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PubMed2006

Refractory generalized seizures: response to corpus callosotomy and vagal nerve stimulation.

PURPOSE: The vagal nerve stimulator (VNS) and corpus callosotomy can reduce seizure frequency when seizures are refractory to medications. However, the efficacy and safety of these two procedures have not been compared. This study evaluates the two procedures for generalized seizures. METHODS: All patients with refractory generalized seizures (generalized tonic-clonic, tonic, or atonic) who underwent a corpus callosotomy (anterior or complete) (n = 53) without other forms of epilepsy surgery and those who underwent VNS placement (n = 25) were evaluated for this study. Seizure response and procedure complications were evaluated. RESULTS: For those with a corpus callosotomy and generalized tonic-clonic seizures (n = 50), 79.5% had >or=50% decrease in the frequency of generalized tonic-clonic seizures, and 60% had >or=80% seizure reduction. For those with a VNS and generalized tonic-clonic seizures (n = 21), 50% had >or=50% seizure reduction, and 33% had >or=80% seizure reduction. Tonic and atonic seizures decreased after either VNS or a corpus callosotomy. The complication rate for corpus callosotomy was higher (21% all complications, 3.8% permanent) than that for VNS (8%; none permanent), but complications for both corpus callosotomy and VNS were rarely permanent. CONCLUSIONS: Both corpus callosotomy and VNS are effective in reducing generalized seizures. Corpus callosotomy is associated with greater efficacy but higher risk for complications, although these were generally transient.

Adolescent↗
PubMed1971

Contribution of a general-practitioner hospital.

A properly functioning general-practitioner hospital with good facilities including visiting consultants can greatly lighten the work load of the district general hospital. A general-practitioner hospital is described, run entirely by general practitioners, which cares for over 70% of the inpatients of a group practice. It deals with 98% of all who attend casualty, and carries out almost all of its x-ray work. Its facilities reduce the estimated demand for outpatient appointments at the district general hospital by almost half.The social advantages of a general-practitioner hospital are obvious, and there may be economic advantages as well. Moreover, such a hospital increases the attractiveness of general practice and improves its quality. It is suggested that the general-practitioner hospital is good for the patient, the community, and the doctor-and even the Treasury. There is room for many more.

Economics, Hospital↗
PubMedDate not supplied

Converting from general anesthesia to cervical block anesthesia for carotid endarterectomy.

Between January 1, 1992 and June 30, 1998, vascular and general surgery residents performed 401 carotid endarterectomies (185 cervical block, 216 general anesthesia) under supervision of vascular attending surgeons. In January 1995, cervical block anesthesia was newly instituted. Initially anesthesiologists were randomly assigned to these cases and anesthetic technique was not standardized. At the surgeons' insistence later in the series, three specially trained anesthesiologists routinely administered cervical block anesthesia. As experience grew, surgeons realized that operating time greater than 2 hours and high neck dissections requiring mandibular retraction were poorly tolerated by cervical block anesthesia patients but that repeat carotid endarterectomies could be safely performed. Shunts were selectively inserted if significant electroencephalographic changes occurred or carotid stump pressures were less than 50 mm Hg systolic when general anesthesia was used; neurologic changes occurred when cervical block anesthesia was used; or there was a history of ipsilateral stroke for either anesthetic method. Despite an initial learning curve with cervical block anesthesia, the stroke-mortality rate was similar between the two groups (general anesthesia: 1.9% [four cerebrovascular accidents, two deaths]; cervical block anesthesia: 1.6% [two cerebrovascular accidents, two deaths]). Eight (12%) of the first 66 cervical block anesthesia patients were converted to general anesthesia compared to 2 (1.7%) of the most recent 119 patients with cervical block anesthesia (p = 0.03). After cervical block anesthesia was initiated, seven of the first eight repeat carotid endarterectomies were performed using general anesthesia compared to one of the most recent six repeat cases (p = 0.02). As surgeons' comfort with cervical block anesthesia increased, 94% (100) of the most recent consecutive 106 carotid endarterectomies were performed using this technique. These results suggest that carotid endarterectomy can be performed as safely using cervical block anesthesia as general anesthesia, specialized anesthesiologists are essential to achieve a successful outcome, selected repeat carotid endarterectomies can be performed using cervical block anesthesia, very cephalad lesions are best treated using general anesthesia, and surgical trainees can safely perform carotid endarterectomy under attending surgeon supervision if the operation is carried out expeditiously.

