Surgical educator preferences regarding key objective structured clinical examination topics.

BACKGROUND: Numerous methods are used for assessing the performance of surgical residents and students. Unfortunately, these same methods are often unsatisfactory. One technique that is gaining increased favor is the Objective Structured Clinical Examination (OSCE). It is unclear what areas of evaluation might best be included in such an examination so as to optimize its value. Therefore, this study evaluated the opinions of an international body of surgical educators. METHODS: A survey was distributed to 674 attending surgical educators; it asked respondents to select and rank the five most important topics from four areas. These areas included 84 topics from History Taking, Physical Examination, Data Interpretation, and Surgical Technique. A weighted score was calculated for each topic by assigning points according to a Likert scale ranking. RESULTS: Among 674 surveys distributed, 243 responses (36.1%) were received; 25 of the 243 responses were excluded, for a usable response rate of 218/674 (32.3%). The five highest ranked topics were (History Taking) "abdominal pain" 29.2%, "breast mass" 10.8%, "gastrointestinal bleeding" 8.5%, "bowel obstruction" 8.5%, "trauma" 7.2%; (Physical Examination) "acute abdomen" 28.9%, "trauma survey" 18.2%, "breast examination" 15.8%, "peripheral vascular" 8.9%, "cardiopulmonary" 7.5%; (Data Interpretation) "chest X ray" 21%, "abdominal series" 20.2%, "CT scan" 19.6%, "mammogram" 10.1%, "cervical spine films" 5.2%; and (Surgical Technique) "central line" 16.1%, "basic suture skills" 14.2%, "bowel anastomosis" 8.0%, "informed consent" 7.9%, "intubation" 6.4%. CONCLUSION: This survey offers useful data regarding those skills viewed as most important by experienced surgical educators, and offers guidelines for composition of surgical OSCEs.

Objective Structured Clinical Examination technical skill stations correlate more closely with postgraduate year level than do clinical skill stations.

Validity of an examination format is supported by its ability to distinguish levels of training among examinees. The Objective Structured Clinical Examination (OSCE) is a developing format generally composed of various types of task-oriented stations used to evaluate clinical skills of students and residents. The ideal composition of OSCE stations to maximize validity has not been determined. We examined the relative correlation between selected types of stations and level of resident postgraduate year (PGY). A 12-station OSCE was administered to surgical residents of all PGY levels at a university program. Individual station scores were correlated with PGY level. The overall correlation of the total examination score with PGY level was good (R = 0.681). Technical skill stations exhibited a significantly greater correlation with PGY level (0.679 vs 0.203) as compared with clinical skill stations (P < 0.05). These data suggest that technical skill evaluation is more sensitive in distinguishing level of training of surgical residents than is clinical skill evaluation.

Large-field, external beam irradiation as a surgical adjuvant for node-positive colon carcinoma: an Eastern Cooperative Oncology Group Pilot Study (PA285).

The Eastern Cooperative Oncology Group (ECOG) PA-285 study was designed as a pilot study to evaluate the effect of large-field, external beam abdominal irradiation as an adjuvant treatment for resectable stage C1 to C2 colon cancer. Eligible patients received 45 Gy directed to the tumor bed and periaortic lymph nodes, as well as 30 Gy to the liver. Patients were followed up for time to recurrence and for survival. Fourteen patients were enrolled. One elected not to have radiation after surgery; one died of acute hepatic radiation toxicity after a major deviation from protocol. Of the 12 remaining patients, seven survived longer than 10 years for a survival rate of 58%. Other than the fatal hepatic toxicity, side effects from radiation were moderate and of short duration. One patient failed to complete therapy because of ascites, had two episodes of partial bowel obstruction (successfully treated conservatively), and subsequently survived more than 10 years. Two of three patients with stage C1 tumors, four of eight with C2 tumors, and one with a C3 tumor were long-term survivors. This study demonstrates the feasibility and acceptable toxicity of this adjuvant regimen. The numbers are too limited to evaluate survival, but all seven survivors have lived more than 10 years.

Comparison of the Objective Structured Clinical Examination with the performance of third-year medical students in surgery.

