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Clinical assessment of laboratory rodents on long term bioassay studies.

The disease status of laboratory rodents should be clinically assessed before the animals are placed on toxicological bioassay programs. This is especially important when the stress of dietary or parenteral intake of toxic substances may trigger the clinical onset of latent diseases in research animals. In clinical evaluation of rodents, the environmental influence on biochemical, physiological and behavioral status of the animals must be continually monitored. Temperature, humidity, ventilation, lighting, and the microenvironment of the cage will all influence, independently or in consort, the response of the animal to various microbial or chemical insults. Unwanted variables in the diet can also markedly after the biological response of the animal and thus alter interpretation of experimental data. Adequately trained personnel, both professional and technical, must be available to provide daily care, clinical observation, and necessary treatment if signs of illness are noted in the laboratory rodent or bioassay experimentation. Clinical signs associated with commonly encountered diseases in laboratory rodents are briefly described. Clinical surveillance and assessment of rodents in part consists of recognition of and detailed recording of clinical signs, coupled with proper diagnostic resources to substantiate clinical observations. It is possible, with proper diagnosis, to evaluate the overall effect of a particular disease on the animal's health, the likelihood that the disease is jeopardizing the health of the other animals on test, and the effect of the disorder on interpretation of experimental results.

Animal Husbandry↗

Closed intramedullary nailing of the femur. Küntscher technique with reaming.

Closed intramedullary reaming and nailing with a prebent cloverleaf nail provides a biomechanically ideal method of internal fixation for femoral fractures. With a properly trained surgical team and careful technical control, all the theoretical advantages of this technique can be realized. These include a very high union rate, minimal risk of infection, early mobilization, and shortened hospitalization. Reaming and insertion of the nail is performed through a starting point at the junction of the base of the femoral neck and trochanter. When reaming is done, the nail can be sufficiently large to withstand the forces of early ambulation, thereby allowing an early return to normal function for most patients. In comminuted fractures an intramedullary nail can be used as an internal splint. In conjunction with traction and/or guarded weight-bearing and/or cast-brace, this procedure can assure earlier and more anatomic union and earlier return to function. In 300 fresh femoral fractures treated with closed intramedullary nailing, most patients had early and nearly anatomic union with excellent knee function and maintenance of muscle strength. Significant complications included one non-union, which required renailing, and 19 malunions, most of which were relatively minor. Because the procedure is technically demanding and requires extensive special equipment, it is best suited for use in trauma centers.

Adolescent↗

The place of arthroscopy in the diagnosis and treatment of internal derangement of the knee: an analysis of 1000 cases.

An analysis of 1,000 consecutive arthroscopies of the knee, representing almost 10 years' experience, has made it possible to identify the patient in whom arthroscopy is deemed essential, very useful, or in some instances, superfluous. In the latter category are the young, often teenagers, with pain as their main symptom and no positive physical findings. In osteochondritis dissecans, added information beyond that supplied by X-rays was obtained infrequently, and routine arthroscopy for chondromalacia of the patella is probably unnecessary. Pain and other symptoms in the older age group are more likely to be the result of intra-articular pathology. Arthroscopy has been most helpful in making an accurate diagnosis, planning a surgery, and in some cases, avoiding unnecessary surgery. When a meniscal tear is suspected and arthrotomy comtemplated, arthroscopy is done routinely because it is now evident that the diagnostic accuracy of arthroscopy in experienced hands is at least 20% greater than clinical diagnostic accuracy. As a research tool, arthroscopy has proved to be an excellent method of adding to our knowledge of the fate of damaged articular cartilage. As a therapeutic tool, its use in meniscectomy and other forms of intra-articular surgery has established a new frontier for orthopedic surgery. Intra-articular arthroscopic surgery requires special training and more than average technical skill.

Adolescent↗

[Biomechanical aspects of cervical trauma].

The biomechanical expert opinion on the injury mechanism is necessary in few cases only. However, the judgement of these cases is extremely compromised if mechanically wrong terms are introduced in the clinical report. Since the injury mechanism in the neck is very complex the clinical physician should concentrate on the clinical findings familiar to him; usually the clinician lacks technical case documentation and specific training in injury biomechanics. The relevant mechanisms of neck injuries are an indirect trauma induced by a) a head contact leading to compression, hyperflexion, hyperextension and/or hypertranslation and b) a non-head-contact mechanism (hyperflexion or hyperextension, hypertranslation, acceleration). A non-contact mechanism occurs e.g. during a rear end impact without head restraint (hyperextension) or a frontal collision of a belted occupant (hyperflexion) without head impact. The term "whiplash" is misleading and incorrect: It presumes a virtually non existing two phase movement back and forth (or vice versa) like during the development of the crack of the whip. Secondly, it mixes the physical criterion mechanism with the anatomical or morphological criterion injury e.g. distortion, sprain etc. A (head)-contact mechanism is due to a corresponding momentum exerted from the head on the neck. Again, the anatomical or morphological terms are equal, but the mechanism is different. During a contact mechanism as well as during a non-contact mechanism not only a hyperflexion or a hyperextension can occur; in the first phase of the impact also a shearing force between the upper vertebral bodies (CO-C2) may load the intervertebral structures by hypertranslation.