Anesthesia, General↗
PubMed2004

The general practitioner and the surgeon: stereotypes and medical specialties.

OBJECTIVE: To investigate and characterize the professional stereotypes associated with general medicine and surgery among Brazilian medical residents. METHODS: A randomized sample of residents of the General Medicine and Surgery Residence Programs were interviewed and their perceptions and views of general and surgical doctors were compared. RESULTS: The general practitioner was characterized by the residents in general to be principally a sensitive and concerned doctor with a close relationship with the patient; (45%); calm, tranquil, and balanced (27%); with intellectual skills (25%); meticulous and attentive to details (23%); slow to resolve problems and make decisions (22%); and working more with probabilities and hypotheses (20%). The surgeon was considered to be practical and objective (40%); quickly resolving problems (35%); technical with manual skills (23%); omnipotent, arrogant, and domineering (23%); anxious, stressed, nervous, and temperamental (23%); and more decided, secure, and courageous (20%). Only the residents of general medicine attributed the surgeon with less knowledge of medicine and only the surgeons attributed gender characteristics to their own specialty. CONCLUSION: There was considerable similarity in the description of a typical general practitioner and surgeon among the residents in general, regardless of the specialty they had chosen. It was interesting to observe that these stereotypes persist despite the transformations in the history of medicine, i.e. the first physicians (especially regarding the valorization of knowledge) and the first surgeons, so-called "barber surgeons" in Brazil (associated with less knowledge and the performance of high-risk procedures).

Education, Medical↗
PubMed2004

Surgery or general medicine--a study of the reasons underlying the choice of medical specialty.

CONTEXT: The reality of medical services in Brazil points towards expansion and diversification of medical knowledge. However, there are few Brazilian studies on choosing a medical specialty. OBJECTIVE: To investigate and characterize the process of choosing the medical specialty among Brazilian resident doctors, with a comparison of the choice between general medicine and surgery. TYPE OF STUDY: Stratified survey. SETTING: Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP). METHODS: A randomized sample of resident doctors in general medicine (30) and surgery (30) was interviewed. Data on sociodemographic characteristics and the moment, stability and reasons for the choice of specialty were obtained. RESULTS: The moment of choice between the two specialties differed. Surgeons (30%) choose the specialty earlier, while general doctors decided progressively, mainly during the internship (43%). Most residents in both fields (73% general medicine, 70% surgery) said they had considered another specialty before the current choice. The main reasons for general doctors' choice were contact with patients (50%), intellectual activities (30%) and knowledge of the field (27%). For surgeons the main reasons were practical intervention (43%), manual activities (43%) and the results obtained (40%). Personality was important in the choice for 20% of general doctors and for 27% of surgeons. DISCUSSION: The reasons found for the choice between general medicine and surgery were consistent with the literature. The concepts of wanting to be a general doctor or a surgeon are similar throughout the world. Personality characteristics were an important influencing factor for all residents, without statistical difference between the specialties, as was lifestyle. Remuneration did not appear as a determinant. CONCLUSION: The results from this group of Brazilian resident doctors corroborated data on choosing a medical specialty from other countries with different social and educational characteristics. This congruence indicates that the choice involves very similar desires and needs in different settings and has little dependence on the students' educational context.

Adult↗
PubMed1981

"Do I have to be good all day? The timing of delayed reinforcement as a factor in generalization.

