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The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group.

There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.

Developing Countries↗

Venous ulcer reappraisal: insights from an international task force. Veines International Task Force.

UNLABELLED: An international task force made up of a panel of 16 experts was mandated to review and objectively evaluate all aspects of chronic venous disease of the leg. All available publications on chronic venous disease of the leg from 1983 to 1997 were identified through computerized search. Three different screenings were then performed in order to select only relevant papers providing moderate to strong scientific evidence. Final conclusions and further therapeutic recommendations were made based on these publications. Compression, medications, local therapies, sclerotherapy and surgery are the existing therapeutic options for which the following recommendations can be made. Compression: Properly applied bandages both fixed and stretched have been shown to be effective. Compression stockings may be used. Compression needs to be in excess of 35 mm Hg. Medications: Although preliminary results have shown a beneficial effect of several vasodilators and oral micronized purified flavonoid fraction, the evidence for the efficacy of medications on venous ulcer healing is still limited and further studies are required before recommendations can be made. There is no evidence to routinely administer antibiotics. Local therapies have an as yet unproven adjunctive role. Sclerotherapy is unlikely to be effective unless there is superficial venous insufficiency, in which it may have an as yet unproven role. SURGERY: Patients with active venous ulcer and sapheno-femoral or sapheno-popliteal junction incompetence benefit from surgical treatment. In the absence of reflux or following deep vein thrombosis, there is no evidence to support surgical treatment.

Algorithms↗

Anatomical variations of the intracavernous branches of the internal carotid artery with reference to the relationship of the internal carotid artery and sixth cranial nerve. A microsurgical study.

Thirty cavernous sinuses were dissected and examined using microsurgical methods under a magnification of X10 and X16. The anatomical variations of the intracavernous branches of the internal carotid artery (ICA) and the anatomical relationship of the sixth nerve with the ICA are described and discussed in relation to the findings from other microsurgical works.

Abducens Nerve↗

International Germ Cell Consensus Classification: a prognostic factor-based staging system for metastatic germ cell cancers. International Germ Cell Cancer Collaborative Group.

PURPOSE: Cisplatin-containing chemotherapy has dramatically improved the outlook for patients with metastatic germ cell tumors (GCT), and overall cure rates now exceed 80%. To make appropriate risk-based decisions about therapy and to facilitate collaborative trials, a simple prognostic factor-based staging classification is required. MATERIALS: Collaborative groups from 10 countries provided clinical data on patients with metastatic GCT treated with cisplatin-containing chemotherapy. Multivariate analyses of prognostic factors for progression and survival were performed and models were validated on an independent data set. RESULTS: Data were available on 5,202 patients with nonseminomatous GCT (NSGCT) and 660 patients with seminoma. Median follow-up time was 5 years. For NSGCT the following independent adverse factors were identified: mediastinal primary site; degree of elevation of alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactic dehydrogenase (LDH); and presence of nonpulmonary visceral metastases (NPVM), such as liver, bone, and brain. For seminoma, the predominant adverse feature was the presence of NPVM. Integration of these factors produced the following groupings: good prognosis, comprising 60% of GCT with a 91% (89% to 93%) 5-year survival rate; intermediate prognosis, comprising 26% of GCT with a 79% (75% to 83%) 5-year survival rate; and poor prognosis, comprising 14% of GCT (all with NSGCT) with a 48% (42% to 54%) 5-year survival rate. CONCLUSION: An easily applicable, clinically based, prognostic classification for GCT has been agreed on between all the major clinical trial groups who are presently active worldwide. This should be used in clinical practice and in the design and reporting of clinical trials to aid international collaboration and understanding.

Chorionic Gonadotropin↗

Triple arterial coronary revascularization using the radial artery and bilateral internal mammary arteries versus the gastroepiploic artery and bilateral internal mammary arteries.