Accidents, Traffic↗

[Specialization of occupational health services workers in Europe].

Postgraduate education of the occupational health service workers is a key issue for the improvement of working conditions and the health state of working populations. It is organised at various levels (specialisation, diploma, certificate, Master of Science degree). Most European countries organise postgraduate education and training for doctors, nurses, hygienists, technical personnel, psychologists, etc. The professional competence of the occupational health service workers is based on the specialisation and other forms of postgraduate education.

Allied Health Personnel↗

[Radiotherapy in northern Germany: data on radio-oncology from 6 Bundesländer].

BACKGROUND: Facts and figures about German radio-oncologic centers are scarcely available. A first glance was made possible by the accumulation of data published by the German Röntgen Society ("Abteilungen und Praxen für Strahlentherapie in der Bundesrepublik Deutschland, 1994"[4]). Detailed and up-to-date information is difficult to collect from the whole Federal Republic. Therefore, a regional data-base limited to the 6 northern German states was created in order to get correct, detailed and current facts and figures from radio-oncologic departments of this region. PATIENTS AND METHOD: Traditionally there was a close cooperation between the Röntgen Society of Northern Germany and the Society of "Niedersachsen" and "Sachsen-Anhalt". Therefore, hospital departments and free standing office-type facilities in radio-oncology from 6 states have put together a regional North German data-base. Detailed questionnaires were sent out in order to get data on heads of departments, professional staff, technical equipment, workload, diagnoses and training facilities. The collected data were distributed to all participating centers for confidential individual analysis. This paper reports the data collected. RESULTS: The survey 1995/96 had an unexpected return. Thirty-six from 38 centers in a region with 17.36 million inhabitants in 6 states (21.3% of Germany) took part. There were 73 megavolt machines and 31 afterloading facilities. Two hundred and forty physicians, 110 physicists, and 350 radiographers were working in radio-oncology; and there were 852 hospital beds specifically assigned to radio-oncology for the care of in-patients. In 1995, 32,000 patients were treated with 37,000 series, 570,000 treatment visits and 1,600,000 radiation fields. The average patient got 1.2 series, 18 treatment visits and 50 fields. Equipment-wise, an average department runs a mean of 2 megavolt machines and 1 afterloading facility. The corresponding data for 1 megavolt machine were 3.5 physicians, 1.6 physicists, 5 radiographers and 13 hospital beds. There was 1 machine for 240,000 inhabitants. The average workload of a megavolt machine was 439 patients a year with 513 series, 7,813 treatment visits and 21,845 radiation fields. CONCLUSIONS: A regional data-base for radio-oncology is being described. It is demonstrated that it is possible to get detailed and current data by this method. It provides transparent data on equipment, personnel and workload in radio-oncology. It should set an example for other regions to collect their data in the same fashion, and then compile all such data for the whole country to identify and correct potential deficiencies for improvement of care.

Databases, Factual↗

[Shock room management of polytrauma].

The emergency room functions as a junction between preclinical and early clinical treatment of patients with multiple trauma and should have defined technical and room possibilities. The personal staff should continue resuscitation measures and perform clinical and technical diagnostic procedures according to trained algorithms. The recognition of life-threatening injuries, the set up of correct priorities and application of respective surgical procedures characterize a good emergency room management.

Algorithms↗

[Prosthetic bilateral laparoscopic hernioplasty. Extra-peritoneal approach].

The use of prosthetic mesh in inguinal hernia repairs is becoming increasingly popular. In recent years different laparoscopic procedures for prosthetic repair of inguinal hernias have been developed. The authors describe their initial experience with a totally extra-peritoneal prosthetic approach in laparoscopic repair of bilateral inguinal hernias. From November 1993 to May 1994, ten consecutive patients with bilateral primary inguinal hernias underwent laparoscopic repair under general anesthesia. A totally extra-peritoneal approach has been performed beginning through a 2 centimeter vertical midline sub-umbilical incision. Two additional trocars have been inserted on the midline: a 10/12 mm one halfway between the umbilicus and the pubis and 5 mm one 2 cm above the pubis. Average operative time was 141 minutes. Two cases were converted to traditional open Stoppa procedure because of holes made in the peritoneum during blunt dissection of the hernia sac. In the remaining 8 cases a polypropylene mesh of about 8 cm in height and 13 cm in length have been placed on each hernia site. No major complications have been observed and recovery was quick in all cases. In conclusion we think that laparoscopic hernia repair through a totally extra-peritoneal approach is technically feasible for general surgeons trained in laparoscopic surgery. Nevertheless the operation in costly and the patient's benefit in terms of rapid recovery, complications and recurrences has not yet been demonstrated in controlled prospective trials.