BACKGROUND: The purpose of this study was to investigate the validity of the Objective Structured Clinical Examination (OSCE) as an evaluation technique by comparing medical student performance on the OSCE with traditional forms of evaluation. SUBJECTS AND METHODS: We analyzed the performance of 129 third-year medical students in the 1997-1998 academic year on clinical evaluations, oral examinations, and NBME subject examinations, and on OSCE, which was not included in the final grade. RESULTS: The OSCE showed high correlation with the final grades received for the clerkship. Seventy-one percent of students receiving High Pass or Honors had high OSCE scores whereas 67% of students with low OSCE scores received poor or Defer grades. Pearson product-moment correlations demonstrated significant bivariate correlations with the other test parameters. CONCLUSIONS: This study demonstrates that the OSCE is similar to the traditional methods in evaluating general ability and is also able to evaluate clinical ability in a standardized manner.

Thrombotic complications resulting from hypercoagulable states in chronic hemodialysis vascular access.

BACKGROUND: Vascular access-related complications are an important cause of morbidity, and they account for 14% to 17% of dialysis patients' hospitalizations with an annual cost in the United States of approximately $1 billion. Previous studies have related the major predisposing factor of thrombotic complications to stenosis of the graft anastomosis. Several recent reports suggest that antiphospholipid antibodies may cause frequent thrombotic complications. The broad spectrum of diseases that cause hypercoagulable states has not been correlated with frequent PTFE graft thrombosis. STUDY DESIGN: A retrospective case series study was performed to determine the frequency of hypercoagulable states in dialysis patients who had repeated thrombotic complications of their PTFE grafts. Between May 1996 and June 1998, 91 operations were performed on 34 patients with end-stage renal disease. All arteriovenous fistulas were created with PTFE grafts and placed by a single surgeon. All patients were evaluated at operation for anastomotic stenosis, and the majority of patients were studied for hypercoagulable states. Patients with a documented hypercoagulable state were considered for warfarin therapy. RESULTS: Twenty-two individuals (64.7%) developed 67 thrombotic complications. Twelve of the 14 patients tested (85.7%) were shown to have hypercoagulable states of various causes and degrees. Thirteen patients developed multiple thrombotic complications, 11 (81.8%) were tested and proved to be hypercoagulable. Thirty-eight of the thrombotic complications had nonanatomic causes and 28 (41.8%) had hypercoagulability as the only determinable cause. Ten of the 12 hypercoagulable patients (83.3%) were relegated to intermediate to high-intensity warfarin therapy to reduce the incidence of thrombotic events. Hypercoagulable patients not receiving warfarin had a thrombosis rate of 4.0 events per year; patients on warfarin had a rate of 1.2 events per year. Twenty-three thrombotic events occurred in the anticoagulated group all with an International Normalized Ratio (INR) less than 2.7. This incidence of vascular access thrombosis may be prevented when patients are maintained at an optimal INR of 2.7-3.0. CONCLUSIONS: Hypercoagulability has been a major etiologic factor in PTFE graft thrombosis. Hypercoagulable states are often found in patients with multiple graft thromboses and in patients with nonanatomic causes for thrombosis. Antiphospholipid antibodies are prevalent in the patients with PTFE graft thrombosis, as well as abnormalities in the Protein-C, Protein-S, and Antithrombin III systems. PTFE graft thrombosis has been a frequent cause of morbidity in patients on hemodialysis, and diagnostic evaluation should include a hypercoagulability profile. Based on our data, warfarin therapy should be instituted when hypercoagulable states are found, unless otherwise contraindicated, and INR maintained at 2.7-3.0 to decrease morbidity and frequency of graft thrombosis.

Phase II evaluation of treatment of complete resection of hepatic metastases from colorectal cancer and adjuvant hepatic arterial infusion of floxuridine: an Eastern Cooperative Oncology Group Study (PB083).

This study was designed to evaluate hepatic arterial infusion of floxuridine (FUDR) in patients with resected hepatic metastases from colorectal cancer. Patients who met eligibility criteria had an Infusaid pump (Infusaid Corporation, Sharon, MA, U.S.A.) implanted for intraarterial administration of chemotherapy. After complete surgical resection of hepatic metastases, FUDR (0.2 mg/kg/day) was given in 28-day cycles consisting of 14 days of treatment followed by 14 days of rest. Of 11 patients enrolled, one was ineligible, one received no treatment because of a blocked pump, and nine were treated per protocol. Of the nine treated patients, all are dead: one from hepatic toxicity, one from unrelated causes, and seven from progressive disease. Grade 3-4 toxicity included three cases of gastritis and two cases of hepatotoxicity from FUDR. Although this regimen was not successful, in part because of toxicity, the patient population studied here should be considered for future studies of adjuvant therapy.

Adjuvant radiation therapy for pancreatic cancer: a 15-year experience.