Arterial grafts are frequently used in modern coronary artery bypass grafting (CABG) and the benefit of the 2 internal mammary arteries (IMA) has already been established. However, the choice of the third arterial conduit, in addition to the IMA, is controversial. We have retrospectively analized perioperative and the follow-up results of patients who underwent CABG with triple arterial bypass using either the radial artery (RA) or the gastroepiploic artery (GEA) in conjunction with the bilateral IMA (BIMA). Between December 1995 and June 2001, 1,516 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. Among them the RA and BIMA were used in 96 patients (78 males, 18 females; mean age, 63.2+/-6.7 years, group R), and the GEA and BIMA in 123 patients (101 males, 22 females; mean age, 61.0+/-11.6 years, group G). Their perioperative and follow-up data were studied. The preoperative risk factors were similar between the 2 groups, except that there were significantly fewer patients with renal dysfunction in group R. The surgical results did not differ between the 2 groups; however, the GEA was more commonly used for revascularization of the right coronary artery, while the RA was used for the diagonal, circumflex or right coronary arteries. Surgical mortality and morbidity rates were not significantly different. During the follow-up period of 2.3+/-1.6 years, the event-free rates as well as the survival rates were not significantly different. CABG with either the RA or the GEA in conjunction with the BIMA can be performed safely. The surgical results as well as the follow-up results were acceptable and no significant differences between the 2 groups were observed.

Aged↗

[Saphenous vein graft bypass from the external carotid artery to the supraclinoid internal carotid artery to treat a giant aneurysm of the cavernous internal carotid: case report].

Alternative surgical procedures to treat unclippable aneurysms of the intracavernous carotid artery include proximal vessel occlusion and trapping. Those techniques, even in patients with rich collateral vessels, are associated with risk of hemodynamic compromise and ischemic complications. Therefore, a safe treatment requires revascularization to maintain blood flow to the involved territories. We report the case of a 47-year-old female, with ischemic signs and symptoms and a right third nerve palsy caused by a giant aneurysm, partially trombosed, of the intracavernous carotid artery. The patient was submitted to trapping after a saphenous vein graft bypass from the external carotid artery to the supraclinoid internal carotid artery. The surgical result was good without complications.

Anastomosis, Surgical↗

Ruptured saccular aneurysm of a dolichoectatic internal carotid artery in a patient with agenesis of the contralateral internal carotid artery--case report.

A 42-year-old woman presented with very rare cases of ruptured saccular aneurysm of a dolichoectatic internal carotid artery (ICA) associated with agenesis of the contralateral ICA manifesting as sudden onset of severe headache and nausea without neurological deficits. Angiography and three-dimensional computed tomography demonstrated intraventricular hemorrhage with slight subarachnoid hemorrhage and dolichoectasia of the right ICA with agenesis of the contralateral ICA, as well as a saccular aneurysm of the ectatic right ICA. The aneurysm neck was clipped successfully. The patient remained ambulatory with no neurological deficits at discharge 15 days after the surgery. The saccular aneurysm in our case was formed in the dolichoectatic ICA, presumably due to both abnormal hemodynamics and abnormal arterial wall.

Adult↗

National study of internal medicine manpower: II. A typology of residency training programs in internal medicine.

This second paper of the National Study of Internal Medicine Manpower describes the differing environments of residency training programs. Using previous studies as prototypes, the authors apply factor analysis to data from questionnaires returned by residency training directors and residents to illustrate the myriad interrelations within training programs. The most important result of this study is the demonstration that the largest residency programs have the most subspecialty programs, and their residents are more likely to pursue subspecialty fellowships after completing their third residency year. However, preliminary findings show no associations between the typology (typologic categories of residencies and their trainees) used and desired practice locations in states having few physicians relative to the population or in states with fewer urban inhabitants. The typology also does not predict the future practice aspirations of residents who are more likely to care for the poor or minority populations. A separate set of factors, possibly unrelated to training environments, will help to predict such career outcomes. Further specification of these factors will be the subject of a later paper in this series.

Environment↗

National Study of Internal Medicine Manpower: V. Comparison of residents in internal medicine--future generalists and subspecialists.

Questionnaire III of the National Study of internal Medicine Manpower was directed to a random sample of residents (and subspecialty fellows) in the spring of 1977. Residents were classified according to whether they sought careers as predominantly general internists (49%) or subspecialty internists (51%), and the two groups were compared. Future generalists, more often, tended to be non-Jewish, to have incurred higher debts, and to have trained in medical schools in the states where they had spent their childhoods. Training experiences also were different. Future generalists, more than subspecialists, were attracted to the field because of the ability to retain independence in their work. Subspecialists, more often, intended to have academic careers and locate in the largest cities. Although subspecialists expected greater financial rewards, neither group selected their fields on this basis. By controlling for the main criterion used to select the medical school attended, we were able to explain several factors that differentiated the two groups.

