograde cholangiopancreatography (ERCP) showed partial obstruction of the common hepatic duct and dilated intrahepatic bile ducts. A computed tomography (CT) scan of the upper abdomen showed no masses. Results of a mesenteric and selective hepatic arteriogram were normal. On abdominal exploration, no tumor was noted. There were no palpable stones in the gallbladder, but a firm mass was felt in the common hepatic duct. Exploration of the CBD produced light-colored debris organized into a cast of the common hepatic duct. Frozen section analysis was negative for tumor cells, but review of the permanent sections confirmed the presence of hepatocellular carcinoma. When non-calculous material is found to be obstructing the CBD, even in the absence of an obvious primary hepatic tumor, tumor embolus or metastasis from a distant site must be considered and the material sent for pathological evaluation.

Aged↗
PubMed1994

Nonfunctioning cystic neuroendocrine neoplasms of the pancreas.

BACKGROUND: Three types (functioning solid, nonfunctioning solid, and functioning cystic) of neuroendocrine neoplasms (benign and malignant) of the pancreas have been reported. PATIENTS: We report three patients with nonfunctioning neuroendocrine neoplasms of the pancreas with cystic components, a type of neoplasm not previously reported. One of the neoplasms we report was benign; the other two were malignant. The patients were admitted with abdominal pain. In each case an abdominal computed tomography scan defined a large multicystic pancreatic mass. RESULTS: In all instances, immunochemical staining was positive for neuroendocrine markers, confirming the neuroendocrine nature of the tumors. The nonfunctional nature of the neoplasms was confirmed by (1) the absence of clinical symptoms traditionally attributed to neuroendocrine secretagogues and (2) the lack of gastroenteropancreatic peptide serum levels. CONCLUSIONS: Two of these three cases represent another subset of pancreatic neuroendocrine pathology: a nonfunctional cystic neoplasm. Increased clinical awareness, appropriate operation, and better immunohistochemical staining techniques may yield more, heretofore unrecognized, subtypes. These cases reemphasize the need for proper surgical exploration and biopsy of all unexplained pancreatic cystic lesions, particularly if they are multicystic.

Adenoma, Islet Cell↗