Spontaneous expulsion of lipoma per rectum occurring with colonic intussusception.

The spontaneous expulsion of lipoma per rectum is an extremely rare phenomenon. The present case report describes this event in a patient with lower abdominal pain and bleeding per rectum leading to exploratory laparotomy. At surgery, a large intussuscepting ulcerated submucosal lipoma remnant was identified in the transverse colon. This unusual presentation of colonic lipoma is discussed and the pertinent literature is reviewed.

A rationale for the teaching of statistics to surgical residents.

The two aims of this study were to investigate the use of statistics in the surgical literature and to assess the degree of statistical comprehension possessed by graduating surgical residents. Two hundred journal articles were randomly selected from the 1984 issues of four surgical journals and were reviewed for statistical content. A classification of statistical techniques was created. A reader who has knowledge of descriptive statistics only has access to 44.5% of the articles. The addition of knowledge of t tests, contingency table analysis, other nonparametric techniques, and life table analysis to a reader's repertoire increases the access rate to 80.5%. The data indicate the specific statistical techniques that would best serve the surgeon who is attempting to increase access rate to the surgical literature. Ninety-one surgical residents in their fifth postgraduate year (PGY-5) responded to a questionnaire regarding their knowledge of statistics. While 90% of the respondents thought they would benefit from a course on statistics, 92% reported that they had received less than 5 hours of instruction in statistics during their residency. Both subjective self-ratings and objective testing revealed that the residents surveyed have a suboptimal knowledge of statistics. The results suggest the need for formal instruction in statistics during surgical residency.

Improved prediction of success in surgical clerkship through measures of information processing.

A new system for predicting success of surgical student performance has been developed. A test of surgical knowledge, with questions given in the form of analogies, was administered to 16 students in their fourth week of clerkship. While solving test items, students' eye movements and fixations were tracked. By analysis of the recordings, eight scores of information-processing capabilities were derived. The processing scores and conventional predictors of medical school clinical performance were analyzed to determine their power to predict success, defined by ratings given on a 1 to 10 scale by 21 faculty members based on three tests of cognitive knowledge, two performance-based examinations, and faculty reports. The ratings were reliable (generalizability coefficient = 0.72; p less than 0.001). Stepwise regression analysis of all variables selected one MCAT score (science problems) and two information-processing scores to the statistical model that maximally predicted success. Regression coefficient for the science problem subset of the MCAT was 0.42. This was augmented to R2 = 0.77 when information processing variables were included. The increment was significant, F (2, 11) = 9.25; p less than 0.01. A newly developed test, coupled with techniques that made possible the derivation of components of information processing, nearly doubled the power of conventional tests to predict success in surgical clerkship.

An evaluation of surgery departments in community-based medical schools.

Since 1960, most newer medical schools have been community-based and have used existing community hospitals and a large number of volunteer faculty. As these schools have evolved, many have developed more traditional characteristics. To assess the positive and negative features of these new schools, chairs of departments of surgery from 21 community-based medical schools and 17 traditional schools were surveyed to acquire information on policies and practices related to faculty development, undergraduate and graduate education, hospital relationships, clinical activities, research, and relationships with community physicians. Responses were analyzed and compared. Most community-based schools have succeeded in their mission, partly at the expense of controls usually found in more traditional schools.

Hashimoto's thyroiditis simulating cancer of the thyroid.

We reviewed a group of 30 patients with Hashimoto's thyroiditis who underwent thyroidectomies for suspicion of cancer. A prominent nodule was present in all of the patients; compression symptoms were present in 13 and pain in the thyroid in six. The nodule was cold on scan in 21 patients. Lack of responsiveness to suppressive therapy or nodule enlargement occurred in 18 patients. In addition to the nodule, operative findings included adherence to surrounding tissues in seven patients, lymphadenopathy in seven, increased vascularity in four, and extension to distant cervical structures in two. Pathologic findings in the nodule were similar to those in the rest of the gland; they consisted of lymphocytic infiltration, fibrosis, and variable follicular size. Examination of lymph nodes demonstrated lymphoid hyperplasia. We emphasize the similarities between chronic thyroiditis and carcinoma of the thyroid; the occasional coexistence of these two conditions stresses the need for newer methods in the differential diagnosis.