Delayed reinforcement, sometimes delivered just after the setting in which the critical behavior had occurred (Early), and sometimes delivered only after several further settings had been encountered (Late), was used to improve a variety of behaviors in seven preschool children, and to control their generalization. Performance of those behaviors was measured in two classroom settings: the Contingent setting, within which performance of the specified behavior determined the latter (Early or Late) reinforcement, and the Generalization setting, in which there were no experimental contingencies, immediate or delayed, for the performance of the same behavior. Performances by all children in the Contingent setting were controlled by delayed reinforcement, whether Early or late. All children showed consistent generalization from the Contingent setting to the Generalization setting during the Late condition, when reinforcement was delivered at the end of the school day. Generalization did not occur during the Early condition, when reinforcement was provided immediately after the Contingent setting (prior to the Generalization setting), unless that condition had been preceded by a Late condition (as it was for S6 and S7). The results suggest that the Late timing of delayed reinforcement was an effective and efficient generalization-promotion technique for performances that did not generalize spontaneously.

Behavior Therapy↗
PubMed1984

Application of the "generalization map" to a self-control intervention with school-aged children.

The assessment of generalization has become a priority of applied behavior analysis. This study provided a thorough assessment of the generality of a comprehensive self-control intervention. This intervention incorporated a number of self-management skills and was designed to increase the math performance of an underachieving student in a regular elementary school classroom. All possible classes of generalization as outlined by Drabman, Hammer, and Rosenbaum (1979) were assessed. An ABAB design with follow-up was used to determine the effectiveness of the intervention for the treated student's math performance in the school setting as well as the degree of generalization across the following untreated dimensions: behavior (disruptiveness); setting (home); subject (classmate); and time period (follow-up). The effective intervention produced: subject, behavior, subject-behavior, setting, subject-setting, behavior-setting, subject-behavior-setting, time, subject-time, setting-time, subject-setting-time, and subject-behavior-setting-time generalization. Generalization was not obtained for behavior-time, subject-behavior-time, and behavior-setting-time generalization. Features of this intervention which may have promoted generalization are discussed.

Behavior Therapy↗
PubMed1998

Effects of variable-interval value and amount of training on stimulus generalization.

In Experiment 1 pigeons pecked a key that was illuminated with a 501-nm light and obtained food by doing so according to a variable-interval (VI) schedule of reinforcement, the mean value of which differed across groups: either 30 s, 120 s, or 240 s. The pigeons in all three groups were trained for 10 50-min sessions. Generalization testing was conducted in extinction with different wavelengths of light. Absolute and relative generalization gradients were similar in shape for the three groups. Experiment 2 was a systematic replication of Experiment 1 using line orientation as the stimulus dimension and a mean VI value of either 30 s or 240 s. Again, gradients of generalization were similar for the two groups. In Experiment 3 pigeons pecked a key that was illuminated with a 501-nm light and obtained food reinforcers according to either a VI 30-s or a 240-s schedule. Training continued until response rates stabilized (> 30 sessions). For subjects trained with the 30-s schedule, generalization gradients were virtually identical regardless of whether training was for 10 sessions (Experiment 1) or until response rates stabilized. For subjects trained with the VI 240-s schedule, absolute generalization gradients for subjects trained to stability were displaced upward relative to gradients for subjects trained for only 10 sessions (Experiment 1), and relative generalization gradients were slightly flatter. These results indicate that the shape of a generalization gradient does not necessarily depend on the rate of reinforcement during 10-session single-stimulus training but that the effects of prolonged training on stimulus generalization may be schedule dependent.

Analysis of Variance↗
PubMedDate not supplied

Dental health behavior of children with BBTD treated using general anesthesia or sedation, and of their parents in a recall examination.

