Traumatic and spontaneous carotid and vertebral artery dissection in a level 1 trauma center.

This study aimed to compare traumatic and spontaneous carotid artery dissection (CAD) and vertebral artery dissection (VAD) with respect to age, pre-morbid risk factors, and site of dissection. Chart review was performed for 49 patients with CAD and VAD admitted to Westchester Medical Center, a level 1 trauma center, from 1999 to 2007. Presentation was categorized into traumatic (n=28, 57%) or spontaneous dissection (n=21, 43%). Pre-morbid risk factors were analyzed. Location of dissection was identified and categorized into four possible segments. Patients with spontaneous dissection were likely to be over the age of 50 years (p<0.05), and had significantly higher proportions of coronary artery disease (33% compared to 7%, p<0.05), hypertension (57% compared to 18%; p<0.01), and hypercholesterolemia (29% compared to 0%; p<0.01). Of the 49 patients, 42 had imaging studies available for segmental analysis. In both traumatic CAD and VAD, dissection at Segment III (corresponds with the first and second cervical vertebrae), was the most common site (37.5% and 50%, respectively, p<0.05). In contrast, Segment I (origin of the vessel to the fifth cervical vertebrae) was the most common site for spontaneous CAD and VAD (55% and 77%, respectively, p<0.05). This cross-sectional study suggests that etiology plays an important role in the location of dissection. Traumatic CAD and VAD occur most commonly in Segment III. Spontaneous CAD and VAD occur most commonly in Segment I and are associated with increasing age and premorbid cerebrovascular risk factors.

The role of blinded interviews in the assessment of surgical residency candidates.

BACKGROUND: Interview assessments of surgical residency candidates may be biased by prior knowledge of objective data. METHODS: Each candidate (site 1: n = 88; site 2: n = 44) underwent two interviews, one by faculty members informed only of a candidate's medical school, the second with prior knowledge of the complete application. Interviewers (site 1: n = 28; site 2: n = 14) independently rated candidates overall and on nine qualitative characteristics. RESULTS: At site 1 only, overall ratings were significantly more favorable for unblinded than blinded interviews (23.0 +/- 17.7 versus 32.6 +/- 23.1, P < 0.01). Blinded and unblinded overall ratings correlated -0.01 (P = 0.90) and 0.31 (P = 0.05) at sites 1 and 2, respectively. At site 1 only, overall ratings correlated significantly with USMLE scores, but in opposite directions for blinded (r = 0.32, P = 0.003) versus unblinded interviews (r = -0.32, P = 0.003). CONCLUSION: Interview assessments may be influenced by objective data, and faculty and program variables. The value of blinded interviewing may vary as a function of individual program characteristics.

Surgeon-specific factors in the acquisition of laparoscopic surgical skills.

BACKGROUND: Training and experience vary widely among surgeons performing laparoscopic surgery (LS). Visual perceptual demands are greater for LS than for traditional surgery, necessitating greater understanding of surgeon variables in skill acquisition and performance. METHODS: During an LS skills course incorporating didactic and simulator-based instruction, 94 surgeons completed an experience/demographic questionnaire, a test of course-specific knowledge acquisition, 10 trials of three dexterity drills, 15 suturing trials using course-specific methods, and 3 standardized tests of visual perception. RESULTS: Age, years posttraining, and visual perception correlated significantly with time required to complete drills and suturing trials (Pearson correlations ranged from r = 0.21, P <0.05, to r = 0.51, P <0.001) even after statistically controlling for variations in knowledge acquisition, which correlated (r = 0.30, P <0.01) with suturing speed. CONCLUSIONS: Surgeon variables play a significant role in speed of acquisition and performance of LS skills. Further studies need to elucidate their role in quality of LS performance.

The effects of practice and instruction on speed and accuracy during resident acquisition of simulated laparoscopic skills.

To assess the effects of practice and dynamic instruction on changes in speed and accuracy during acquisition of simulated laparoscopic surgical skills.Fourteen PGY-1 general surgery residents were randomly assigned to 1 of 2 experimental conditions (n = 7 per group), either practice only or practice with instruction, and required to perform 10 trials of each of 2 laparoscopic surgical skills-cannulation and object passing. Practice only subjects were given verbal instructions for each task, and corrective feedback only after trial 1. Practice with instruction subjects were treated the same, but also saw a videotaped demonstration and received dynamic feedback during and between each trial. Performance speed was recorded for each trial and number of errors was recorded for trials 8 to 10 by videotape review.Mean speed for subjects in both groups increased significantly for both tasks (p < 0.01). Practice with instruction subjects committed significantly fewer errors on object passing (p < 0.04) and were less variable in the number of errors committed during the cannulation task (p < 0.01).Practice, with or without dynamic instruction, results in significant improvement in the speed of performance of simulated laparoscopic surgical skills. The addition of dynamic instruction to simulator-based practice improves the quality and consistency of resident acquisition of laparoscopic surgical skills.