Description and evaluation of the Surgeons as Educators course.

BACKGROUND: Since 1993, the American College of Surgeons has sponsored an annual 6-day course entitled the Surgeons as Educators. The course was designed to provide academic surgeons with the knowledge and skills necessary to enhance the surgical education curriculum, teaching strategies, educational program administration, and performance evaluation. This article describes the development, implementation, and effect of the course on the classes graduating in 1993 and 1994. STUDY DESIGN: The effect of the course was studied by using a longitudinal survey approach. A survey was mailed to participants 3 to 6 months after they completed the course. Graduates were asked to describe any education-related actions taken attributable to attending the Surgeons as Educators course. The quality of course content and presentations were evaluated by using end-of-course evaluation forms and daily feedback forms and by an external reviewer. RESULTS: Within 6 months of returning from the course, more than one half of the graduates initiated actions related to curriculum development, teaching strategies, or educational administration. One third or more of the graduates modified their performance and program evaluation systems. Using a five-point scale, ratings of the course content ranged from 3.78 to 4.64 for "value of topic" and from 3.77 to 4.76 for "quality of presentation." Items evaluated by the graduates on the end-of-course evaluation forms ranged from 7.8 to 8.7 on a nine-point scale. CONCLUSIONS: The Surgeons as Educators course offered an opportunity for participants to interact among themselves and with course faculty about educational issues and to practice teaching skills. The course was highly rated for educational quality and value. The retreat environment and the length of the program helped attendees become immersed during this "protected time" to analyze strengths and weaknesses of their programs and devise achievable plans to improve their abilities as educators and the effectiveness of their programs.

Effect of sleep deprivation on the performance of surgical residents.

Surgical residents were tested under sleep-deprived and nonsleep-deprived conditions. Three performance domains were tested: factual recall, the ability to concentrate, and manual dexterity. Sleep deprivation was defined as less than 3 hours of sleep in a 24 hour period. A randomized, repeated measures design was used. Split-plot analysis of variances was used to analyze the mean scores, and it revealed that there were no significant differences in performance in the sleep-deprived condition compared with performance in the nonsleep-deprived condition in any of the three domains tested. Moderate sleep deprivation appeared to be well tolerated by the surgical residents studied in this investigation.

Gastroesophageal physiology after stapled gastroesophagostomy in dogs.

A stapled vertical gastroesophagostomy (VGE) has been proposed for benign esophageal stricture. The VGE involves performing an anastomosis using a linear cutting stapler inserted via a gastrotomy (one limb in the esophagus, the other in the proximal fundus). In phase I of the study, a 50-mm VGE was performed in 13 dogs; 7 received an additional fundoplication. Endoscopy with pinch biopsies, esophageal manometry, and 4-hour ambulatory pH recordings were performed in each dog prior to and 1 month after VGE. The only difference between groups postoperatively was a higher lower esophageal sphincter pressure in the group with the added fundoplication. The incidence of histologic esophagitis was low in both groups. In phase II of the study, a VGE was performed in six dogs using a 75-mm linear cutting stapler, accompanied by fundoplication in each dog. These dogs were then followed for 6 months to more completely assess the long-term risk of developing reflux esophagitis. At necropsy, no gross or histologic evidence of esophagitis was found. The performance of a VGE through the lower esophageal sphincter in normal dogs does not result in significant reflux esophagitis. VGE may be an alternative to resection for esophageal stricture.

The practicing doctor's perspective on the surgical curriculum.

The purpose of this study was to identify deficiencies of surgical clerkship and residency curricula in the training of family physicians. Responses to a survey from 202 practicing family practitioners were analyzed. Orthopedics, otolaryngology, urology, neurosurgery, and cardiovascular surgery were surgical specialty areas where more than 40 percent of the respondents thought they had spent too little time. Learning objectives were either not presented or were used ineffectively, according to the majority of respondents. Fifty percent believed that indicating a career interest in family medicine resulted in a negative bias toward them during the surgery clerkship. Over 45 percent thought they were moderately or totally unprepared at the completion of their training to perform several basic surgical procedures. The results of this survey indicate the need for an increased allocation of curricular time to several surgical specialties and an augmented emphasis on outpatient experiences within the surgical curriculum.

Description and results of a needs assessment in preparation for the "Surgeons as educators" course.

