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PubMed2002

Trends in aortic aneurysm surgical training for general and vascular surgery residents in the era of endovascular abdominal aortic aneurysm repair.

HYPOTHESIS: The emergence of endovascular abdominal aortic aneurysm (AAA) repair may negatively impact the open AAA experience of general surgery residents. METHODS: Prospectively collected data on general and vascular surgery resident training in AAA repair for a 5-year period (1997 to 2001) at a single institution were retrospectively reviewed. Five general surgery residents and one vascular resident completed training yearly. Institutional volume of open and endovascular repair of AAA was also assessed. RESULTS: The cumulative mean general surgical resident experience with open AAA repair fell significantly over a 5-year period; 9.5 +/- 2.5 cases were performed per general surgical resident finishing in 1997, 7.5 +/- 0.3 cases in 1998, 4.6 +/- 0.4 cases in 1999, 4.0 +/- 1.3 cases in 2000, and 4.2 +/- 1.0 cases in 2001 (P =.03). The vascular resident experience with open AAA repair did not change significantly over the 5-year period. However, the active development of an endovascular AAA program increased total AAA exposure of the vascular resident from 26 cases in 1997 to a mean of 70 cases in 2000 and 2001. The institution volume of open nonsuprarenal AAA repairs fell 38% during the 5-year period (P =.33) during a period when endovascular AAA repair increased from 9 (1996) to 55 (2000) cases (P <.001). The complexity of open AAA surgery also increased: 23.3% of open cases (7/30) in 2000 were juxta/pararenal versus 2.9% (1/35) in 1996 (P =.05). CONCLUSION: The introduction of endovascular AAA repair may have negatively impacted general surgical resident training in open AAA repair. The number of open AAA cases declined, and their complexity significantly increased. Many uncomplicated AAAs were managed with endovascular means. At programs with such a paradigm shift in AAA treatment, expectation that general surgery residents gain the proficiency necessary to safely perform AAA repair without additional training may be unrealistic.

Aortic Aneurysm, Abdominal↗
PubMed2006

Generalization decrement in human contingency learning.

An association between a cue and an outcome will generalize to a similar novel cue to some extent, but not completely. Learning theorists refer to the discrepancy between responding elicited by the original cue and the novel cue as a generalization decrement. Two experiments used a contingency learning task with human participants to compare the size of a generalization decrement between configurations of cues that were altered by adding or subtracting compositional elements. The results suggest that adding elements to a configuration can produce a generalization decrement, but removing elements produces a more robust generalization decrement. Furthermore, the generalization decrement caused by adding elements was not likely to be caused by competing orienting responses. The results are used to contrast Pearce's (1987, 1994) and Wagner's (2003) models of stimulus generalization.

Cues↗
PubMed1998

The differences in electroencephalographic changes in patients undergoing carotid endarterectomies while under local versus general anesthesia.

OBJECTIVE: This study compared the electroencephalographic (EEG) changes occurring during carotid occlusion in 225 consecutive patients undergoing carotid endarterectomies performed by two surgeons, one using local and the other using general anesthesia. METHODS: A retrospective review of patients undergoing carotid endarterectomies for carotid occlusive disease was conducted. EEG changes associated with intraoperative ischemia (decreased amplitude, generalized slowing, and loss of fast activity) resulting in the need for an indwelling arterial shunt were recorded for the two anesthesia groups. To determine the similarities or differences between the two groups, the groups were compared regarding age, risk factors, and indications for surgery. RESULTS: Significant EEG changes were noted in 6 of 96 patients (6.3%) in the local anesthesia group versus 19 of 121 patients (15.7%) in the general anesthesia group. EEG changes consisted solely of generalized slowing in the local anesthesia group, whereas a more varied spectrum was observed in the general anesthesia group. The two groups were similar regarding age and risk factors. Although the local anesthesia group had more asymptomatic patients, symptomatic patients did not have a greater incidence of EEG changes. CONCLUSION: There is a large difference in EEG changes potentially requiring shunt placement in patients undergoing surgery while under local (6.3%) versus general (15.7%) anesthesia. This could not be explained based on age, risk factors, interpretation of EEG findings, or indications between the two groups. We conclude that EEG monitoring may be insensitive and may fail to detect ischemia in patients who are under regional anesthesia. Alternately, the presence of general anesthetics may alter the character of the EEG findings and increase the sensitivity of EEG monitoring to ischemic events.