Experience and visual perception in resident acquisition of laparoscopic skills.

Assess the role of experience and visual perception (VP) in resident acquisition of laparoscopic surgical skills (LSS).Thrity-nine residents (20 PGY-1s tested just before starting residency; 19 PGY 3+) completed an LSS course, including examination of course-specific knowledge before and after didactic tutorials, 10 trials of 3 dexterity drills and suturing, and 3 standardized VP tests.Mean speed increased significantly (p < 0.001) across trials for all dexterity drills and suturing. Senior residents performed suturing trials 1 to 4 significantly faster (p < 0.05) than did PGY 1's (M +/- SD averaged across trials 1 to 4: 166.5 +/- 59.9 vs 252.3 +/- 108.2 seconds, p < 0.01). Group differences on later trials were progressively smaller and nonsignificant, as were all group differences on dexterity drills. Significant correlations between VP and speed on drills ranged from (r = -0.41, p < 0.01) to (r = -0.71, p < 0.001). Visual perception did not correlate significantly with suturing speed; neither pretest nor posttest scores correlated significantly with drill or suturing speeds.Residents at all levels can significantly increase LSS performance speed to comparable levels during a brief intensive skills course. Proficiency in specific aspects of VP is directly associated with performance speed on dexterity drills, shown in previous studies to be fundamental in the development of intracorporeal suturing skill. (Curr Surg 57:368-372. Copyright 2000 by the Association of Program Directors in Surgery.)

Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training.

BACKGROUND: Computer-assisted instruction (CAI) can benefit surgical education by improving efficiency, effectiveness, standardization, and access. This study compares knowledge gains for laparoscopic skill acquisition following a standardized tutorial delivered via CD-ROM versus live instructor. METHODS: A standardized tutorial was written and subsequently converted to multimedia CD-ROM format by its author (JR). During a laparoscopic development course, experienced US-trained surgeons (n = 52) participated in the tutorial delivered live by the author. The CD-ROM tutorial replaced the instructor for the following groups: (1) experienced US-trained surgeons (n = 27); (2) US-trained surgical residents (n = 59); and (3) Greek surgeons (n = 63). A 51-item knowledge test was administered before and after tutorial instruction. RESULTS: The mean increase in scores between pretest and posttest was significant (P <0.01) and of similar magnitude in each group, with nonsignificant posttest mean differences among US-trained groups. CONCLUSIONS: The CD-ROM tutorial effectively transfers cognitive information necessary for skill development. Distance learning modes of this tutorial program may be feasible.

Interobserver variability among faculty in evaluations of residents' clinical skills.

OBJECTIVE: To describe interobserver variability among emergency medicine (EM) faculty when using global assessment (GA) rating scales and performance-based criterion (PBC) checklists to evaluate EM residents' clinical skills during standardized patient (SP) encounters. METHODS: Six EM residents were videotaped during encounters with SPs and subsequently evaluated by 38 EM faculty at four EM residency sites. There were two encounters in which a single SP presented with headache, two in which a second SP presented with chest pain, and two in which a third SP presented with abdominal pain, resulting in two parallel sets of three. Faculty used GA rating scales to evaluate history taking, physical examination, and interpersonal skills for the initial set of three cases. Each encounter in the second set was evaluated with complaint-specific PBC checklists developed by SAEM's National Consensus Group on Clinical Skills Task Force. RESULTS: Standard deviations, computed for each score distribution, were generally similar across evaluation methods. None of the distributions deviated significantly from that of a Gaussian distribution, as indicated by the Kolmogorov-Smirnov goodness-of-fit test. On PBC checklists, 80% agreement among faculty observers was found for 74% of chest pain, 45% of headache, and 30% of abdominal pain items. CONCLUSIONS: When EM faculty evaluate clinical performance of EM residents during videotaped SP encounters, interobserver variabilities are similar, whether a PBC checklist or a GA rating scale is used.

Comparison of analgesics in ameliorating the pain of circumcision.