BACKGROUND: In August 1993 the American College of Surgeons sponsored a course entitled "Surgeons as Educators" (SAE) aimed at equipping academic surgeons with the knowledge and skills necessary to enhance surgical education administration, curriculum, teaching, and evaluation. METHODS: The instructional design model used to construct the course called for a formal needs assessment to determine the importance, current skill level, and priority of what needed to be learned to be an effective educator. The needs assessment was accomplished using a job analysis and questionnaire approach. The 68-item questionnaire was mailed to 320 academic surgeons representing eight medical schools. RESULTS: A 62% response rate was achieved. Results indicated the education-related tasks or activities that faculty felt were important to their careers, as well as their perceived level of development in each area. Descriptive statistics were used to summarize the responses that were critical to the SAE faculty in helping prioritize, sequence, and time ration course content. Collective results became the foundation for developing the SAE curriculum by the course's five faculty members. CONCLUSIONS: A well-done needs assessment does not necessarily guarantee course success; however, it is the first and critical step to planning an educationally sound faculty development course or program designed for adult learners.

Reliability of different grading systems used in evaluating surgical students.

Inter-rater agreement in assigning grades using five different grading systems was determined. The performance of 16 students in a surgery clerkship was rated by 21 faculty raters using a pass-fail grading system, a pass-fail-honors system, a letter grade system, a number grade scale from 1 to 10, and a number grade scale from 1 to 100. Inter-rater agreement coefficients were used to assess relative and absolute reliabilities, respectively. Both the letter grade and 1 to 10 number grade systems provided good discrimination, had high to moderate reliability, and required only five raters to achieve a mean rating with the commonly recommended reliability of 0.80. Using the letter grade system, however, a majority of raters agreed on a specific grade assignment for 14 of 16 students, in contrast to the 1 to 10 scale, for which this was true for only 4 of 16 students. The results of this reliability study favor the use of a letter grading system.

Evaluation of students' physical examination skills during their surgery clerkship.

BACKGROUND: Faculty often presume that students possess adequate physical examination skills upon graduation. Yet assessments of their performance with these skills often reveal deficiencies. This study was designed to determine if students' physical examination skills improved during their clerkship year. METHODS: Sixty-six students performed four specific physical examinations on patients during the first and last week of their surgery clerkship. Four consecutive clerkship rotations were examined. Encounters were videotaped and evaluated by faculty members. RESULTS: Posttest mean percent correct scores significantly improved for three examinations (P <0.01). Analysis of variance found no significant differences between clerkship mean percent correct scores. CONCLUSIONS: Students' physical examination skills improved slightly during their clerkship, however, no relationship was found between clerkship rotation and performance. These findings suggest unsupervised experiences during the third year do not positively influence student performance with physical examination skill proficiency.

Topics and skills in orthopaedics for the general practitioner.

We conducted a survey to identify topics and skills in orthopaedics that should be included in a curriculum for the education of general practitioners. Forty-one program chairpersons responded to a questionnaire that asked respondents to rate the importance of each of eighty topics or skills related to orthopaedic surgery. The questionnaires were analyzed with use of descriptive statistics. The stability of the results was assessed with a follow-up questionnaire five months after the first survey had been completed, and the results were analyzed with a correlation coefficient of the mean ratings of importance and percentage agreement on individual items. The results produced a rank-order listing of important topics and skills in orthopaedics for the general practitioner. The topics and skills that were rated highly by program chairpersons corresponded to the types of musculoskeletal problems most commonly seen by family practitioners. This survey provides concurrent validity for the rank-order lists and confirms the need to include these items in a core curriculum for general practitioners.

Late development of metachronous colorectal cancer.

The incidence of metachronous colorectal cancer has been reported to be 1 to 5 percent, with most of the cases being discovered within ten years of the initial cancer. A retrospective review of all colorectal cancer patients was conducted at the Southern Illinois University Affiliated Hospitals to determine the incidence of metachronous colorectal cancer at the authors' institution. In this study, a metachronous cancer was defined as a second colorectal primary occurring at least three years following discovery of the initial lesion. Between 1978 and 1984, there were 24 patients with metachronous colorectal cancer identified in an operative series of 707 patients for a frequency of 3.4 percent. These metachronous cancers were discovered at intervals ranging from 3 to 35 years. Sixteen (67%) metachronous lesions occurred 11 years of more after the original cancer. Synchronous or interval adenomatous colorectal polyps were noted in 17 (71 percent) of the patients. Thirteen of the metachronous cancers appeared in the right colon, while six were distributed throughout the transverse and descending colon, and five were in the rectosigmoid region. The incidence of late-appearing metachronous colorectal cancers and the propensity to occur in the right colon underscores the need for evaluation of the entire colon as part of lifelong follow-up of the colorectal cancer patient.