Anesthesia, General↗
PubMed1997

Generalization of D-, L- and DL-chlorpheniramine and zolantidine to the discriminative stimulus effects of cocaine and methamphetamine.

We recently demonstrated that some H-antagonists have cocaine or methamphetamine-like discriminative stimulus effects. In the present study, the effects of optical isomers of chlorpheniramine (D-, L- and DL-forms) on the discriminative stimulus effects of cocaine and methamphetamine were examined in rats trained to discriminate between cocaine (10.0 mg/kg) or methamphetamine (1.0 mg/kg) and saline, to determine whether these effects of H1-antagonists are mediated by the blockade of H-receptors. In generalization tests with optical isomers of chlorpheniramine, the D-, L- and DL-forms all completely generalized to the discriminative stimulus effects of cocaine, but did not generalize to those of methamphetamine. Dose-generalization by the optical isomers of chlorpheniramine to the discriminative stimulus effects of cocaine did not correlate with the H-antagonistic potency of these drugs. These results suggest that all of the optical isomers of chlorpheniramine have cocaine-like discriminative stimulus effects, but that these effects are not mediated by H1-receptor blockade. On the other hand, the H2-antagonist, zolantidine, generalized to the discriminative stimulus effects of methamphetamine, but not to those of cocaine, suggesting that zolantidine may have methamphetamine-like discriminative stimulus effects. In the present study, GBR12909 (dopamine uptake inhibitor) completely generalized to the discriminative stimulus effects of cocaine, but not to those of methamphetamine, whereas apomorphine (dopamine receptor agonist) generalized more potently to the discriminative stimulus effects of methamphetamine than to those of cocaine. These findings imply that although the dopaminergic system plays an important role in the discriminative stimulus effects of both cocaine and methamphetamine, there may be differences between their effects.

Animals↗
PubMed2000

Short-acting general anaesthesia facilitates therapeutic ERCP in frail elderly patients with benign extra-hepatic biliary disease.

AIMS AND OBJECTIVES: To ascertain whether therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease in frail elderly patients with comorbid conditions can be safely undertaken in a district general hospital, and whether the procedure is facilitated by the use of short-acting general anaesthesia. SETTING: District general hospital in South East England. DESIGN OF STUDY: Clinical study of 25 consecutive patients with benign biliary disease. METHODS: Describes the process of bile duct clearance by therapeutic ERCP under short-acting general anaesthesia in 25 patients with co-morbidity aged > or = 80 years and gives details of the general anaesthesia and monitoring. RESULTS: Twenty-two patients had their bile ducts successfully cleared locally and one patient was stented for a benign biliary stricture. The ampullae of two other patients were lying within diverticula, which hindered cannulation and only pancreatograms were obtained; one of the patients had a successful bile duct clearance at a tertiary centre, the other refused further intervention. Complications (melaena, bronchopneumonia and a Clostridium difficile infection) occurred in two patients (8%). There was no morbidity associated with the anaesthesia, and no mortality occurred within 30 days of the procedure. CONCLUSIONS: Bile duct clearance by therapeutic ERCP can be safely carried out in frail elderly patients in a district general hospital and the process is facilitated by the use of short-acting general anaesthesia. The importance of optimizing the patient's condition before ERCP, and not overfilling the pancreatic duct, is highlighted.

Aged↗
PubMed2005

General anaesthesia does not improve outcome in opioid antagonist detoxification treatment: a randomized controlled trial.