The aim of the study was to assess the dental status and dental health behavior of children with Baby Bottle tooth Decay treated using general anesthesia or sedation, and the dental health behavior of their parents in a recall examination. The study population consisted of sixty-five children, among whom thirty-four were treated using general anesthesia and thirty-one using sedation. The recall examination included a full dental examination from which the children's dif index could be drawn. Loe's plaque index was used to assess the amount of plaque on the teeth. Sociodemographic information and the dental health behavior of the parents and children were obtained. Plaque index was similar in the general anesthesia and sedation groups. The parents of the general anesthesia group were younger than the parents of the sedation group (35.0 +/- 6.7 and 38.8 +/- 6.2 for the fathers, and 32.4 +/- 5.9 and 34.9 +/- 5.3 for the mother, respectively). More firstborn children were treated using general anesthesia than using sedation. Significantly more siblings were treated in the sedation group. Children treated using sedation had significantly more siblings treated in the same mode. Parents of the children in the general anesthesia group were significantly more involved in brushing their children's teeth than the other group. In the sedation group, more children brush their teeth without parental help. Significantly more children in the general anesthesia group reduced their sweet consumption than in the sedation group. We conclude that preventive behaviors were more frequently adopted among the families of children treated using general anesthesia.

Adult↗
PubMed2001

The use of general anaesthesia for orthodontic extractions.

AIM: The aims of the study were to evaluate 1) the uptake of general anaesthesia 2) the dental factors influencing use of general anaesthesia for routine orthodontic extractions. RESEARCH DESIGN: Retrospective cross-sectional. PARTICIPANTS: All patients, aged 16 years and under (n=145), currently undergoing orthodontic treatment at the University Dental Hospital of Manchester, who had received extractions, for their current course of treatment. METHOD: Patients were asked to complete a questionnaire after appliance adjustment. MAIN OUTCOME MEASURES: 1) type of anaesthesia received for the most recent orthodontic extractions 2) whether a choice of anaesthesia was given 3) number of permanent teeth removed for the current course of orthodontic treatment 4) previous experience of general anaesthesia. RESULTS: The response was 87%. Twenty-two per cent of patients received general anaesthesia, 64% local anaesthesia and 14% inhalation sedation. Sixty-five per cent of patients were not given a choice of anaesthesia for extractions. Stepwise logistic regression analysis revealed that a patient was more likely to receive a general anaesthetic if: 1) they had received a GA in the past (for fillings or extractions) 2) more than four teeth were extracted. CONCLUSIONS: Local anaesthesia was predominantly used for orthodontic extractions although the use of general anaesthesia was still quite high. The majority of patients were not given a choice of anaesthesia for routine extractions. Previous exposure to general anaesthesia and removal of more than four teeth increased the likelihood of a patient receiving general anaesthesia.

Adolescent↗
PubMed2001

The addition of interscalene block to general anesthesia for patients undergoing open shoulder procedures.

Several studies have demonstrated that interscalene brachial plexus anesthesia alone decreases postoperative pain, nausea, vomiting, urinary retention, and unplanned hospital admissions compared with general anesthesia alone. Anecdotal evidence suggests that an interscalene block combined with general anesthesia decreases unwanted effects of general anesthesia following open shoulder surgery. We compared the effect of combined interscalene block and general anesthesia with general anesthesia alone on Aldrete scores, length of postanesthesia care unit (PACU) stay, verbal rating scale (VRS) pain scores, incidence of postoperative narcotic administration and nausea, and patient satisfaction in a convenience sample of 52 men and women, ASA physical status I, II, or III. Group 1 received standard general anesthesia alone. Group 2 received an interscalene block in combination with general anesthesia using a standard technique. Group 2 had significantly lower VRS scores than group 1 while in the PACU, on the day of surgery, and on postoperative days 1 and 2. Overall satisfaction with the anesthetic technique was higher in the group 2 than in group 1. Results suggest that adding an interscalene block to general anesthesia can be of value in today's outpatient-dominated surgery schedule.

Adult↗
PubMed2001

Referral of children to a general anaesthetic dental service in Tayside.

