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PubMed1999

Rapid sequence intubation of the pediatric patient. Fundamentals of practice.

Rapid-sequence intubation and rapid sequence induction of general anesthesia are synonyms and refer to the technique of choice for tracheal intubation in many pediatric patients in the emergency department. The principles of safe practice and basic standards of care uniformly apply to all clinical situations in which the technique is performed. RSI has two basic technical components: induction of general anesthesia and direct laryngoscopy with tracheal intubation. The technique is a prescribed protocol that can be modified slightly by the clinical circumstances. RSI is designed to rapidly create ideal intubating conditions, attenuate pathophysiologic reflex responses to direct laryngoscopy and tracheal intubation, and reduce the risk for pulmonary aspiration. Optimal performance requires appropriate training and knowledge, technical skill, and sound medical judgment. Medical and airway evaluation, careful patient selection, recognition of the need for consultation or safer alternatives, thorough familiarity with appropriate drug management, and attention to detail are essential for minimizing the risk for adverse complications. RSI with a rapid injection of preselected dosages of an anesthetic induction agent and muscle relaxant is the pharmacologic technique of choice. Premedication should not be routinely used. Anticipation, recognition, and management of complications are inherent to the competent delivery of all medical care. The unanticipated difficult airway is arguably the most severe complication of RSI, and all individuals performing the technique must prepare in advance a specific plan for this scenario. As with all such skills or procedures, a quality assurance program is important to monitor care, and individuals practicing RSI need to take appropriate steps to maintain competence.

Anesthetics↗
PubMed2006

The 24 h urinary cortisol/cortisone ratio and epinephrine/norepinephrine ratio for monitoring training in young female tennis players.

The effect of training variations on the 24 h urinary cortisol/cortisone (C/Cn) ratio and the epinephrine/norepinephrine (E/NE) ratio in relation with mood (evaluated using the Brunel Mood Scale: BRUMS) and performance was investigated in seven trained young female tennis players (12.8 +/- 1.7 years). Like the proposed model in adults, the monitoring of hormonal and mood parameters could be a useful index in training follow-up in young sportswomen. Assessment of nutritional intake, nitrogen excretion rate and nitrogen balance were also determined to measure the dietary practice of these athletes. Nitrogen balance was calculated from the mean daily protein intake and the urinary nitrogen excretion. Data were collected after a 1-month rest (September, T1), 3 months after T1 (after technical and endurance training: December, T2) and 7 months after T1 (after 4 months of increasing-volume/high-intensity training: March, T3). A significant increase in C/Cn ratio (+ 30 %, p < 0.05) were noted from T1 to T3. In the same time, urinary NE concentrations decreased significantly. The E/NE ratio increased from T1 to T2 and decreased at T3 (T1 vs. T3: - 30 %, p < 0.05). The BRUMS inventory at T3 reflected changes in specific mood states with a significant increase in fatigue and anger scores, while vigor scores decreased significantly compared to T1. This period also corresponded with the lowest percentage of matches won and with the highest training load. Energy intake was about 16 % lower than the French recommendations for girls of the same age. However, a positive nitrogen balance was observed from a mean intake of 1.0 g x kg (-1) x day (-1). Our results reveal that an increase of overnight urinary C/Cn ratio and a decrease of E/NE ratio are concomitant with alterations in mood state and performance, all these parameters being associated with physical and psychological stress.

Affect↗
PubMed2000

Soft systems, hard lessons.

This paper is concerned with practical experiences of achieving human factors and safety interventions in the nuclear power and process control industries. It rests upon the premise that, although human factors (HF) and safety may be technological in approach, they nevertheless must operate in a socio-technical environment, within companies with corporate structures and cultures, interacting with regulatory authorities. A crucial ingredient to the successful implementation and integration of human factors into company practices and procedures is therefore the nature of the inter-relationships between human factors personnel and those who control the existing procedures determining all aspects of the design and operational processes. Such inter-relationships can largely determine whether HF is implemented or not. These human-human interactions and interfaces in a socio-technical system may be referred to as soft systems. When training in human factors, much of the training is concerned with technical aspects of the discipline. However, when entering industry or consultancy, one quickly discovers that technical aspects are usually the least of one's problems. This paper is concerned with experiences and guidance to better help the human factors professional starting out in industry. There is little scientific method in the paper. It is, instead, a distillation of this author's and others' experiences in acting either as a practitioner or consultant, or as leader of a human factors unit in industries that have at times been reluctant or even hostile about the perceived 'invasion' of human factors. However, to avoid being purely anecdotal, the experiences are placed in a framework concerned with the life cycle of integrating human factors into an industry, from being the first HF person in a company, to the development of a successful unit, or the absorption of a successful unit into other departments. Within this framework a range of strategic aspects are dealt with, such as integration of HF into the design process, and selection of test-case projects.