AIM: Opioid detoxification by administering opioid-antagonists under general anaesthesia has caused considerable controversy. This study is conducted to determine whether rapid detoxification under general anaesthesia results in higher levels of opioid abstinence than rapid detoxification without anaesthesia. DESIGN: Randomized controlled open clinical trial from September 1999 to August 2001. SETTING: Four addiction centres in collaboration with three general hospitals in the Netherlands. PARTICIPANTS: A total of 272 opioid-dependent patients whose previous attempts to abstain were unsuccessful. INTERVENTION: Patients received rapid detoxification with general anaesthesia (RD-GA) or without general anaesthesia (RD). MEASUREMENTS: Urine screens and an interview (EuropASI) to assess opioid abstinence; two questionnaires (SOOS, OOWS) to measure withdrawal symptoms and one to measure craving (VAS). FINDINGS: One month after the intervention 62.8% of the patients in the RD-GA group and 60.0% in the RD group were abstinent for opioids (P = 0.71). No adverse events or complications occurred during RD; however, in the RD-GA group, five adverse events necessitated admission to a general hospital. The average 1-month cost for RD was Euros 2517 versus Euros 4439 for RD-GA. CONCLUSIONS: Rapid detoxification under general anaesthesia did not result in higher levels of opioid abstinence than rapid detoxification without anaesthesia. The cost of the former intervention was much higher.

Adult↗
PubMed1998

An operation under general anesthesia as a risk factor for age-related cognitive decline: results from a large cross-sectional population study.

OBJECTIVE: To evaluate the factor 'operation under general anesthesia' as a possible risk factor for age-related cognitive decline. DESIGN: A retrospective, population-based, cross-sectional study. SETTING: Maastricht Aging Study (MAAS), Maastricht, The Netherlands. PARTICIPANTS: 1257 normal healthy subjects aged 24 to 86 years. Of the 1257 healthy subjects, 946 subjects appeared to have undergone at least one operation under general anesthesia. MEASUREMENTS: The history of an operation under general anesthesia, number of operations, duration of anesthesia, cognitive performance, subjective health, and subjective memory were measured. RESULTS: A history of an operation under general anesthesia, the number of operations, and the total duration of anesthesia significantly contributed to the number of subjective health-related complaints but did not predict cognitive performance or memory complaints. Subjects with a history of an operation under general anesthesia felt less healthy than subjects who had never undergone an operation under general anesthesia. No interactions with age were found. CONCLUSION: The present study found no support for the notion that a history of an operation under general anesthesia is a determinant or risk factor for accelerated age-related cognitive decline.

Adult↗
PubMed1990

Mental illness and admission to general hospitals: a register investigation.

Admissions to psychiatric departments and general hospitals in an 8-year period were studied for the 17- to 49-year-old population in 2 Danish municipalities. Information was extracted from the National Patient Register and the Danish Psychiatric Register, registers containing information on all admissions to nonpsychiatric and psychiatric departments, respectively, in Denmark. Fourteen percent of the patients who had been admitted at least once to a general hospital (or 7.5% of the background population) had an indication of a mental disorder. They comprised one fourth of all general admissions of the population during the 8-year period. Patients who had been admitted to a general hospital had a 4 times greater risk of having been admitted to a psychiatric department than the rest of the population and the risk increased markedly with number of general admissions. A pronounced association was found between the number of admissions to general hospitals and psychiatric departments; i.e., both types of admissions clustered in some individuals. The excessive general admissions of psychiatric patients were found to be correlated to all types of psychiatric diagnoses, but was less prominent in nonorganic psychoses. The implication is that there is a very close association between somatic and psychiatric morbidity and that the mentally disturbed use a great part of the nonpsychiatric health services.

Adolescent↗
PubMed1990

Coronary arteriography in a district general hospital: feasibility, safety, and diagnostic accuracy.

