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PubMed2000

Teaching as a Social Practice: Implications for Faculty Development.

What we believe about the nature of teaching has important implications for faculty development. In this article we contrast three different beliefs about the nature of teaching and highlight the implications for faculty development. If teaching were merely a technical enterprise where well trained teachers delivered packaged lessons, a very directive style of faculty development might be appropriate. If teaching were primarily a craft where teachers made personal judgments daily about how and what to teach, then faculty development which encouraged individual reflection and artistry might be more suitable. This article advances the argument that teaching generally (and teaching in medical schools in particular) is best characterized as a type of social practice. Social practices (such as parenting, being polite, and going to university) are purposive, rational, moral, communal, and are identified by their activities. The communal aspect of teaching means, among other things, that the prevailing social norms of faculty at particular institutions of higher education have a large role to play in shaping the practice of teaching. This being the case, faculty development needs to provide teachers the opportunity to address and reshape these powerful social norms where necessary.

Journal Article↗

PubMed2002

[Breech presentation in obstetrics in Germany--an assessment of current status].

Nowadays, the CS seems to be the most favourite way of delivery in case of breech presentation. Our opinion is that the vaginal delivery has no disadvantage for the physical and mental development of the newborns [11, 12]. The outcome depends on the set-up and organisation of each department. The most important condition to reach a good outcome by breech presentation is a well-established practical training of the whole team, a careful risk selection and a well structured perinatal centre. In our opinion the CS is the second choice to deliver a pregnant woman with a breech presentation at term. High CS-rates as well as a increased perinatal morbidity at vaginal breech delivery are a sign for insufficient training of the staff and insufficient organisation in small departments not being perinatal centres. Not the breech presentation is the real risk factor, but the unqualified Obstetrician and the insufficient set-up in the most of OB/Gyn-departments. We have a very high ethic responsibility against young women resultating from our profession. It's our duty to decide and recommend the best way to save the wellbeing of the mother and the unborn child. It's also our duty to avoid surgical manoeuvers resulting from economic reasons. Therefore a complete, sufficient practical training concerning breech delivery technics is absolutely needed. In future the answer of the question: "Delivery of breech presentation--vaginally or through CS?" will depend on, if we will be able to change this politic and professional undesirable trend.

Breech Presentation↗

PubMed2002

Experience of surgery for rectal cancer with total mesorectal excision in a general surgical practice.

BACKGROUND: Results from specialist centres have shown that total mesorectal excision (TME) produces excellent control of local disease in patients with carcinoma of the rectum. METHODS: The results of TME were reviewed in a surgical practice in which patients with rectal cancer comprised 1 per cent of the total caseload and mean case numbers were less than 15 each year. RESULTS: Eighty-two consecutive patients underwent rectal excision with TME over a 72-month period (68 anterior resection, eight abdominoperineal excision and six Hartmann's procedure). Sixty-nine operations were deemed 'curative' at the time of surgery. Anastomotic leak occurred in two (3 per cent) of 68 patients, both of whom recovered without additional surgery. There were two local recurrences (3 per cent) among 69 patients who underwent 'curative' surgery. At a median follow-up of 190 weeks, the survival rate for Dukes' stage A, B, C and 'D' was 100, 83, 68 and 18 per cent respectively. CONCLUSION: Outcome as measured by perioperative morbidity and local disease control achieved in a surgical practice with a broad case mix and relatively low annual case volume was comparable to that from larger centres. Appropriate surgical training and attention to technical detail may be as important as case volume in determining outcome after surgery for rectal cancer.

Adult↗

PubMed2002

Clinical supervision using video-conferencing technology: a reflective account.

This paper discusses three nursing practitioners' experiences of clinical supervision using video-conferencing (VC) technology. The study, based on supportive action research, involved 40 practising community and hospital nurses from a variety of specialties and took place over an 18-month period. The research was collaborative, educational and applied and focused on the effects of remote clinical supervision on the development of professional practice. Data were obtained through pre- and post-study questionnaires, repertory grids, focus group interviews and written narratives. The three research participants found that clinical supervision, as a mediator of learning, was vital in enabling them to develop their reflective and problem-solving skills. Through critical conversations with either a supervisor or within peer group supervision, the participants increased both their confidence and self-awareness and gained more insight into the practices and needs of other practitioners. They also examined critically patient care issues resulting in attention to existing or the development of new care protocols. They did, however, experience some impediments to the process of clinical supervision, mainly lack of peer and management support and ongoing education. The participants had mixed perceptions with regards to using VC technology for clinical supervision. They experienced technical and accessibility problems and communication problems, suggesting the need for clear protocols for both technical support and applied training.