Communication↗
PubMed1999

[Years of training: a new risk factor in acute badminton injuries].

The incidence of badminton injuries is low compared with other sports, but acute injuries are generally more severe. Little is known about the risk of competitive badminton players to get an acute badminton injury. The purpose of this study was to define for the first time "years of playing badminton on a competitive level" as a risk factor for acute badminton injuries. 179 badminton injuries of 102 Austrian competitive badminton players, some of them being elite players in the european championships, were retrospectively registered. The years 1993, 1994 and 1995 were covered by our investigation. Injury incidences were defined as injuries/1000 h and were calculated separately for the 0. through the 21st year of competitive badminton. The incidence of acute badminton injuries increased constantly from the 0 to the 7th year of competitive badminton. The 6th and 7th year of competitive badminton showed a threefold increased incidence of acute badminton injuries when compared with the first year and the late years of the career as a competitive badminton player. We found no correlation between the incidence of acute badminton injuries and age, gender, hours played per year or time of warming up. We conclude that players being engaged in competitive badminton for 5 to 8 years represent a high risk population for acute badminton injuries. In contrast players at the beginning and towards the end of the competitive career showed a markedly lower risk for acute badminton injuries. We recommend additional training efforts concerning technical skills and endurance as well as proper rehabilitation of sports injuries for the high risk group of badminton players.

Adolescent↗
PubMed2005

Non-technical constraints to eradication: the Italian experience.

Although technical constraints to eradication of bovine tuberculosis are well-recognised, non-technical constraints can also delay progress towards eradication, leading to inefficiency and increased programme costs. This paper seeks to analyse the main non-technical constraints that can interfere with the successful implementation of tuberculosis eradication plans, based on experiences from an area of high tuberculosis prevalence in Regione Piemonte, Italy. The main social and economic constraints faced in the past 20 years are reviewed, including a social reluctance to recognise the importance of seeking eradication as the goal of disease control, effective communication of technical issues, the training and the organization of veterinary services, the relationship between the regional authority and farmers and their representatives, and data management and epidemiological reporting. The paper analyses and discusses the solutions that were applied in Regione Piemonte and the benefits that were obtained. Tuberculosis eradication plans are one of the most difficult tasks of the Veterinary Animal Health Services, and non-technical constraints must be considered when progress towards eradication is less than expected. Organizational and managerial resources can help to overcome social or economic obstacles, provided the veterinary profession is willing to address technical, but also non-technical, constraints to eradication.

Animal Husbandry↗
PubMedDate not supplied

[Sexual aspects of physician-patient relations].

The emotional aspects of the doctor-patient relationship are often overlooked in clinical training, as are the sexual problems. A questionnaire was drawn up in order to obtain further information about the gynecologist's emotional reactions during pelvic examination. An analysis of the results suggests that the doctor's emotional reaction during pelvic examination is not the same in both sexes, whereas both sexes show equal concern for the patient's sexual activity. This suggests that adequate technical and emotional training is necessary in order to establish a good relationship between the gynecologist and the patient.

Emotions↗
PubMed2001

Prescription of resistance training for healthy populations.