Attitude of Health Personnel↗

Exposure assessment of upper limb repetitive movements: a consensus document developed by the Technical Committee on Musculoskeletal Disorders of International Ergonomics Association (IEA) endorsed by International Commission on Occupational Health (ICOH).

This consensus document intends to supply a set of definitions, criteria and procedures useful to describe and, wherever possible, to assess the work conditions that can represent a physical overload for the upper limbs. The document is aimed at all the operators, i.e. occupational doctors but mainly technicians, who are, involved in risk exposure assessment and management. The document intends to provide methods and procedures easily applicable in the field, possibly not requiring sophisticated instrumentation and when possible based on observation procedures. The proposed methods shall be based as far as possible on knowledge and data from scientific literature: should they be contradictory or deficient, reference will be made to standards or pre-standards issued by national and international agencies and bodies, with the experience of researchers involved and common sense. In this regard, it is to be emphasized that the potential users increasingly demand an easily applicable method for description and assessment of work with repetitive movements. The group intends to give a response even if there are still uncertainties from a strictly scientific standpoint: however the group commits itself to perform subsequent validations especially of as yet unconsolidated issues. This document focuses specifically on identification of risk factors and describes some of the methods that have been developed for evaluating them. There is a rapidly developing body of literature on job analysis and not yet agreement on a single best way to analyze jobs. Professional judgement is required to select the appropriate methods. Analysis and design of jobs should to be integrated into an ongoing ergonomics program that includes management commitment, training, health surveillance, and medical case management. In summing up this report, space must be given to the check lists that are so often seen in the medical press, although this is not the occasion to propose a detailed analytical review.

Arm↗

Spontaneous thrombosis of a giant intracavernous internal carotid artery aneurysm and ipsilateral internal carotid artery occlusion.

A 75-year-old man who had suffered from right visual disturbance for 10 years suddenly experienced right cavernous sinus syndrome. Magnetic resonance imaging revealed a giant thrombosed aneurysm in the right cavernous sinus extending to the right middle cranial fossa. Digital subtraction angiography disclosed occlusion of the right internal carotid artery at the petrous portion and good cross filling in the right-sided circulation through the anterior communicating artery. There was no filling of the aneurysm. In this case, the mechanism of parent artery occlusion is unclear, but direct compression and stretching of the parent artery by the aneurysm may be involved.

Aged↗

An evidence base for International Health Regulations: quantitative measurement of the impacts of epidemic disease on international trade.

When cholera broke out in Mozambique, Kenya, Tanzania and Uganda in 1997, an urgent measure was filed with the Sanitary and Phytosanitary Committee of the World Trade Organization, by the European Union, citing the protection of human health, to limit imports of fish products. The authors analysed import data on specified products over time to quantify the trade impact of this measure. Using previous specific trade trends, the authors modelled expected trade flows and compared observed imports with expected imports to calculate the potential cost of lost trade. The conclusion of this analysis was that the impact of European restrictions on fish exports from Mozambique, Kenya, Tanzania and Uganda on the economies of these African countries was at least US dollar 332,217,415 for the years 1998 to 2002. Insights from such quantitative studies will be important in making policy choices under the revised International Health Regulations of the World Health Organization and should inform the discussion about the adoption of these regulations.

Animals↗

[Evaluation of various personality characteristics and professional training of interns--internal medicine specialists].

On the basis of the anonymous questionnaires filled by 131 therapeutic interns from 18 higher medical establishments young specialists distinguished certain personality traits which, in their opinions, should be inherent in a doctor; they evaluated training in the institute and during internship and pointed out its shortcomings. The information obtained is important for further improvement of the medical training.

Humans↗

An international collaborative study on the performance of protein C antigen assays. Report of the ICTH subcommittee on protein C. International Committee on Thrombosis and Haemostasis.