OBJECTIVE: Our objective was to compare two methods of pain control during neonatal circumcision: a sucrose-dipped pacifier and an analgesic cream (EMLA). STUDY DESIGN: This study was conducted in our well-baby nursery where 80 male infants were placed into one of four groups: control (water-dipped pacifier only), sucrose alone, EMLA alone, or sucrose and EMLA. Heart rate, oxygen saturation, systolic and diastolic blood pressure, and crying time were measured as indicators of pain. The primary data analysis was a 2 x 2 factorial analysis of variance with repeated measures. RESULTS: Physiologic and behavioral parameters indicated significantly (p < 0.05) decreased pain response in all treatment groups compared with that in the control group. The combination of sucrose and EMLA was most effective in reducing pain responses; sucrose alone was significantly less effective. There were no side effects of treatment. CONCLUSION: Pain during neonatal circumcision can be optimally ameliorated by combined use of a sucrose-dipped pacifier and a local analgesic cream.

A neuropsychological approach to the assessment of adults with learning disabilities in vocational rehabilitation.

A description of cognitive, academic, and personality characteristics of adults with learning disabilities (LD) referred for services through the state/federal vocational rehabilitation system is presented. This study builds on the work of Minskoff, Hawks, Steidle, and Hoffmann (1989) and validates their conclusions that, as a group, adults with LD participating in vocational rehabilitation are homogeneous relative to other groups of adults with LD. By taking a neuropsychological approach to the assessment process, the current study further subdivided the assessment categories described by Minskoff et al. This approach assumes that the vocational competence of adults with learning disabilities may be better understood in terms of their visual and auditory perception; verbal and nonverbal reasoning; verbal and mixed (verbal/nonverbal) learning; linguistic and nonlinguistic memory; semantic, expressive, and receptive language; basic and conceptual academic skills; and social and psychological adjustments. The data analyses identify several potential patterns of psychosocial and neuropsychological strengths and weaknesses that may be important in vocational rehabilitation efforts.

Cerebroprotective effects of aminoguanidine in a rodent model of stroke.

BACKGROUND AND PURPOSE: During a cerebral infarction, a complex cascade of cytotoxic events ultimately determines the volume of brain cell loss. The studies presented here demonstrate that aminoguanidine, an experimental therapeutic currently in clinical trials to prevent diabetic complications, is cerebroprotective in focal cerebral infarction. METHODS: Adult Lewis rats (n = 6 to 12 per group) were anesthetized with ketamine and subjected to focal cerebral infarction by tandem permanent occlusion of the right middle cerebral artery and ipsilateral common carotid artery (CCA), followed by temporary occlusion of the contralateral CCA. Infarct volume (cortical) was assessed 24 hours after the onset of ischemia by planimetric analysis of coronal brain slices stained with tetrazolium. RESULTS: Aminoguanidine (320 mg/kg IP) administered 15 minutes after the onset of ischemia resulted in a significant reduction of infarct volume (7.6 +/- 2.6% of hemisphere in controls versus 1.3 +/- 0.2% of hemisphere in aminoguanidine-treated rats; P < .05). Administration of aminoguanidine conferred significant cerebroprotection even when administered 1 or 2 hours after the onset of ischemia (88% and 85% reduction from control, respectively; P < .05). Cerebroprotection by aminoguanidine was independent of systemic physiological variables known to influence stroke size (eg, temperature, mean arterial blood pressure, blood glucose, and arterial pH, PCO2, and PO2). CONCLUSIONS: These results indicate that the stroke-reducing properties of aminoguanidine are dose and time dependent, with substantial cerebroprotection persisting even with drug delivery up to 2 hours after the onset of ischemia. It is now plausible to pursue development of aminoguanidine as an experimental therapeutic in stroke, and possible mechanisms of these cerebroprotective effects are under consideration.

Neurotoxicity of advanced glycation endproducts during focal stroke and neuroprotective effects of aminoguanidine.

Cerebral infarction (stroke) is a potentially disastrous complication of diabetes mellitus, principally because the extent of cortical loss is greater in diabetic patients than in nondiabetic patients. The etiology of this enhanced neurotoxicity is poorly understood. We hypothesized that advanced glycation endproducts (AGEs), which have previously been implicated in the development of other diabetic complications, might contribute to neurotoxicity and brain damage during ischemic stroke. Using a rat model of focal cerebral ischemia, we show that systemically administered AGE-modified bovine serum albumin (AGE-BSA) significantly increased cerebral infarct size. The neurotoxic effects of AGE-BSA administration were dose- and time-related and associated with a paradoxical increase in cerebral blood flow. Aminoguanidine, an inhibitor of AGE cross-linking, attenuated infarct volume in AGE-treated animals. We conclude that AGEs may contribute to the increased severity of stroke associated with diabetes and other conditions characterized by AGE accumulation.

Personality, clinical performance and knowledge in paediatric residents.