Adult↗

[Programms of community psychiatry].

Three main resources in all Health Care Programs are classified into three groups: The Psychiatric Hospital. It is a strictly hierarchical organization, where decisions are made at the top of the pyramid, and authority flows down administrative channels. Tasks are clearly defined, and so are responsibilities. The Therapeutic Community. It is a non-hierarchical group, with the goal of re-socializing disturbed individuals. It stresses group and individual responsibilities, aiming at learning new patterns of interaction. All members, patients and personnel alike, are equal members sharing full responsibilities, including decisions concerning the group and/or the individuals. Joining the group, leaving it, or dismissing a member, are all joint decisions. The underlying theory assumes therapeutic potentialities for a group with those special requirements, and for each of its members, regardless of its roles. The Programs of Community Psychiatry. All resources of large population groups are oriented and origanized into comprehensive community programs. All physical facilities are co-ordinated into a network. Personnel is recruited, whenever possible, using the human resources within the same community. All actions, at all scales, are organically co-ordinated in order to maximize benefits and minimize efforts and expenses. All three systems collide substantially, because of their radically different conceptions, grounds and operating requirements. Their many conflicts are analyzed in detail, assessing their consequences on the efficacity of services. A general conclusion is drawn on the valuable data emerging from the application of different systems simultaneously, allowing for future further evaluations. The author stresses that all three systems must be analyzed within a much broader socio-economical framework, and taking into account additional difficulties emerging from: a) great social distance between patient and therapeutic team, impeding exchanges; b) politically unstable climate for officials in charge of mental health policies; c) lack of psychological and technical fitness and heterogeneity of training affecting most mental health workers and agents.

Community Psychiatry↗

[Quality assurance of Doppler sonographic procedures].

For new diagnostic procedures, such as Doppler sonography, measures for quality assessment are of particular importance. Certificates are required by the professional authorities attesting adequate training and practical experience. In addition, minimum technical requirements for the equipment are laid down. The scientific associations may give advice in the preparation of training programme. They can also propose suitable trainers and training centres. For the doctor, Doppler sonography is only one link in the chain of the diagnostic procedures for vascular disease. It should only be employed when the investigation is clearly directed and if the user is familiar with the methods concerned. The decision to undertake further diagnostic examinations, which frequently involve risks, and the therapeutic consequences demand clinical experience and the cooperation of the individual clinical disciplines involved.

Curriculum↗

Clinical biochemistry education in Spain.

Clinical biochemistry in Spain was first established in 1978 as an independent specialty. It is one of several clinical laboratory sciences specialties, together with haematology, microbiology, immunology and general laboratory (Clinical analysis, análisis clinicos). Graduates in Medicine, Pharmacy, Chemistry and Biological Sciences can enter post-graduate training in Clinical Chemistry after a nation-wide examination. Training in an accredited Clinical Chemistry department is 4 years. A national committee for medical and pharmacist specialties advises the government on the number of trainees, program and educational units accreditation criteria. Technical staff includes nurses and specifically trained technologists. Accreditation of laboratories is developed at different regional levels. The Spanish Society for Clinical Biochemistry and Molecular Pathology (SECQ), the national representative in the IFCC, has 1600 members, currently publishes a scientific journal (Química Clinica) and a newsletter. It organizes a continuous education program, a quality control program and an annual Congress.

Biochemistry↗

Capacity-building activities for local leadership in Egypt from the local to the national and regional levels.

In order to make the Sustainable Ismailia Project institutionally sustainable, the National Project Manager identified the need to build the capacity of local leadership. The Training Section, in UNCHS, proposed a capacity-building program designed to respond to this demand focusing on the skill-training and attitude formation needed for effective local leadership. The proposed program is adapted from the "Training for Elected Leadership" series widely tested and used in many regions. It combines direct training for local officials from villages in Ismailia, and indirect training for trainers from the Ministry of Local Administration (MLA). After the course, the MLA trainers would design a training program which they will implement nationally. The Minister for Local Administration decided to finance the translation and production of the manuals, while the Governor of Ismailia offered to cover the trainees' expenses. The UNCHS Training and Capacity-Building Section would provide technical guidance and coordinate and implement the program. Once the Arabic version of the training materials would be available, UNCHS would use it regionally to reach out to other Arab States. This example illustrates how concerned stakeholders cooperate to address capacity-building needs. The UNCHS Training Section assumes the role of facilitator and acts as a catalyst for the formulation of such activities. The feeling of ownership of the locally produced/adapted training materials enhances the propensity of their effective and extensive use. This approach has succeeded across regions, cultures, and languages with out-reaching multiplier effects.