OBJECTIVE: To determine the feasibility, safety, and diagnostic accuracy of coronary arteriography in the radiology department of a district general hospital using conventional fluoroscopy and videotape recording. DESIGN: Observational study of the feasibility and safety of coronary arteriography in a district general hospital and analysis of its diagnostic accuracy by prospective within patient comparison of the video recordings with cinearteriograms obtained in a catheter laboratory. SETTING: Radiology department of a district general hospital and the catheter laboratory of a cardiological referral centre. SUBJECTS: 50 Patients with acute myocardial infarction treated with streptokinase who underwent coronary arteriography in a district general hospital three (two to five) days after admission. 45 Of these patients had repeat coronary arteriography after four (three to seven) days in the catheter laboratory of a cardiological referral centre. MAIN OUTCOME MEASURES: Incidence of complications associated with catheterisation and the sensitivity and specificity of video recordings in the district general hospital (judged by two experienced observers) for identifying the location and severity of coronary stenoses. RESULTS: Coronary arteriograms recorded on videotape in the district general hospital were obtained in 47 cases and apart from one episode of ventricular fibrilation (treated successfully by cardioversion) there were no complications of the procedure. 45 Patients were transferred for investigation in the catheter laboratory, providing 45 paired coronary arteriograms recorded on videotape and cine film. The specificity of the video recordings for identifying the location and severity of coronary stenoses was over 90%. Sensitivity, however, was lower and for one observer fell below 40% for lesions in the circumflex artery. A cardiothoracic surgeon judged that only nine of the 47 video recordings were adequate for assessing revascularisation requirements. CONCLUSIONS: Coronary arteriography in the radiology department of a district general hospital is safe and feasible. Nevertheless, the quality of image with conventional fluoroscopy and video film is inadequate and will need to be improved before coronary arteriography in this setting can be recommended.

Aged↗
PubMed1996

Mental disorders in public, private nonprofit, and proprietary general hospitals.

OBJECTIVE: The authors' goal was to assess the effects of facility ownership on the characteristics of psychiatric inpatients treated in public, private nonprofit, or proprietary general hospitals. METHOD: Data from the 1993 National Hospital Discharge Survey were analyzed to determine the number, sociodemographic and diagnostic composition, and treatment characteristics of patients with primary mental disorders discharged from public, private nonprofit, and proprietary general hospitals. RESULTS: An estimated 1.83 million patients with a primary mental disorder diagnosis were discharged from general hospitals in 1993; the number of such discharges in the National Hospital Discharge Survey, which excluded federal general hospitals, was 13,086. These patients were unevenly distributed among public (9.4%), private nonprofit (78.9%), and proprietary (11.7%) hospitals. Psychiatric patients of public and private nonprofit hospitals were more likely to be diagnosed with schizophrenia (public: 23.4%, nonprofit: 18.8%, proprietary: 12.6%), a comorbid substance-related disorder (public: 29.9%, nonprofit: 31.0%, proprietary: 17.4%), a personality disorder (public: 11.6%, nonprofit: 11.3%, proprietary: 4.7%), or a general medical disorder (public: 62.4%, nonprofit: 57.4%, proprietary: 41.1%) than patients of proprietary hospitals. Uninsured psychiatric patients were far more common at public hospitals than at the other types of facilities (public: 17.0%, nonprofit: 9.9%, proprietary: 6.4%). CONCLUSIONS: Public general hospitals play an important role in caring for uninsured patients with severe mental illness. Before widespread closures occur in the public general hospital sector, it is critical that policy makers identify and develop resources to replace the care these institutions currently provide to poor patients with severe psychiatric disorders.

Adolescent↗
PubMed2002

Psychiatric units in Brazilian general hospitals: a growing philanthropic field.

BACKGROUND: Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. OBJECTIVE: To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. METHOD: A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. RESULTS: Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. CONCLUSION: The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.