Although there are well documented protective health benefits conferred by regular physical activity, most individuals of all ages are not physically active at a level for sufficient maintenance of health. Consequently, a major public health goal is to improve the collective health and fitness levels of all individuals. The American College of Sports Medicine (ACSM) and other international organisations have established guidelines for comprehensive exercise programmes composed of aerobic, flexibility and resistance-exercise training. Resistance training is the most effective method available for maintaining and increasing lean body mass and improving muscular strength and endurance. Furthermore, there is an increasing amount of evidence suggesting that resistance training may significantly improve many health factors associated with the prevention of chronic diseases. These health benefits can be safely obtained by most segments of the population when prescribed appropriate resistance-exercise programmes. Resistance-training programmes should be tailored to meet the needs and goals of the individual and should incorporate a variety of exercises performed at a sufficient intensity to enhance the development and maintenance of muscular strength and endurance, and lean body mass. A minimum of 1 set of 8 to 10 exercises (multi-joint and single joint) that involve the major muscle groups should be performed 2 to 3 times a week for healthy participants of all ages. More technical and advanced training including periodised multiple set regimens and/or advanced exercises may be more appropriate for individuals whose goals include maximum gains in strength and lean body mass. However, the existing literature supports the guidelines as outlined in this paper for children and adults of all ages seeking the health and fitness benefits associated with resistance training.

Adolescent↗
PubMed2001

[Malaria--rapid diagnostic tests and emergency self-medication].

WHO recommendations have adopted the option of stand-by emergency treatment (SBT) for travellers to areas where malaria is endemic and medical attention may not be obtained within 24 hours after onset of symptoms. Indication and choice of drugs for SBT depend on use and kind of a chemoprophylactic regimen, situation of plasmodial resistance at the destination, and contraindications and tolerability in the individual traveller. However, the diagnosis of malaria on clinical grounds alone is unreliable, and fever occurs frequently during travel to malaria endemic areas from various reasons. The possibility of malaria has to be considered in all cases of unexplained fever that starts after the 7th day of stay in an endemic area. Studies in European travellers have shown that only 0.5-1.4% of all travellers to whom SBT medication has been prescribed, will finally use it. SBT use in febrile travellers (8.1-10.4% of all travellers) has been 4.9-17%, but plasmodial infection could be confirmed retrospectively in 10.8-16.7% of SBT-users only. The recent introduction of rapid diagnostic tests (RDT) for malaria has provided a potential tool to self-diagnose and treat a possible malaria attack when medical attention or microscopic diagnosis is not available. However, the utilisation of currently available RTDs by travellers has been shown to be technically problematic. Healthy volunteers were able to learn how to perform the tests, especially when standard written instructions were supplemented with verbal information (75 vs. 90% successful performance). But their interpretation of test results was unsatisfactory, with a high rate of false-negatives (14.1%). In another study in febrile European tourists in Kenya, only 68% of patients were able to perform the RDTs correctly, and 10 out of 11 with microscopically confirmed malaria failed to diagnose themselves accurately. Thus, besides appropriate training before departure, technical improvements are required before such RDT kits can be recommended for self-use by travellers.

Africa↗
PubMed1989

[Producing technical drawings using the feet--a special work site for a thalidomide-damaged technical draftswoman].

Persons with upper limb deficiency do not find it easy to lead a somewhat "normal" private, occupational and social life. True, society offers many kinds of assistance and support; it nevertheless is very much a matter of how the individual concerned reacts to the positive and negative influences and imponderabilities encountered. The present report sets out the efforts of a thalidomide-affected young woman who, in the face of numerous obstacles, left nothing untried to create a life basis of her own by obtaining a good vocational qualification as a technical draftswoman, regardless of her congenital upper limb amputation. Her success is proof enough that she chose the right course. This example, in more general terms, should perhaps be considered a prompting for society, on the one hand, to undertake the endeavour of providing quality assistance even in extreme situations and, on the other, to be prepared to have confidence even in those with very severe physical disablement to be able to accomplish goals which at the first glance may appear "nonsensical", such as a desire to be trained as a technical draftswoman even though one's hands are missing. The account not least shows the positive impact help and self-help may have in the rehabilitation of very severely disabled persons. The disabled person's reward primarily lies in the sense of independence achieved and in financial self-reliance, which in turn generate a sense of feeling free inwardly and outwardly.

Adult↗
PubMed1994

Are pediatric emergency medicine training programs meeting their goals and objectives? A self-assessment of individuals completing fellowship training in 1993.