PURPOSE: A retrospective analysis to determine differences in survival of patients with pancreatic adenocarcinoma treated by radical surgery with and without adjuvant radiation therapy. METHODS AND MATERIALS: Between 1980 and 1995, 249 patients with pancreatic tumors were identified at the Medical College of Ohio. Forty-four of these patients underwent radical surgical procedures with curative intent. These patients were divided into four groups according to treatment: surgery alone (n = 14), surgery plus intraoperative radiation therapy (IORT) (n = 6), surgery plus external beam radiation therapy (EBRT) (n = 14), or surgery plus both IORT and EBRT (n = 10). Outcome and survival were analyzed among the four groups. RESULTS: The median survival time of patients treated with radical surgery alone was 6.5 months. The median survival time for the surgery plus IORT group was 9 months; however, 33.3% (two of six) of these patients survived longer than 5 years. This survival pattern was borderline significantly better than that for the surgery alone group (p = 0.0765). The surgery plus EBRT and the surgery plus IORT and EBRT groups had median survival times of 14.5 and 17.5 months, respectively. These were significantly better than that of the surgery alone group (p = 0.0004 and p = 0.0002, respectively). The addition of radiation therapy did not affect the treatment complication rate. CONCLUSION: The survival of patients who were treated with radical surgery alone was significantly poorer than that of patients who received adjuvant radiation therapy. These results are consistent with other studies in the literature. Patients treated with all three modalities (surgery, IORT, and EBRT) displayed the best median survival time.

Use of ileal urinary diversion in conjunction with intraoperative radiotherapy.

Intraoperative radiotherapy (IORT) was introduced in the 1970s as a new modality of cancer therapy. It has been especially useful after local irradiation or surgical failure. We report on the use of IORT in 13 patients with pelvic tumors requiring urinary diversion. All 13 were managed with ileal conduits. Despite the associated problems of prior abdominal procedures (11/13 patients), prior external beam radiation to the pelvis (11/13 patients), systemic chemotherapy (4/13 patients), and prolonged operative time (> 10 hours), perioperative mortality (1/13) and morbidity rates were low. We conclude that in cases of prior colonic resection and pelvic radiation, potentially irradiated ileum can be safely used for urinary diversion.

Expression and localization of elements of the plasminogen activation system in benign breast disease and breast cancers.

The malignant potential of solid tumors is related to the ability to invade adjacent tissue and to metastasize. These properties of cancer cells depend on the synthesis of proteolytic enzymes which are able to digest adjacent connective tissue and basement membranes. We hypothesized that all elements of the plasminogen activation system might be overexpressed in malignant human breast tumors, functioning as an essential element in tumor invasion and metastasis. As determined by histopathological methods, the malignant tumors showed statistically significantly higher expression of urokinase plasminogen activator (uPA), type-1 plasminogen activator inhibitor (PAI-1), and especially urokinase plasminogen activator receptor (uPAR) than benign tissues. All those elements were present in higher amounts in the cancer cells than in the cells of benign or normal breast tissues. High exhibition of tissue plasminogen activator (tPA) found in cancer seems to be random and not related to the malignant or benign state, since benign and malignant tumors show overexpression of tissue plasminogen activator with similar frequency. When the tumors express high amounts of uPA, they express a high amount of uPAR in 50% of cases and PAI-1 in 57.3% of cases. When urokinase is expressed in low amount, the receptor is low in 28.6% and inhibitor in 21.4% of malignant breast tumors. This statistically significant consensus, 78.6% in the case of urokinase and its receptor and 78.6% in case of urokinase and its inhibitor, suggests that these activities may be the result of a unique mechanism of control, activated in the last steps of malignant transformation.

Radiation therapy and 5-fluorouracil modulated by leucovorin for adenocarcinoma of the pancreas. A phase I study.

This Phase I study was designed to build on the Gastrointestinal Tumor Study Group's experience with combined modality therapy in patients with pancreatic cancer. Thirteen patients with adenocarcinoma of the pancreas received weekly 5-fluorouracil by rapid intravenous infusion midway through a 2-h infusion of high dose leucovorin during external beam radiation therapy. Twelve patients received 100% of planned external beam radiation; treatment delays occurred in only three. Four patients received 100% of planned chemotherapy doses. Leukopenia and thrombocytopenia caused reduction of the number of chemotherapy doses given during radiation in six patients; diarrhea, severe nausea and vomiting, and wound abscess caused reduction in three patients. Ten patients were evaluable for response; two had complete responses, one had a partial response, and two had minor responses. In this small series baseline and post-treatment CA 19-9 levels predicted and correlated with response. We conclude that radiation and 5-FU modulated by leucovorin is a tolerable treatment regimen for carcinoma of the pancreas, with preliminary suggestion of activity, that warrants further Phase II testing.