Aged↗
PubMed1998

Generalized tonic and tonic-clonic seizures of childhood.

In a retrospective analysis of all our patients with seizure onset prior to age 16 years, 25 patients with primary generalized tonic (n = 10) or tonic-clonic (n = 15) seizures were identified. These patients constituted 5.7% of the total seizure patient population in our institute between the ages of 1 month and 16 years. The natural history of generalized tonic-clonic seizures is known to be benign; however, that of isolated primary generalized tonic seizures is not clear. Therefore, an attempt was made to characterize the patients suffering from primary generalized tonic seizures and determine their outcome. Analysis of our patient population shows that both seizure types are characterized by early onset of generalized seizures that appear in normally developed children with a normal electroencephalographic background. The children usually respond quickly to antiepileptic drugs. A long-term follow-up (mean period of 7.6 years) was possible in 84% of the patients, and showed that 95% of them were seizure free at the end of the follow-up period. There was no significant difference between the two groups in regard to age of onset, family history, and seizures at follow-up. In conclusion, the natural history of patients with generalized tonic seizures is similar to the benign course of those with generalized tonic-clonic seizures.

Adolescent↗
PubMed1996

Dyshormia revisited: generalized seizures and arousal.

Niedermeyer has described dyshormia, or deviant arousal, and related this EEG pattern to generalized seizures. We describe a patient with generalized seizures who in the same EEG had spindles transforming into generalized epileptiform discharges and generalized epileptiform discharges transforming into spindles. This suggests that similar neural circuitry may underlie both spindles and generalized epileptiform discharges, and that the mechanism described by Gloor for feline generalized penicillin induced epilepsy may also apply to some humans with generalized epilepsies.

Adult↗
PubMed1986

The general hospital psychiatrist: too many tasks and too few roles?

What should the general hospital psychiatrist do, and how should he do it? In psychiatric settings, psychiatrists may legitimately confine their attention to those patients whose disorders can be classified according to ICD-9, but in general hospital settings, the same approach defines a very restricted range of activities. Evidence is reviewed which highlights the differences between psychiatric disorders encountered in psychiatric hospitals and those found in primary care or general hospital settings. Different activities proposed for the general hospital psychiatrist, and the results of research comparing these, are reviewed. A recent study is discussed in which alteration of the psychiatrist's method of practice in a general medical unit produced considerable changes in the pattern of psychiatric referrals. Evaluation of the efficacy of their interventions should remain the ultimate goal of general hospital psychiatrists. This can be adequately undertaken only by means of better understanding of the process by which general hospital patients attract psychiatric referral.

Hospitals, General↗
PubMed2003

The effects of epidural and general anesthesia on tissue oxygenation.

UNLABELLED: The risk of wound infections is inversely related to subcutaneous tissue oxygen tension. General anesthesia increases local blood flow by direct vasodilation and central inhibition of thermoregulatory vasoconstriction. Epidural anesthesia can increase perfusion in blocked regions by decreasing sympathetic tone. We therefore tested the hypothesis that epidural anesthesia increases tissue oxygen tension in awake and anesthetized subjects. Fifteen healthy volunteers underwent epidural, general, and combined epidural and general anesthesia. Subcutaneous tissue oxygen tension was measured using tonometers in the lateral upper arm and the lateral thigh. Epidural anesthesia to a T10 level was maintained with 0.75% mepivacaine. General anesthesia was maintained with 1.5% sevoflurane in 30% oxygen; 30% inspired oxygen was given via a sealed facemask during baseline and epidural anesthesia. Baseline subcutaneous tissue oxygen tensions for arm and thigh were 57 +/- 11 and 54 +/- 8 mm Hg, respectively. Epidural anesthesia significantly increased tissue oxygenation in the thigh by 9 mm Hg, to 63 +/- 7 mm Hg, without increasing arm oxygenation. Tissue oxygenation in the arm and thigh were similar during general anesthesia alone, 58 +/- 11 and 63 +/- 12 mm Hg. Arm oxygenation remained unchanged with the addition of epidural anesthesia; however, thigh subcutaneous oxygen partial pressure increased 8 +/- 3 mm Hg, from 63 +/- 12 to 71 +/- 9 mm Hg. Although epidural anesthesia increased tissue oxygenation significantly with and without general anesthesia, the magnitude of this increase might be of marginal clinical importance in regard to surgical wound infections. IMPLICATIONS: Epidural anesthesia significantly increased subcutaneous tissue oxygenation in the thigh both with and without general anesthesia. Although each increase was statistically significant, previous work suggests that the magnitude of these changes is unlikely to markedly reduce the risk of surgical wound infection.