Africa↗

A pilot study comparing the effectiveness of conventional training and virtual reality simulation in the skills acquisition of junior dental students.

The use of virtual reality (VR) in the training of operative dentistry is a recent innovation and little research has been published on its efficacy compared to conventional training methods. To evaluate possible benefits, junior undergraduate dental students were randomly assigned to one of three groups: group 1 as taught by conventional means only; group 2 as trained by conventional means combined with VR repetition and reinforcement (with access to a human instructor for operative advice); and group 3 as trained by conventional means combined with VR repetition and reinforcement, but without instructor evaluation/advice, which was only supplied via the VR-associated software. At the end of the research period, all groups executed two class 1 preparations that were evaluated blindly by 'expert' trainers, under traditional criteria (outline, retention, smoothness, depth, wall angulation and cavity margin index). Analyses of resulting scores indicated a lack of significant differences between the three groups except for scores for the category of 'outline form', for group 2, which produced significantly lower (i.e. better) scores than the conventionally trained group. A statistical comparison between scores from two 'expert' examiners indicated lack of agreement, despite identical written and visual criteria being used for evaluation by both. Both examiners, however, generally showed similar trends in evaluation. An anonymous questionnaire suggested that students recognized the benefits of VR training (e.g. ready access to assessment, error identification and how they can be corrected), but the majority felt that it would not replace conventional training methods (95%), although participants recognized the potential for development of VR systems in dentistry. The most common reasons cited for the preference of conventional training were excessive critical feedback (55%), lack of personal contact (50%) and technical hardware difficulties (20%) associated with VR-based training.

Competency-Based Education↗

[Quality of sputum microscopy in the network of tuberculosis bacteriology laboratories in Colombia].

The objective of this study was to evaluate the technical quality of sputum microscopy carried out for diagnostic purposes in the Network of Tuberculosis Bacteriology Laboratories in Colombia. The National Central Reference Laboratory received 6,529 slides for reexamination from the network of 513 sectional, regional, and local laboratories, which contributed 33.2%, 27.6%, and 39.2%, respectively, of the slides. These included all the positive (3,283) and negative (3,246) smears processed during a 4-month period. The reexamination was carried out by six laboratory workers who did not know the origin of the slides or the original diagnosis. When qualitative problems were detected, a second reexamination was done, which significantly increased the percentage of agreement for both the positive results (93.9%) and the negative (98.7%). Overall, the level of agreement was 96.3%. A significant correlation was found (P < 0.05) between good slide preparation and staining and agreement in the readings, as well as between thin smears, presence of fuchsin precipitates, and deficient coloration and conflicting readings (P < 0.05). The highest percentages of agreement were associated with laboratories that performed the largest number of sputum examinations each month (96.5%), and with readings done by experienced, university-trained bacteriologists (96.6%). It is concluded that indirect technical supervision and ongoing training of laboratory personnel are important determinants of the impact of the tuberculosis control program.

Bacteriology↗

Failure of simulation training to change residents' management of oesophageal intubation.

BACKGROUND: There are few scientific reports documenting the effects of simulation training on learning. Issues of scientific validity challenge investigators who measure such outcomes. We perceived a failure of residents to change their technical management of oesophageal intubation after simulation training and sought clarification of this observation. METHODS: Twenty-one residents were randomly exposed to two deliberate oesophageal intubation scenarios, first as a junior assistant (JS group) or as a senior managing resident (SS group), and secondly as a senior managing resident. After the first episode, residents were given an explanation and demonstration of the suggested technical management strategy, including: (i) confirmation of oesophageal intubation with a second direct laryngoscopy; and (ii) concurrent insertion of a second tube into the trachea. After the second episode, we retrospectively sought to confirm improvement in technical management within the SS group by measuring videotaped performances. Questionnaires were sent to the residents before and after reporting their performance results. RESULTS: There were 14 SS and seven JS subjects. Within SS, there was no improvement in "confirmation of oesophageal intubation with direct laryngoscopy" (8/14 vs 9/14) or any improvement in "concurrent insertion of a second ETT (tracheal) tube" (1/14 vs 2/14). Questionnaire responses offered considerable insight into these negative results. CONCLUSIONS: This failure to change may have been secondary to a lack of criterion validity, lack of repetition or a long duration between episodes. The expectations for management were not regarded as being advantageous in simulation, but they were successfully adopted in actual clinical emergencies.

Anesthesiology↗