Clinical Nursing Research↗

PubMed2005

Management of hemophilia with minimal factor replacement in developing countries: role of ancillary therapy.

Compared with developed countries, the care of hemophiliacs in still relatively poor in developing countries. There are three major factors that influence this problem: inadequate knowledge, lack of laboratories to diagnose the disorder, and inadequate supply of factor concentrates. It is important that healthcare providers and family members of these patients be adequately educated about all of the aspects of hemophilia. Basic laboratories could be established at a reasonable price, technical personnel could be trained, and quality-assurance programs could be initiated. Even in the absence of high-quality factor concentrates, which are expensive, there are affordable means to manage these patients, although certainly not optimally. To overcome these problems, hemophilia care services need to be established and integrated to facilitate the basic needs for these patients.

Blood Coagulation Factors↗

PubMed1983

Management of calculi in the common duct.

Management of choledocholithiasis requires several strategies to solve the various clinical problems encountered. A maximal effort during cholecystectomy at discovery of the duct stones in almost one of every six patients should, of course, be continued. Cystic duct cholangiography should routinely be used in deciding whether to explore the common duct. Postexploratory choledochoscopy has demonstrated discovery value and will hopefully be increasingly used. More training and sharing of technical details is indicated. When a retained stone is discovered on T tube cholangiogram, several options are available with no one clearly superior. Waiting for the T tube tract to mature and attempting extraction via flexible endoscopes or Burhenne technique is probably most cost effective if appropriate skills are available, especially for small calculi. Calculi greater than 8 mm in diameter with some probability of having high cholesterol content may be best managed with monooctanoin infusion. Parenthetically, monooctanoin dissolution may reduce morbidity of ERS, since large stones that would require large, more risky sphincterotomies can in some instances be reduced to passable size by monooctanoin infusion via an endoscopically placed nasobiliary tube. Endoscopic sphincterotomy for retained stones is ordinarily reserved for patients in whom nonoperative retrieval has failed or the T tube has fallen out. When common duct obstruction due to stones occurs prior to or remote from cholecystectomy, ERS is the preferred method of management when available, under conditions previously noted. With improved discovery methods and less morbid therapeutic options, consequences of choledocholithiasis will be less formidable.

Age Factors↗

PubMed1998

Reduced-size lung transplantation from adult to neonatal swine.

BACKGROUND: Lung donor shortage is a critical factor limiting the expansion of pediatric lung transplantation programs. This report details the surgical technical feasibility of a training model of lobar lung transplantation as well as the perioperative monitoring to evaluate the appropriate pulmonary graft function. METHODS: Ten hybrid Large-White pigs underwent left lower lobe lung allotransplantation; Donors weighed 15 to 20 kg and recipients 5 to 7 kg. The first five animals were used to learn the surgical anatomy and to establish the surgical technique and instrumentation's model (Group A). One hour after transplantation the right lung was excluded. Lung function and hemodynamic data were collected sequentially in the following five animals (Group B). RESULTS: The left inferior pulmonary lobe was found to be the most suitable allograft for transplantation. Usually, bronchial size discrepancy allowed telescoping of the airway anastomosis. Left atrial clamping was well tolerated during the pulmonary vein anastomoses. Preoperative antiaggregation and postoperatively heparinization achieved with ACT values over 200 seconds, prevented left atrial thrombosis. After right lung exclusion, hemodynamic changes consisted of a sustained increase in pulmonary vascular resistance and a reduction in cardiac output. Lung mechanics were also modified, with a gradual rise in airway resistance and a fall in compliance. CONCLUSIONS: The neonatal pig tolerates left lobar pulmonary transplantation satisfactorily. Although it is a useful and promising surgical learning model, questions remain regarding the applicability of this experience to clinical pediatric lung transplantation.

Animals↗

PubMed2002

Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial.