Adult↗
PubMed1992

Generalization and maintenance of preschool children's social skills: a critical review and analysis.

This paper summarizes the results of a retrospective review of generalization in the context of social skills research with preschool children. A review of studies from 22 journals (1976 to 1990) that assessed generalization as part of social interaction research provided information concerning the prevalence of studies that have assessed generalization, common practices concerning the production and assessment of generalization, and the overall success of obtaining generalization and maintenance of social behaviors. A comparison of the most and least successful studies, with respect to generalization, revealed some differences concerning the practices employed by studies within each group. Differences differentially related to the production of generalization are discussed and recommendations are provided to guide and support future research efforts.

Behavior Therapy↗
PubMed1997

Programming generalization of social skills in preschool children with hearing impairments.

The efficacy of a social skills training package in producing stimulus generalization, both with and without the systematic application of generalization programming techniques, was evaluated with 5 preschool children with hearing impairments. The evaluation was conducted within a multiple baseline design. Generalization probes were conducted daily. The social skills training package was implemented in a training setting and produced high, stable rates of social interaction in that setting. However, generalization of the social skills to new teachers, peers, and play activities did not occur until generalization programming strategies were applied in the original training setting. Using sufficient stimulus exemplars and contacting natural consequences appeared to be the key strategies for promoting generalization of social interaction. In addition, the use of supplementary procedures (e.g., a fluency criterion and treatment integrity checks) may have contributed to stimulus generalization.

Behavior Therapy↗
PubMed2000

Clinical outcomes after carotid endarterectomy: comparison of the use of regional and general anesthetics.

OBJECT: The authors analyzed their series of carotid endarterectomies (CEAs), which were performed after administration of either a general or regional anesthetic, to determine whether the choice of anesthetic affected patients' clinical outcomes and length of hospital stay. METHODS: A series of 803 consecutive CEAs performed between July 1990 and February 1999 was reviewed. Cases were analyzed for patient demographics, comorbid medical states, and perioperative complications. Contingency-table statistical analysis was used to compare the incidence of comorbid medical states and perioperative complications between patients who underwent CEA in which either a regional or general anesthetic was used. Student's t-test was used to compare the length of hospital stay and mean patient age. A regional anesthetic was used for 632 CEAs, and a general anesthetic was used for 171 operations. There were no statistically significant intergroup differences in demographics or comorbid medical states. The incidence of perioperative stroke and death did not differ significantly between the regional (2.7%) and the general anesthetic groups (2.3%). However, the incidence of nonneurological, nonfatal complications was significantly less in the regional anesthetic (1.6%) than in the general anesthetic group (14.6%, p<0.0001). Patients undergoing CEA in which a regional anesthetic was used had a significantly lower incidence of cardiopulmonary complications (myocardial infarction and postoperative intubation), cervical complications (neck hematomas and cranial nerve injuries), and urological complications (urinary retention) than patients who underwent surgery after receiving a general anesthetic. CONCLUSIONS: Patients undergoing CEA in which a regional anesthetic was used had significantly fewer nonneurological, nonfatal complications, particularly cardiopulmonary complications, than similar patients surgically treated after induction of general anesthesia.

Aged↗