[Professionalism: Values and competences in specialized medical training]. / Profesionalismo: valores y competencias en formación sanitaria especializada.

OBJECTIVE: To determine the perception of healthcare professionals (tutors, residents and teaching collaborators) involved in specialist medical training on the core values and skills to develop their tasks. METHODS: A tailor-made questionnaire aimed at healthcare professionals in 9health care centres and a referral hospital. Questionnaire: 4 sections and 51 variables (scale 1-10). RESULTS: A total of 287 professionals participated, which included 97% tutors (n=59), 38% residents (n=61), and 56% others (97 teaching collaborators and 70 not associated with teaching). The alfa Cronbach coefficient was 0.945. Best rated values were work compliance (8.7 points), ethics in professional practice (8.6 points), and respect for their team (8.3 points). The best rated competence was communication with patients and families (8.1 points), followed by self-motivating leadership (7.9 points), and the practical application of medical and healthcare theoretical knowledge (7.8 points). The values received, on average, 0.7 points above competences (95% CI: 0.5-0.9). There were no differences between tutors and residents, although differences were found between doctors and nurses, and between males and females. CONCLUSION: Most of the professionals (tutors, residents, and teaching collaborators) share the same perception of the values and competencies that influence their professional development. This perception was influenced by the professional category and gender, but not age or working in a hospital or primary health care.

Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction.

BACKGROUND: The objective of this prospective study is to determine cognitive dysfunction after thoracic surgery. METHODS: Seventy-six patients undergoing thoracic surgery with single-lung ventilation (SLV) of an expected duration of >45 min were enrolled. Monitoring consisted of standard clinical parameters and absolute oximetry (S(ct)O(2)). The Mini-Mental State Exam (MMSE) test was used to assess cognitive function before operation and at 3 and 24 h after operation. Data were analysed using Spearman correlation test; risks for cognitive dysfunction were expressed as odds ratios. P<0.05 and data are presented as median (interquartile range). RESULTS: One patient was excluded from the study. S(ct)O(2) during SLV decreased to critical values of <65%, 60%, and 55% in 40 (53%), 15 (20%), and 5 patients (7%), respectively. Twenty-two patients (29%) had a decrease of MMSE>2 points 3 h after surgery, eight patients (10%) had a decrease of MMSE>2 points 24 h after surgery. Postoperative cognitive dysfunction correlated at r(2)=0.272, 0.285, 0.297 with patient exposure times to S(ct)O(2)<65% (P=0.018), <60% (P=0.013), <55% (P=0.010), respectively. The odds ratios of developing early cognitive dysfunction ranged from 2.03 (95% CI: 0.74-5.59) for a short (<5 min) exposure to S(ct)O(2)<65% to a maximum of 9.56 (95% CI: 1.75-52.13) when S(ct)O(2) was <60% for more than 30 min. CONCLUSIONS: Early cognitive dysfunction after thoracic surgery with SLV is positively related to intraoperative decline of S(ct)O(2).

Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates with postoperative complications.

BACKGROUND: Regional cerebral oxygen saturation (S(ct)O(2)) has recently been shown to decrease significantly during thoracic surgery. The present study investigates whether these desaturations are related to postoperative complications. METHODS: Fifty patients undergoing thoracic surgery with a single-lung ventilation (SLV) of >45 min duration were enrolled. Regional cerebral oxygen saturation was measured using absolute oximetry; standard clinical variables, and SOFA and Clavien scores were recorded. Correlation between minimum S(ct)O(2) during SLV and postoperative complication scores was analysed using Pearson's correlation test, chi(2) test, and logistic regression. RESULTS: Forty-seven patients underwent lobectomy, two patients a pneumonectomy and 1 patient a chest wall resection. Eighty-two per cent of the patients had a decrease in S(ct)O(2) of >15% from baseline value, and 10% of the patients had a minimal absolute S(ct)O(2) value between 45% and 55%. The minimal absolute S(ct)O(2) values during SLV correlated with the Clavien score (R(2)=0.098, P=0.0201) and the non-respiratory SOFA score (R(2)=0.090, P=0.0287). By defining a threshold of S(ct)O(2)=65%, the odds ratio of having a non-respiratory organ failure was 2.37 (95% CI 1.18-4.39, P=0.043) and a complication according to the Clavien score (Clavien score >0) was 3.19 (95% CI 1.60-6.34, P=0.0272). CONCLUSIONS: Thoracic surgery with SLV seemed to be associated with a significant decrease in S(ct)O(2), and minimal S(ct)O(2) values correlated positively with postoperative complications.