A mutation in the tRNAAsp gene from yeast mitochondria. Effects on RNA and protein synthesis.

We have characterized a mutation that affects the tRNAAsp coded by yeast mitochondrial DNA. Comparison of the DNA sequences of the tRNAAsp gene from a wild type strain and the mutant demonstrates that the mutant differs by a C to U base change in position 72 of the tRNA. This mutation abolishes mitochondrial protein synthesis, presumably because the tRNAAsp made from this gene cannot be charged with aspartic acid (FAye, G., Bolotin-Fukuhara, M., and Fukuhara, H. (1976) in The Genetics and Biogenesis of Chloroplasts and Mitochondria (Bucher, C. T., Neupert, W., Sebalt, W., and Werner, S., eds) pp. 547-555, North Holland Publishing Co., Amsterdam). It also reduces the amount of tRNAAsp transcripts in the mutant as compared to the wild type.

Identification and consequences of a guanosine-15 to adenosine-15 change in the yeast mitochondrial tRNASerUCX gene.

We have characterized a mutation affecting the yeast mitochondrial tRNASerUCX. The mutation is a single nucleotide substitution located within the structural portion of the tRNASerUCX gene which causes the strain to be respiratory deficient. The substitution is a G leads to A transition located in the dihydrouridine arm. The tRNASerUCX transcripts from the mutant gene are present in the same amount and are the same size as transcripts from the wild-type gene. The mutant tRNASerUCX can be charged in vitro with mitochondrial aminoacyl-tRNA synthetase. Mitochondrial protein synthesis does occur in the mutant, but the amount of cytochrome oxidase subunit I is significantly decreased relative to other mitochondrial translation products.

Content knowledge and problem-solving skill in reviewing medical charts.

Skills in reviewing medical charts have been demonstrated components of clinical competence related to knowledge base, level of clinical experience, and basic observational skills. A study of the generalizability of performance on chart review exercises, which controlled for knowledge in the content area, was undertaken to determine their potential in evaluating students' problem-solving ability. Results of the study indicate that the case specificity which has characterized simulated problem-solving tasks is largely case, rather than content, specificity: correlations between scores on single charts demonstrated no consistent relationships for measures of proficiency, efficiency, and diagnostic accuracy. However, averaging the scores on two charts and then computing correlations resulted in significant positive measures for both proficiency and efficiency. The effects of length and difficulty level on the generalizability of tests of problem-solving ability are areas suggested for future research.

Vascular surgery in the United States. Report of the Joint Society for Vascular Surgery--International Society for Cardiovascular Surgery Committee on Vascular Surgical Manpower.

The Joint Committee on Vascular Surgical Manpower was established in 1985 by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. It was charged to provide recommendations regarding vascular surgical manpower requirements for the next 15 years. Analysis of National Center for Health Statistics vascular operative rate data and 1690 questionnaire responses from vascular surgeons documented that vascular surgeons performed 235,400 (41%) of the total of 571,000 vascular operations undertaken in 1985. Vascular surgeons performed 87% of 30,000 aortoiliofemoral reconstructions, 77% of 72,000 peripheral vessel bypasses, 75% of 33,000 abdominal aortic aneurysm repairs, 59% of 55,000 angioaccess procedures, and 50% of 107,000 carotid endarterectomies. However, lack of accurate data on caseloads of surgeons who were not vascular specialists precludes precise prediction of manpower requirements for vascular surgery. It is important that surgical leaders and policy makers define the types of vascular surgical procedures that may be undertaken by vascular and other surgeons. Ongoing analyses must include such determinations to establish accurate data for the prediction of future manpower needs for vascular surgery. Furthermore, future manpower studies should be linked to outcome studies to assess not only numbers of surgeons and operations but quality of care as well.