The purpose of this study was to evaluate the overall training experience of those individuals completing fellowships in pediatric emergency medicine. Specific attention was given to the technical skills portion of training as set forth by the American Academy of Pediatrics Curriculum Committee on Pediatric Emergency Medicine. We surveyed those individuals completing their second year of fellowship training in pediatric emergency medicine. The questionnaire incorporated a self-assessment of the technical skills portion of the Subcommittee on Pediatric Emergency Medicine's most recent curriculum statement. It also contained several questions designed to evaluate the overall training experience. Eighty percent of respondents completing the self-assessment questionnaire rated their overall experience as favorable, whereas those who rated it unfavorable stressed a lack of training in research and teaching. Ninety-two percent of respondents felt they had a good clinical experience, but 80% expressed a need for further training in administration, 74% in research, and 46% in teaching. Although the majority claimed to be comfortable with most technical skills, several skills, including lifesaving procedures such as external pacing, peritoneal lavage, pericardiocentesis, shunt tap, airway foreign body removal, and needle cricothyrotomy, posed a significant degree of discomfort.

Clinical Competence↗
PubMed2005

Statewide community-based health promotion: a North Carolina model to build local capacity for chronic disease prevention.

BACKGROUND: Public health faces major challenges to building state and local infrastructure with the capacity to address the underlying causes of chronic disease. We describe a structured statewide approach to providing technical assistance for local communities to support and develop health promotion capacity. CONTEXT: Over the last two decades, the North Carolina Statewide Health Promotion program has supported local approaches to the prevention and control of chronic disease. In 1999, a major change in the program required local health departments to focus on policy-change and environmental-change strategies for addressing three major risk factors: physical inactivity, poor diet, and tobacco use. METHODS: State program consultants provided technical assistance and training opportunities to local programs on effective policy-change and environmental-change strategies and interventions, based on needs defined by a statewide monitoring and evaluation system. CONSEQUENCES: The percentage of health departments in North Carolina with interventions addressing at least one of three targeted risk factors in 2004 approached 100%; in 2001, this percentage was 62%. Additionally, between 2001 and 2004, the number of health departments reporting policy or environmental outcomes related to these risk factors almost doubled. INTERPRETATION: Requiring local programs to implement policy-change and environmental-change interventions that address the three major behavioral risk factors provides an organized framework for accountability. An established reporting system guides technical assistance efforts and monitors their effectiveness based on standardized objectives that address the full scope of the socioecologic model.

Chronic Disease↗
PubMed1998

[Difficulties in the management of supracondylar fractures of the humerus in children living in Central African Republic].

Like many developing countries, the Central African Republic lacks the technology and skills to perform certain medical procedures. One example of this situation can be found in the Pediatric Surgery Department of Bangui with regard to first intention management of supracondylar fractures of the humerus (SCF). Due to a lack of proper technological facilities (e.g. absence of brightness enhancement) and to insufficient staff training, management of SCF must be limited to orthopedic reduction followed cast application and brachio-anti-brachio-palmar traction such problems. This retrospective study describes management of 119 cases of SCF involving children between the ages of 0 and 15 years. Special emphasis was placed on factors impairing outcome, namely, inadequate staff training, availability of brightness enhancement, and poor awareness on the part of the parents concerning the seriousness of SCF. The quality of reduction was compared according to whether reduction was done with or without brightness enhancement (reduction without brightness enhancement was imperfect in most cases: 78/119) and according to fracture grade (high number of imperfect reductions in grade 3 and 4:69%). Assessment of outcome at one month showed a high incidence of poor results due to severe fracture or imperfect reduction. A prospective study including 35 cases with a follow-up of three years showed poor results for the same reasons. Comparison of these results with those reported by previous authors showed a large gap which must be filled by upgrading technical facilities and training staff.

Adolescent↗
PubMed1989

[The efficacy of electromyographic biofeedback treatment on cardiovascular disease and the correlation of type A behavior and traditional Chinese medicine syndrome differentiation].

Using the method of trilineal relaxation training, electromyographic biofeedback technic (EMGBT) in the treatment of 400 cases of cardiovascular disease was reported. There were 274 (68.5%) cases of hypertension and coronary heart disease, more than other diseases. After treatment, average systolic blood pressure reduced 1.85 Kpa (13.86 mmHg), and average diastolic blood pressure reduced 1.29 Kpa (9.73 mmHg). The treatment was more effective for the type A behavior patients, so was it in the treatment of various extrasystoles (75%). To analyse the correlation between TCM syndrome differentiation and behavior pattern, it was found that there were 90.66% of Heart Yin deficiency and Liver Yang ( ) associated with Phlegm among type A behavior patients and 82.5% of Heart Qi ( ) Yang deficiency and Qi Yin deficiency among non-type A behavior patients. By means of relaxation training, EMGBT might reduce sympathetic tone, dilate blood vessels, so as to reduce blood pressure and treat arrhythmia.