Significant decrease of cerebral oxygen saturation during single-lung ventilation measured using absolute oximetry.

BACKGROUND: Single-lung ventilation (SLV) during thoracic surgery causes important cardiopulmonary disturbances. Absolute cerebral oximetry was used to determine the incidence and magnitude of the decrease in cerebral oxygen saturation (Sct(o(2))) in patients undergoing SLV during thoracic surgery. METHODS: Data were obtained from 20 consecutive patients undergoing thoracic surgery and necessitating SLV of more than 1 h. The FORESIGHTtrade mark (CASMED, USA) absolute oximeter was used to measure left, right, and average absolute Sct(o(2)) every 5 min from the awake state to extubation. Bispectral index and standard monitoring parameters were also recorded every 5 min. Blood gas analysis was performed every 15 min. Data median (IQR) (range) were analysed using repeated-measures anova and Spearman's correlation test, P<0.05. RESULTS: Patients [median age 65 yr (range 46-75)] showed an absolute Sct(o(2)) of 80% (78, 82) (74-87) in the awake state, which decreased to a minimum Sct(o(2)) value of 63% (57, 65) (53-73) during SLV to recover to an Sct(o(2)) of 71% immediately after extubation. During SLV, all patients had a decrease of more than 15% of the initial Sct(o(2)) and 70% of patients had a decrease of more than 20%. The decrease in Sct(o(2)) was not correlated with any standard clinical parameters, for example, arterial pressure, blood loss, peripheral oxygen saturation, or Pa(o(2)). CONCLUSIONS: Thoracic surgery with SLV seems to be associated with a significant decrease of Sct(o(2)) in the majority of patients. Parameters such as peripheral oxygen saturation or Po(2) which are used to guide SLV during thoracic surgery are not sufficient to detect significant cerebral oxygen desaturations.

Chondrosarcoma of the jugular foramen.

Chondrosarcoma, although uncommon, must be included in the differential diagnosis of skull base tumors. The potential for morbidity and mortality, similar to other lesions located at this anatomic site, is related to compromise of adjacent vital neurovascular structures. Optimal surgical management is controversial and reliant on adequate tumor exposure. A case of myxoid chondrosarcoma of the jugular foramen is presented with a review of the common presenting signs and symptoms along with the radiographic and histologic features of these lesions. The surgical approach to chondrosarcoma and other lesions at this location has undergone an evolution in technique in recent years. This report details the approach used by the authors, which allows for reconstruction of the skull base with subsequent normal anatomic contour and functional hearing. The technique employs hydroxylapatite for reconstruction, which has not been previously described in skull base applications.

The retrolabyrinthine approach and vascular loop.

Several researchers have made progress toward determining the cause of hemifacial spasm, tinnitus, and episodic vertigo. During the past 5 years, we have encountered a vascular loop in six of 36 patients who were undergoing retrolabyrinthine vestibular neurectomy for recurrent disequilibrium and vertigo. In five of these six patients, disequilibrium improved after neurectomy. This report describes the clinical symptomatology and the results of preoperative cochleovestibular testing for those patients found intraoperatively to have a vascular loop and suspected neurovascular compression syndrome. Audiograms, although varied, characteristically did not demonstrate the low-frequency sensorineural hearing loss characteristic of Meniere's disease. No preoperative marker, with the single exception of computed tomography pneumocisternography, dependably predicted the presence of a vascular loop.