OBJECTIVE: To determine the adequacy of child referral for dental general anaesthesia (DGA) by local dental practitioners, given the recent guidance document to dentists from the General Dental Council and in addition, to determine the subsequent treatment and factors which influence treatment selection. DESIGN: A prospective study. SETTING: Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee. SUBJECTS: Children [n = 84] who were referred for dental extractions under general anaesthetic over a three month period. RESULTS: Non-surgical dental extractions under general anaesthetic were requested in nearly 90% of referrals. In the majority of cases, the referral was deemed inadequate; e.g. the medical history was not mentioned in the majority of cases (85.7%) despite nearly one-fifth of patients having a relevant medical history. In general, referring practitioners under-estimated the extent of disease, requiring treatment plans to be changed in 76% of cases; all changes represented an increase in the number of dental extractions undertaken. The most common reasons for general anaesthetic use were: multiple dental extractions (73.8%); the patient's anxiety (63.1%); and patient's age (41.7%). As an alternative to general anaesthesia, treatment was undertaken successfully using inhalation sedation in nearly 15% of cases. CONCLUSION: Dental extractions under general anaesthetic are still a common reason for referral. Referring practitioners frequently provide inadequate information, in addition to under-estimating the treatment required. Alternative forms of anxiety management are available and should be considered for children requiring dental extractions.

Adolescent↗
PubMed1992

Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department.

Knowledge of the range of pediatric illness presenting to a general emergency department (ED) is needed to optimize the quality of care delivered there. It was hypothesized that the pediatric population treated at a general ED exhibited a broad range of medical complaints, while differing significantly from children seen in a pediatric ED. General ED records from 1 week each season were reviewed, and patient age, chief complaint, diagnosis, time of arrival, season, and disposition were recorded. Data on 874 patients were analyzed and compared with pediatric ED data. General ED patient age affected chief complaint, diagnosis, and admission rate (9.5% less than or equal to 1 year admitted vs 2.6% greater than 1 year, P less than .001). General ED patients were older (7.9 vs 6.0 years, P less than .001) and admitted less frequently (3.8% vs 11%, P less than .001). Admission rates varied by arrival time only at the general ED, where minor trauma was more common (41% vs 22%, P less than .001). It is concluded that a wide range of pediatric illness is treated in a general ED, supporting the decision to have pediatric emergency physicians on staff, and that significant differences exist in the spectrum and frequency of pediatric illness seen in a general ED and pediatric ED.

Adolescent↗
PubMed2006

[Effects of general anesthesia for cesarean section on infants].

OBJECTIVE: To determine the safety of general anesthesia during cesarean section for neonates. METHODS: Singleton pregnant women for whom elective cesarean sections were planned after 37 gestation weeks were allocated to general anesthesia or epidural anesthesia. After preoxygenation, general anesthesia was induced with fentanyl (2.0 microg/kg), propofol (1.5 mg/kg) and vencuronium (0.08 mg/kg) followed by tracheal intubation. Oxygen-nitrous oxides (50%) was inhaled before delivery. Epidural anesthesia was performed at L(1 - 2) or L(2 - 3) on the left lateral decubitus position with 1.73% lidocaine carbonate (including 1:200 000 adrenaline). We studied arterial samples withdrawn from the infants 30 min after birth for the pH, PaO(2), PaCO(2), SPO(2) and Hct. Neonatal behavioral neurological assessments (NBNA) 3 - 5 days after birth were recorded. RESULTS: (1) The pH, PaO(2), PaCO(2), SPO(2) and Hct in the general anesthesia group were 7.34 +/- 0.08, (40 +/- 11) mm Hg, (73 +/- 17) mm Hg, (96.8 +/- 1.0)%, and (53 +/- 5)%, while in the epidural anesthesia group were 7.35 +/- 0.05, (41 +/- 8) mm Hg, (71 +/- 17) mm Hg, (96.6 +/- 1.0)%, and (54 +/- 6)%. (2) NBNA scores: In the general anesthesia group, neonatal adaptive capacity, passive tone, active tone, primary reflexes and general status were 12.6 +/- 0.7, 7.2 +/- 0.7, 7.4 +/- 0.6, 5.6 +/- 0.8, and 5.9 +/- 0.3 respectively. While in the epidural anesthesia group they were 13.4 +/- 0.8, 7.3 +/- 0.5, 7.3 +/- 0.8, 5.6 +/- 0.6, and 5.9 +/- 0.3 respectively. No significant difference was seen (P > 0.05) between the general anesthesia group and the epidural anesthesia group in NBNA scores, mean pH, PaO(2), PaCO(2), SPO(2) and Hct of newborn infants. CONCLUSION: It study suggests that general anesthesia for the elective cesarean section does not influence significantly the outcome of the newborn infants.