OBJECTIVE: The purpose of this study was to determine the effect and validity of an intensive laboratory-based laparoscopic skills training curriculum on operative proficiency in obstetrics and gynecology residents. STUDY DESIGN: This was a prospective, randomized, block-design trial of postgraduate year 3 and 4 residents. The following study schedule was used: week 1 (pre-randomization) included an orientation to study objectives, the administration of a laparoscopic experience questionnaire, timed video-laparoscopic drills (5 total), and the performance of a video-recorded laparoscopic partial salpingectomy; during weeks 2 and 3, the skills group residents repeated the laparoscopic drills 30 minutes daily for 10 days, and the control group residents had no formal practice sessions; during week 4, the week 1 evaluation was repeated. Operative proficiency was quantified by the Global Skills Assessment Tool through blinded, independent scoring of videotapes. RESULTS: Twenty-six residents (skills group, 12; control group, 14) consented to the trial. Patient-related issues excluded 8 residents (30%). At week 1, no significant differences existed in previous laparoscopic experience, timed video skills, or resident operative proficiency (Global Skills Assessment Tool score) between cohorts. At week 4, both groups significantly improved their timed drill test scores. The percent reduction in time from baseline was of greater magnitude in the skills group versus control group (51% vs 18%,P <.0001). Laparoscopic performance also improved in both cohorts (P =.002). However, only the skills group demonstrated significant intra-cohort improvement from baseline (mean, 4.9 points; P =.015; 95% CI, 1-7.5). CONCLUSION: A core curriculum of intensive video laparoscopic skills training improves not only technical but also operative performance among postgraduate year 3 and 4 residents.

Clinical Competence↗

PubMed1997

Stress echocardiography: personnel and technical equipment.

In recent years, stress echocardiography has gained broad acceptance as a non-invasive method for the diagnosis of coronary artery disease. Facing different protocols, dosages and instrumentation, official guidelines for the performance, standardization and quality control of stress echocardiograms are needed; however, so far they are not available. This paper recommends the type of personnel and technical equipment needed for stress echocardiography laboratories, based on experience gained during more than 2000 stress echocardiographic procedures. To perform stress echocardiography, a cardiologist and a technical assistant--both well trained over a large number of tests--should be involved. The laboratory must have basic equipment such as a 12-lead ECG, blood pressure monitoring capacity, a treadmill or bicycle for ergometry, a precision intravenous delivery system for pharmacological stress testing as well as an adequate echo table; additionally, emergency equipment is mandatory. The ultrasound machine should contain transducers with high 2-D resolution; most important is a digital image acquisition system which facilitates performance and interpretation through side-by-side display of synchronized rest and stress images. Finally, there is a need for proper patient preparation and the obtaining of informed consent.

Cardiovascular Diseases↗

PubMed1998

Explicit guidelines for qualitative research: a step in the right direction, a defence of the 'soft' option, or a form of sociological imperialism?

Within the context of health service research, qualitative research has sometimes been seen as a 'soft' approach, lacking scientific rigour. In order to promote the legitimacy of using qualitative methodology in this field, numerous social scientists have produced checklists, guidelines or manuals for researchers to follow when conducting and writing up qualitative work. However, those working in the health service should be aware that social scientists are not all in agreement about the way in which qualitative work should be conducted, and they should not be discouraged from conducting qualitative research simply because they do not possess certain technical skills or extensive training in sociology, anthropology or psychology. The proliferation of guidelines and checklists may be off-putting to people who want to undertake this sort of research, and they may also make it even more difficult for researchers to publish work in medical journals. Consequently, the very people who may be in a position to change medical practice may never read the results of important qualitative research.

Anthropology, Cultural↗

PubMed1990

Improving the quality of hospital services in The Netherlands. The role of CBO--The National Organization for Quality Assurance in The Netherlands.

In The Netherlands, quality assurance activities in hospitals began in 1976 with a formal declaration of the National Specialists Organization that quality assurance is a task of the medical profession. It was also recognized that physicians in hospitals were as yet unable to execute the various tasks that come with formal quality assurance. Hence the creation of a support organization that would assist clinicians in taking up and fulfilling their commitment to quality assurance. The creation of CBO took place in 1979; its role has been expanded to encompass such functions as technical assistance, education and training, research and development, acting as a clearing-house, and providing a forum. CBO has recently obtained an additional function; acting as a role model for similar structures in other countries in Europe and on other continents. A network of support organizations has been formed through which the development of quality assurance in health care is furthered.

Europe↗

PubMed2003

Swiss EMBnet node web server.

EMBnet is a consortium of collaborating bioinformatics groups located mainly within Europe (http://www.embnet.org). Each member country is represented by a 'node', a group responsible for the maintenance of local services for their users (e.g. education, training, software, database distribution, technical support, helpdesk). Among these services a web portal with links and access to locally developed and maintained software is essential and different for each node. Our web portal targets biomedical scientists in Switzerland and elsewhere, offering them access to a collection of important sequence analysis tools mirrored from other sites or developed locally. We describe here the Swiss EMBnet node web site (http://www.ch.embnet.org), which presents a number of original services not available anywhere else.