Age considerations in acoustic neuroma surgery: the horns of a dilemma.

Experience has shown that early removal of acoustic tumors results in less morbidity because the rate of surgical complications increases with tumor size. Nevertheless, acoustic tumors are benign and grow slowly--facts that support conservatism in elderly patients. We managed 21 patients with acoustic tumors over the age of 65. Eleven patients underwent immediate surgical excision. Ten patients were monitored clinically and with serial magnetic resonance imaging (MRI) or computed tomographic (CT) scans. To date, two of these patients have required surgical excision because of continued tumor growth. Our experience managing these patients both surgically and with "watchful waiting" is the subject of this report.

Surgical treatment of vertigo with retrolabyrinthine vestibular neurectomy.

Results for control of vertigo and preservation of hearing in patients who have had a retrolabyrinthine vestibular neurectomy (RVN) by our group were analyzed retrospectively. This procedure consists of selective section of the vestibular nerve in the posterior cranial fossa. Vertigo was completely controlled in all but two of 31 patients, one of whom required revision surgery to control attacks. Analysis of these two cases suggests that the cause of persistent vertigo is incomplete neurectomy. With our current surgical technique in patients with Meniere's disease, hearing results were not statistically different from our results with surgery of the endolymphatic sac. Control of vertigo was much more successful with the RVN than endolymphatic sac surgery.

Complications in the approach to acoustic tumor surgery.

Earlier diagnosis and cooperation with allied specialists in neurosurgery have lessened complications of acoustic tumor surgery. To date, complications cannot always be prevented. The controversy over which approach is best for acoustic tumor extirpation still continues. While teams must answer this question themselves, our experience favors the transtemporal approach. Of the potential disabilities from this operation, facial paralysis or its sequelae remain the most frequent. The transtemporal approach gives a more accurate anatomical definition of the facial nerve. Efforts to preserve hearing (especially with tumors 2 cm or larger), when matched with the potential sequelae of facial paralysis, may prove futile.

Skull base mapping.

Early experience with medium to large tumors of the temporal region has re-emphasized the value of radiologic preoperative plotting of these space occupying lesions in the sagittal, coronal, and horizontal planes. Attention to probable pathology, neurovascular structures and patient's medical status has been important in determining resectability. A standard format of the interior and exterior of the skull base and cervical spine has been employed to map these lesions. Such devices have been used by otolaryngologists in the past to depict laryngeal lesions; and provide for the skull base surgeon a common base of comparison of tumor size, chart documentation, and a means to facilitate communication among other specialists. Experience with 36 cases of skull base tumors seen since July 1979 has emphasized the occult manner in which these lesions may present.

An holistic approach to Ménière's disease. Medical and surgical management.

A review of the medical and surgical management of 195 patients with Meniere's disease is presented. In order to avoid a piecemeal approach to the problem of Meniere's disease, the "whole" patient must be treated. Psychological counseling, medical management, and when indicated selective surgical management is advocated. The diagnosis of Meniere's must be confirmed through careful history, physical, neurological evaluation and selective testing. The majority of patients can be controlled medically; however, in this study 52 (26%) patients underwent surgical therapy. Twenty-eight patients underwent some type of saccus surgery for Meniere's disease with overall relief of 71%; however, better relief of vertigo was seen with labyrinthectomy and nerve section. The most common indication for surgery was disabling vertigo. However, fluctuating progressive sensorineural loss, may be an important reason to advise surgery. Surgical techniques for Meniere's disease continue to evolve. A graduated approach is preferred, starting with endolymphatic-mastoid shunt, proceeding to middle fossa vestibular nerve section when medical status and hearing and adequate. When hearing is socially inadequate, labyrinthectomy with or without vestibular nerve section is preferred. A good working relationship with a neurosurgeon is advised for otolaryngologists performing middle fossa surgery.