Adult↗
PubMed1991

Presidential address, 1990. Should general surgery be redefined?

The definition of general surgery, adopted by the Canadian Association of General Surgeons in 1983, has raised the expectations of the general surgical community. It was thought, at the time, that a definition that took into account the broad aspects of the specialty would make general surgeons more aware of their role in clinical and teaching activities, counteract the negative effects of subspecialization and prevent further fragmentation. Because of the many changes that have taken place in the 1980s, the author considered that a review of that definition was justified. To address this issue, the author has attempted to answer the following two questions: What are general surgeons doing in 1990? To what extent are they trained to do what they are supposed to do, according to the definition of general surgery? Data were obtained from la Régie de l'assurance-maladie du Québec in order to answer to the first question; with respect to the second, a questionnaire was sent to the chairmen of the 16 Canadian departments of surgery. The results of the study indicate that the definition of general surgery has not kept up with the times and should be revised. The author suggests that a modified definition should include primary and secondary components of the specialty in order to allow some flexibility. In the event that such a change seems appropriate, head and neck surgery should be only a secondary component of general surgery.

Canada↗
PubMed1990

Canadian general surgery: alive and well.

General surgery in Canada is alive and well because general surgeons remain versatile and adaptable. If this were not the case, the specialty of general surgery would go the way of the dinosaur. The continuing evolution of general surgery can only be maintained by reviewing the following: (a) training; (b) continuing education; (c) maintenance of competence; (d) manpower and economic aspects; and (e) interaction of general surgeons with other surgeons and specialties. The Canadian Association of General Surgeons will continue to play a vital role in maintaining liaison between all types of general surgeons across the country and help, in any way possible, to support the ever-changing face of general surgery.

Canada↗
PubMed2000

Top-cited dermatology authors publishing in 5 "high-impact" general medical journals.

BACKGROUND: In addition to publishing in the dermatologic literature, some dermatologists also publish articles in the general medical journals, which enjoy wide circulation and whose articles are often cited. OBJECTIVE: To identify articles and citations to these articles that the most frequently cited authors in the dermatologic literature published in highly cited general medical journals. DESIGN: We obtained a citation database from the Institute of Scientific Information, Philadelphia, Pa, that identified all articles published by the top-cited authors in the dermatologic literature in 5 "high-impact" general medical journals. SETTING: The 5 high-impact general medical journals with the historically highest impact factors. SUBJECTS: Two hundred top-cited authors in dermatology journals and their coauthors. MAIN OUTCOME MEASURE: Number of citations to articles published in 5 high-impact general medical journals. RESULTS: From 1981 to 1998, 120 of the 200 top-cited dermatology authors published a total of 674 papers in the 5 most highly cited general medical journals. Original articles published in these high-impact general medical journals were cited an average 7.5 times more often than articles published in dermatology journals. CONCLUSIONS: Top-cited authors in dermatology journals also frequently publish in the leading 5 high-impact general medical journals. Publications in these journals by dermatologists are often highly cited.

Databases as Topic↗
PubMed1998

General pediatricians, pediatric subspecialists, and pediatric primary care.

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.

Adult↗