Databases, Protein↗

PubMed2003

Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults.

BACKGROUND: A variety of devices are used to evaluate patients with a potential diagnosis of obstructive sleep apnea (OSA). A committee comprised of members of the American Academy of Sleep Medicine, American Thoracic Society, and American College of Chest Physicians systematically evaluated data on the use of these devices and developed practice parameters. DEVICES REVIEWED: Three categories of portable monitoring (PM) devices were reviewed with regard to assessing the probability of identifying an apnea-hypopnea index (AHI) of greater or less than 15 in attended and unattended settings. Type 2 (minimum of seven channels, including EEG, EOG, chin EMG, ECG or heart rate, airflow, respiratory effort, oxygen saturation), Type 3 (minimum of four channels, including ventilation or airflow (at least two channels of respiratory movement, or respiratory movement and airflow), heart rate or ECG and oxygen saturation) and Type 4 (most monitors of this type measure a single parameter or two parameters) devices were evaluated, and in-laboratory, attended polysomnography was used as a reference. SPECIFIC RECOMMENDATIONS: (1) Insufficient evidence is available to recommend the use of Type 2 PM devices in attended or unattended settings. (2) Type 3 PM devices appear to be capable of being used in an attended setting to increase or to decrease the probability that a patient has an apnea-hypopnea index greater than 15. (3) The use of Type 3 PM devices in an unattended setting is not recommended to rule in, rule out, or both rule in and rule out a diagnosis of OSA. (4) There is some evidence that the use of Type 3 PM devices in an attended in-laboratory setting may be acceptable to both rule in and rule out a diagnosis of OSA if certain limitations are in place. These limitations include manually scoring the records, using the devices only in patients without significant comorbid conditions, having an awareness that symptomatic patients with a negative study should have a Type 1 study, and not using these devices for titrating positive airway pressure or conducting split-night studies. (5) The use of Type 4 PM devices in attended or unattended settings is not recommended. GENERAL RECOMMENDATIONS: Type 3 and 4 PM devices cannot score sleep and, therefore, do not meet some current Medicare guidelines. The use of PM devices is not recommended for general-population screening or in the absence of a pretest probability of the patient having a diagnosis of OSA, for complaints other than those associated with OSA, without review of raw data during interpretation, by physicians without familiarity with their use and limitations, and without trained personnel to perform technical scoring. Future research should address the use of PM devices in patients with comorbid conditions; non-White patients and women; larger, better-controlled studies; studies focused on the use of Type 2 and 3 devices; studies focusing on decision making and outcomes rather than simple classification using arbitrary cutoffs; and studies that seek to elucidate cost-effectiveness data on the use of PM devices.

Electrocardiography↗

PubMed1998

Coalition building for prevention: lessons learned from the North Carolina Community-Based Public Health Initiative.

This article examines the four-year development of the North Carolina Community-Based Public Health Initiative consortium (NC CBPHI). The NC CBPHI consisted of four separate county coalitions and differed in both its agenda and membership from the many examples of coalitions described in the literature. This article presents and describes evaluation findings that identify six factors as important in coalition functioning and success in the CBPHI coalitions. These factors are: participation, communication, governance and rules for operation, staff/coalition member relationships, technical assistance and skills training, and conflict recognition and containment. Selected CBPHI coalition activities are also described and implications for public health practitioners are presented.

Community Health Planning↗

PubMed2002

Deoxyribonucleic acid fingerprinting in an outbreak of Staphylococcus aureus intracranial infection after neurotologic surgery.

BACKGROUND: Meningitis is the most common life-threatening infection occurring as an early postoperative complication of neurotologic surgery. From January to March 2001, Staphylococcus aureus intracranial infection developed in three patients; two cases were consecutive. METHODS: All staff members involved in surgery on any of the three patients had nasal swabs for S. aureus. The three patient isolates and all S. aureus isolates from staff members were typed by pulsed-field gel electrophoresis. Operating room procedures were reviewed. RESULTS: All three patient isolates were identical by pulsed-field gel electrophoresis. Six staff members (40%) were found to be S. aureus carriers. The isolate from one staff members was identical to the patient isolates. A procedure audit of the operating room revealed several breaks in recommended practice. The staff carrier was immediately removed from patient care duties, given decolonization therapy, and treated for chronic rhinosinusitis. Practice changes in the operating room were implemented. CONCLUSIONS: S. aureus remains a common cause of surgical site infections. S. aureus carriage is common, and carriers with intercurrent respiratory infections have increased shedding and are a higher risk to patients. Proper use of barrier devices and consistent hand hygiene reduce bacterial contamination of the wound. Current operating room technology involves technical personnel not traditionally trained in operating room procedures. Epidemiologic investigation may be delayed if operating room records are incomplete with respect to these personnel. Molecular typing of bacterial isolates can identify common source outbreaks and effectively focus investigations.