An international collaborative study was undertaken to evaluate the performance and specificity of protein C antigen (PC) assays. Thirteen lyophilized plasma samples were distributed among 17 laboratories and analysed with 24 methods. No statistically significant results were obtained with the different methods in plasmas containing only the protein C zymogen. ELISA's, RIA's and IRMA's were found to be more sensitive than the electro-immunoassay. In plasmas of patients on oral anticoagulant treatment ELISA methods tend to give lower PC antigen levels than the electro-immunoassay. Complexes between activated protein C (APC) and the protein C inhibitor (PCI), when present in plasma together with PC zymogen, are detected with 100% efficiency in the electro-immunoassay, with 50% efficiency in the ELISA, and with less than 10% efficiency in the RIA or in assays using monoclonal antibodies against PC. Mean coefficient of variation was calculated to be 22%, and could be reduced - especially in case of the ELISA by normalisation. Within laboratory variation was calculated to be 11.7% and between laboratory variation 17.8%.

Administration, Oral↗

[Postoperative transient occlusion of internal carotid artery due to shift of the clip used for neck clipping of the huge left internal carotid aneurysm (author's transl)].

A 49-year-old female, having had suffered from a huge left internal carotid (IC) aneurysm and a right IC aneurysm, was treated surgically. The neck of huge aneurysm, was treated surgically. The neck of huge aneurysm was clipped with Sugita's spring clip after its body was dissected and the otherone was clipped simply. Right hemiparesis was seen postoperatively. And the angiograms, taken on the 4th postoperative day, showed not only an aneurysmal disappearance but also an occlusion of the left ICA which presumably due to shift of the spring clip to the direction of antero-lateral. Right hemiparesis disappeared, however, suddenly on the 40th postoperative day and reopening of the left ICA was confirmed angiographically despite the further shift of the clip. The possible genesis of the curious course in this case and the possible complications in the use of large aneurysmal clip was discussed.

Carotid Artery Diseases↗

Proposed 'World Health Organization staging system for HIV infection and disease': preliminary testing by an international collaborative cross-sectional study. The WHO International Collaborating Group for the Study of the WHO Staging System.

OBJECTIVE: To evaluate a universally applicable staging system for HIV infection and disease proposed by the Global Programme on AIDS (GPA) of the World Health Organization (WHO). The system consists of both a 'clinical' and a 'laboratory' axis. The 'clinical axis' is represented by a sequential list of clinical conditions believed to have prognostic significance, which subdivides the course of HIV infection into four clinical stages. The 'laboratory axis' subdivides each clinical stage into three strata according to CD4+ cell or total lymphocyte count. DESIGN: International cross-sectional study. SETTING: Twenty-seven clinical centres in 20 countries. PATIENTS AND PARTICIPANTS: A total of 938 confirmed HIV-positive patients, aged at least 13 years. MAIN OUTCOME MEASURES: Presence of the clinical condition belonging to the highest stage and its correlation with recent laboratory data (CD4+ cell counts, total lymphocyte counts, beta 2-microglobulin levels, haemoglobin, haematocrit, erythrocyte sedimentation rate, p24 antigen, p24 antibody and delayed hypersensitivity skin test). RESULTS: There was general agreement between the proposed attribution of clinical conditions and the corresponding laboratory markers. Significant differences were observed between stages 3 and 4 for seven laboratory markers and between stages 2 and 3 for six, but not between stages 1 and 2, for any of the nine laboratory markers. CONCLUSIONS: Longitudinal studies are needed to assess whether the proposed system is useful in predicting survival time in patients with HIV disease.

Adolescent↗

[Abbreviations or acronyms in the internal medicine discharge reports. Study Group of the Quality of Information in Internal Medicine (Castilla-La Mancha)].

OBJECTIVES: Quality of discharge reports is very important for an adequate health care activity. Clinical data of these reports must be comprehensible by patients and in the different levels of Health Services. Presence of abbreviations causes severe shortcomings in the clinical data of these records. METHODS: We analyzed the presence of abbreviations in the Internal Medicine discharge reports of 7 hospitals of Castilla-La Mancha in the year 1992. We evaluated 835 discharge reports. RESULTS: Abbreviations were found in personal background 72.4%, present disease 31%, physical examination 87.2%, clinical judgement 39.4%, complementary explorations 95.8%, evolution 61.4% and treatment-follow up after discharge 67.4%. CONCLUSION: These results indicate that abbreviations must be avoided in discharge reports in order to obtain a better communication between patient and doctor and between medical personnel.

Internal Medicine↗