Adolescent↗
PubMed2003

Learning disabilities, professionalism, and the practice of medical education.

The authors use the interface of learning disabilities (LDs) and medical education to explore several issues relevant to medical professionalism and the training of future physicians. First, they examine arguments given by Little (in the preceding article) that a successful suit for accommodations on a state bar exam is generalizable to LDs and medical education, and suggest ways in which this may not be true. They then explore two frameworks for understanding medical education: (1) as a process of academic achievement linked to degree attainment, and (2) as a process of professional acculturation linked to competencies. Within this dichotomy, they then explore (1) the legitimacy accorded to different types of accommodations, (2) differing meanings of a "level playing field," and (3) the legal standard of "otherwise able." They also examine the use of intermediaries (e.g., a reader) as a "leveling" strategy and how, in clinical settings, this might violate core standards of autonomous decision making. The authors investigate the nature of "technical standards" in training across medicine and nursing and find a number of differences, particularly in the intent and levels of detail of standards. Across these two domains, they observe a status hierarchy, medical hubris, and the emergence of a "right to fail" as one travels down that hierarchy. The authors also examine medicine as an undifferentiated degree and consider arguments that medical school course requirements should be unbundled. They close by insisting that medical schools have a social responsibility to shift their pedagogic gaze from identifying handicaps in individuals to understanding how the education of physicians can become, quite literally, "handicapping."

Clinical Competence↗
PubMed1998

Survey of risk reduction and pollution prevention practices in the Rhode Island automotive refinishing industry.

In 1996 a survey of pollution prevention, environmental control, and occupational health and safety practices was conducted in the Rhode Island automotive refinishing industry sector. In conjunction with project partners, the Rhode Island Department of Environmental Management developed a multidimensional survey instrument to identify risk reduction opportunities. Investigators sought to characterize the range of environmental and industrial hygiene control employed by Rhode Island facilities for the purposes of focusing state technical and compliance assistance efforts. Data were collected on a diverse range of subject areas including work force demographics; source reduction; potential health hazards; worker protection and safety; solid and hazardous waste management; and air pollution control. Nearly one-half of the shops employ three or fewer people, and in many cases, spray painters double as body repair technicians thereby increasing their potential exposure to workplace contaminants. While nearly all of the shops reported that they use spray painting booths, only 38% own booths the more effective downdraft design. Based on the self-reported data, recently promulgated state air pollution control regulations (requiring the use of compliant coatings, enclosed or modified spray gun cleaners, and high-volume, low-pressure, spray guns) appear to be effective at motivating companies toward source reduction. A range of risk reduction opportunities were identified as input material changes, technology changes, and improved operating practices. Better methods of risk communication; a professional licensing requirement; and targeted training, compliance, and technical assistance would help to achieve greater levels of risk reduction in this mature, high-hazard industry.

Adult↗
PubMed2002

Laparoscopic vagotomy using mini-instruments in the rat: a new laparoscopic small animal model.

PURPOSE: Animal models are necessary for research, technical developments, and training purposes in laparoscopic surgery. Although various operations on small animals have been described, there is still a need for a simple and practical laparoscopic small animal model. We acknowledged truncal vagotomy as a simple procedure, and aimed to develop a model of laparoscopic truncal vagotomy (LTV) in the rat, an inexpensive and easily available animal. METHODS: Fifty Wistar rats were randomized into an LTV group (n = 25) and an open truncal vagotomy (OTV) group (n = 25). LTV was effected with two minitrocars inserted into the left upper and right lower quadrants. Two techniques of vagotomy were developed: first, with the esophagus in its anatomical position, and second, with the distal esophagus retracted anteriorly with a grasper inserted into the retroesophageal space. OTV was performed through a midline incision. Animals were sacrificed 24h postoperatively, and autopsy was performed. RESULTS: The mean +/- SD operating time was 8.3+/-1.4 min in the LTV group and 5.5+/-0.2 min in the OTV group (P < 0.05). The laparoscopically magnified view provided a better distinction of vagal fibers compared with open surgery, with the second laparoscopic technique providing the best exposure. Complications developed in three rats (12%) from the LTV group and one (4%) from the OTV group (P > 0.05). Vagotomy was confirmed to be complete at autopsy in all of the animals. CONCLUSION: This is the first technical description of laparoscopic peptic ulcer surgery in the rat. Although subsequent histopathological and physiological studies may be required, technically, laparoscopic vagotomy in the rat seems to be a simple, inexpensive, and expeditious small-animal model for laparoscopic research.