Adult↗

PubMed2006

Experience with the extensor digitorum brevis muscle flap for foot and ankle reconstruction.

Soft tissue defects of the foot and ankle region are difficult to treat, given the lack of local flaps. Some methods available are unreliable, multistaged, have significant donor-site morbidity, or are technically complex, requiring significant training and postoperative equipment or monitoring not available at all institutions. We report the largest experience using the extensor digitorum brevis muscle flap for foot and ankle reconstruction. The charts of 20 patients were retrospectively reviewed. Eighty-five percent of the wounds were successfully treated with this flap, with minimal donor-site morbidity. The extensor digitorum brevis muscle flap has minimal morbidity, is easy to elevate, does not require microsurgical skills, and can be performed at most institutions. The extensor digitorum brevis muscle flap is a practical option for wounds located at the foot and ankle region and should be considered in patients potentially requiring a free flap.

Adult↗

PubMed2026

Development and Crossover Evaluation of an Artificial Intelligence-Assisted System for Solid Pancreatic Lesion Detection and Pancreatic Parenchyma Recognition in Endoscopic Ultrasonography (With Video).

BACKGROUND AND STUDY AIMS: Pancreatobiliary endoscopic ultrasonography (EUS) is technically demanding, and supervised training opportunities are limited. We developed an artificial intelligence (AI) overlay system for detecting solid pancreatic lesions (SPL) and recognizing pancreatic parenchyma (PP) and evaluated its effect on reader performance. PATIENTS AND METHODS: Across six centers, two deep learning-based models were trained using expert-annotated EUS frames. We then conducted a randomized, two-sequence, two-period crossover reader study in which eight endosonographers (five novices and three experts) interpreted image sets with and without AI assistance. The primary endpoint was superiority of sensitivity for SPL detection among novices; key secondary endpoints included specificity and PP recognition. RESULTS: From 118 patients, 120 SPL-positive/negative image sets and 160 PP-positive/negative image sets were constructed. Among novices, AI assistance improved SPL detection sensitivity (88.7% vs. 76.8%, p < 0.001) and accuracy (86.4% vs. 78.7%), while specificity met the predefined noninferiority criterion (84.2% vs. 80.5%, p < 0.001). For PP recognition, sensitivity increased numerically (86.3% vs. 83.3%) but did not meet the predefined superiority criterion (p = 0.095); specificity met the noninferiority criterion (87.8% vs. 81.0%), and accuracy increased from 82.1% to 87.0%. Among experts, sensitivity was maintained for both tasks, whereas specificity increased with AI assistance. CONCLUSIONS: AI assistance improved SPL detection among novice endosonographers. For PP recognition, sensitivity increased without reaching statistical superiority, whereas specificity met the predefined noninferiority criterion. These findings support a potential adjunctive role for AI in EUS interpretation.

Humans↗

PubMedDate not supplied

Comparative overview of cardiac output measurement methods: has impedance cardiography come of age?

Cardiac output, usually expressed as liters of blood ejected by the left ventricle per minute, is a fundamental measure of the adequacy of myocardial function to meet the perfusion needs of tissue at any time. Decreases in cardiac output over time (when cardiac output is measured under similar conditions) may signal myocardial functional deterioration and the onset or progression of heart failure. Conversely, improvements in cardiac output may indicate a positive response to medical therapy. However, most methods for evaluating cardiac output are technically demanding, require specialized training and specialized environments for measurement, and are costly. Therefore, most measurement techniques are impractical for routine evaluation of disease progression and/or response to treatment in the prevention and/or management of heart failure. This paper provides a comparative overview of commonly employed cardiac output measurement strategies with emphasis on developments in impedance cardiography which suggest that impedance cardiography has the potential to make routine assessment and trending of cardiac output a viable alternative to assist in the management of both chronically and acutely ill patients, including those with heart failure. (c)2000 by CHF, Inc.

Journal Article↗