Whole liver intraoperative irradiation after partial hepatectomy produces minimal functional and pathologic lesions.

Intraoperative radiation therapy (IORT) was delivered to remnant rat liver after partial hepatectomy to determine the chronic effects of treatment on survival, blood chemistry, liver weight, and histology. Survival at one year was 100%. Remnant liver weight was markedly increased in all animals. Liver function appeared to be unaltered in all groups and at all observation times. Inflammatory cell infiltration occurred immediately after treatment in all animals, showing a slight progression until day 45; by day 180 the values had returned to baseline. Vascular changes were seen early in all groups, then progressively decreased; the vascular score was back to baseline at days 180 and 365. Nuclear alterations were observed in both irradiated and nonirradiated hepatic cells; in all cases these were limited to isolated or focal areas of hepatocytes. There was little fibrosis formation and by day 180 all scores were back to baseline. We conclude that the chronic effects of whole liver IORT after one-third hepatectomy are minimal in the rat and are similar to those observed after surgery alone.

Percutaneous decompression for femoral neuropathy secondary to heparin-induced retroperitoneal hematoma: case report and review of the literature.

Retroperitoneal hematoma resulting in femoral nerve injury is a serious potential complication of systemic heparin anticoagulation. Review of the literature reveals lack of agreement with respect to conservative versus surgical management. The authors report the first case in which return of function was established by percutaneous decompression of a retroperitoneal hematoma in a patient who was not a candidate for immediate surgery. The favorable result suggests that percutaneous drainage may represent a reasonable alternative or first step in surgical treatment of this compression.

Pass/fail grading: a disadvantage for students applying for residency.

We polled general surgery residency program directors to determine whether the evaluation system used by a medical school--pass/fail versus competitive grading--has an effect on a student's ability to compete for a residency position in general surgery. A vast majority (89%) of respondents preferred to review medical student transcripts that use grades rather than pass/fail evaluations. In addition, 83% would prefer to evaluate their own students with a grading system rather than a pass/fail mark. Eighty-one percent of program directors believed that the medical student's ability to compete for a residency position was adversely influenced by the pass/fail method of evaluation. Since program directors appear to be biased in favor of an evaluation system that provides them with more objective data, we conclude that the use of the pass/fail grading system puts the medical student at a disadvantage in competing for general surgery residency positions.

Intraoperative radiation therapy for pancreatic, biliary and gastric carcinoma: the US experience.

The experience with pancreatic, biliary and gastric cancer in the US has demonstrated that IORT is technically a feasible and therapeutically relatively safe modality. However, much research remains to be done. The toxicity in humans of single large dose radiation to normal tissue has not been firmly established. Clinical studies must be able to demonstrate the efficacy of IORT as well as a therapeutic advantage for this approach. IORT is potentially a very effective adjuvant therapy in treating tumors which are technically difficult to treat surgically or which have a high rate of recurrence following radical surgery. The combination of surgery and IORT may improve local control of the tumor by removing gross disease and identifying areas of potential risk for recurrence. Regional and distant failure, however, remains a problem. Because of this, future investigations are underway to combine chemotherapy with IORT, surgery and EBRT. The effectiveness of IORT needs to be established with prospective randomized trials. The appeal of this procedure is demonstrated by its rapidly growing popularity, and this very appeal requires that the value of the procedure be determined.

Intraoperative electron beam radiation therapy (IOEBRT) for carcinoma of the exocrine pancreas.

The abdominal cavities of 50 patients were explored in a specially constructed intraoperative radiotherapy operating amphitheater at the Medical College of Ohio. Twenty-six patients were treated with intraoperative and postoperative precision high dose external beam therapy, 12 with intraoperative irradiation but no external beam therapy, and 12 with palliative surgery alone. All but two patients completed the postoperative external beam radiation therapy as initially prescribed. The median survival time for patients treated with palliative surgery alone was 4 months, and that for patients treated with intraoperative radiotherapy without external beam therapy was 3.5 months. Patients undergoing intraoperative irradiation and external beam radiation therapy had a median survival time of 10.5 months. Four patients died within 30 days of surgery and two patients died of gastrointestinal hemorrhage 5 months posttreatment.