Animals↗
PubMedDate not supplied

[At the beginning of the third millennium: what kind of surgery, what kind of surgeon?].

Technological progress and the evolution of biological knowledge lead us to expect major developments in the fields of organ replacement, minimally invasive surgery and tumour therapy in the coming decades. It is widely believed that xenotransplantation may offer a possible solution to the problem of the current chronic shortage of donors, though their use at present encounters formidable immunological obstacles, particularly as regards discordant transplants. Genetic engineering and the realisation of transgenic donors as well as new strategies aimed at modifying the immune status of the donor may well be the key to new developments in this sector. Selective culturing of tissues and the production of totally implantable artificial organs are additional lines of research which may provide useful means of meeting the increasing demand for organs. The enormous advances made in the field of high-tech solutions applied to the biomedical disciplines are destined to open up new frontiers in diagnostics, operating technique and the permanent training of surgeons. In particular, we are about to witness an extension of the use of computer technology and robotics, embracing the simulation and reproduction of virtual reality, telemedicine (teleconsulting and telesurgery) and the creation of experimental models. Minimally invasive surgery will unquestionably benefit from this progress with the possibility of extending its range of indications to procedures in which human limitations are more evident owing to difficulties of access and the size of the target, at the same time guaranteeing high-precision manoeuvres. In the oncological field, high expectations accompany the advances in our knowledge of molecular biology with the genetic mapping of tumours which may pave the way for screening programs and gene therapy. Alongside the scientific and technological development of the surgery of the future, we can expect to see the increasing emergence of: a) economic problems related to the progressive increase in healthcare costs, amongst other things as a result of the powerful impact of high-tech solutions; b) social problems in terms of the inevitable conflict between cost-containment policies and the right to healthcare; c) moral and bioethical problems relating to the possible establishment of genetic registries and to the different patient-care provider relationship which is likely to come about as the result of the interference of machines or robots. The surgeon's persona may undergo profound changes, not merely from the technical and professional training standpoint, but also with regard to his or her effective role, which may no longer be that of a central, dominant figure, but may be scaled down in a context of multidisciplinary co-operation.

Ethics, Medical↗
PubMed2006

Resident education regarding technical aspects of cesarean section.

OBJECTIVE: To survey obstetric/gynecologic residents around the country regarding different technical aspects of and indications for cesarean section, trends in vaginal birth after cesarean (VBAC) and patient choice of cesarean. STUDY DESIGN: A questionnaire was designed to address the above issues and selected demographic information. The questionnaire was sent by e-mail to all the residency programs in the country. The first 400 responses were analyzed. RESULTS: Although a midline vertical incision is considered faster for entry into the abdomen, 77% of residents use a Pfannenstiel incision for urgent/emergency cesarean sections. Fifty-five percent of respondents use single-layer closure of the uterine incision, 37% use double-layer closure, while 11% use single-layer closure only in patients undergoing concomitant sterilization. When questioned regarding a trial of labor, one-third of respondents stated that they would not induce labor in patients with a prior cesarean if the patients did not go into labor spontaneously but offer repeat cesarean for fear of a uterine rupture. Further, 42% said that they would never offer VBAC for an undocumented scar, 12% would and 45% would depending on the history. Regarding the issue of cesarean section by patient request, 94% would not offer an elective cesarean section for uncomplicated primigravidas, while 6% would. However, if a well-informed patient desired an elective cesarean delivery, the majority of residents would respect the patient's request. CONCLUSION: There is wide variation in the way residents are trained regarding different technical aspects of and indications for cesarean section, choice of repeat cesarean versus VBAC and patient choice of cesarean. Recent trends in the literature are not always reflected in reported practice patterns.

Cesarean Section↗