This study examines the relationship between personality, knowledge and teachers' evaluations of paediatric residents at a large, urban teaching hospital. All residents (n = 30) were graduates of foreign medical schools. Each resident completed the Myers-Briggs Type Indicator (MBTI) as a measure of personality and was rated (on a scale of 1-7) by teachers on each of 35 items representing 14 different aspects of clinical performance. These data were correlated with performance on the American Board of Pediatrics In-training Examination (ABPITE), and with demographic data. Ratings of knowledge were directly associated with scores on the ABPITE (r = 0.51, P < 0.01) and with the MBTI continuous score for extraversion (r = 0.51, P < 0.01), but inversely associated with age (r = -0.41, P < 0.01). ABPITE scores were also associated directly with MBTI Extraversion (r = 0.44, P < 0.01) and inversely with age (r = -0.56, P < 0.001). Age and MBTI Extraversion were independently significant predictors of ABPITE (Multiple R = 0.64, P < 0.01) and ratings of knowledge (Multiple R = 0.59, P < 0.01). Results suggest that teachers' evaluations of knowledge have validity, and that age and introversion/extroversion play a significant role in both subjective and objective evaluations of paediatric knowledge. Demographic and personality variables may be predictive of knowledge acquisition, but are unrelated to many dimensions of clinical performance.

Reliability and accuracy of resident evaluations of surgical faculty.

This study examines the reliability and accuracy of ratings by general surgery residents of surgical faculty. Twenty-three of 33 residents anonymously and voluntarily evaluated 62 surgeons in June, 1988; 24 of 28 residents evaluated 64 surgeons in June, 1989. Each resident rated each surgeon on a 5-point scale for each of 10 areas of performance: technical ability, basic science knowledge, clinical knowledge, judgment, peer relations, patient relations, reliability, industry, personal appearance, and reaction to pressure. Reliability analyses evaluated internal consistency and interrater correlation. Accuracy analyses evaluated halo error, leniency/severity, central tendency, and range restriction. Ratings had high internal consistency (coefficient alpha = 0.97). Interrater correlations were moderately high (average Pearson correlation = 0.63 among raters). Ratings were generally accurate, with halo error most prevalent and some evidence of leniency. Ratings by chief residents had the least halo. Results were generally replicable across the two academic years. We conclude that anonymous ratings of surgical faculty by groups of residents can provide a reliable and accurate evaluation method, ratings by chief residents are most accurate, and halo error may pose the greatest threat to accuracy, pointing to the need for greater definition of evaluation items and scale points.

Resident evaluation of surgical faculty.

This study examines the association between resident evaluations of surgical faculty and measures of teaching activity and practice characteristics. Twenty-three of 33 general surgery residents, anonymously and voluntarily rated 62 faculty surgeons in 10 areas of performance. This was repeated 1 year later with 24 of 28 residents and 64 surgeons. Ratings were reliable (test-retest on overall mean rating, r = 0.91, P less than 0.01). Factor analysis of ratings by residents in postgraduate year (PGY) 5 extracted a judgment factor and an interpersonal skills factor. Ratings by other PGYs were unidimensional. Faculty subgroups that performed more than two major procedures per week at the hospital (P less than 0.01) attended the weekly Mortality and Morbidity conference more than once per month (P less than 0.05) and/or published one or more research reports (P less than 0.05) received higher ratings than those who did not. Among general surgeons (n = 35), ratings of interpersonal skill by PGY 5 residents correlated inversely with complication rate (r = -0.41, P less than 0.05) and overall ratings by PGYs 3 and 4 correlated inversely with mean patient length-of-stay (LOS; r = -0.44, P less than 0.05). These remained significant after statistical adjustment for case mix differences and differences in the amount of contact with residents. Resident ratings were unrelated to mean patient age, the mean number of diagnoses per patient, and the mean number of procedures per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

In-hospital cardiopulmonary resuscitation: patient, arrest and resuscitation factors associated with survival.

Data on 470 adults with single in-hospital cardiac arrest resuscitations were analyzed to determine 24-h and discharge survival rates and to identify significant correlates of survival. One hundred fifty-three (33%) patients were alive 24 h after initiation of cardiopulmonary resuscitation; 69 (45% of 24-h survivors, 15% of all patients) were discharged alive. Logit analysis identified the following independently significant correlates of 24-h survival: arrest locations other than emergency room or cardiac care unit, CPR duration less than 15 min, non-cardiac primary diagnosis, non-asystolic dysrhythmia, less than one intravenous and one drip-administered inotrope and absence of pacemaker insertion and defibrillation. Fifty-one (94%) of 54 patients with all of these characteristics were alive 24 h after initiation of CPR. The same variables, as well as age less than 68 years and absence of intubation were statistically associated with discharge survival. Nine (64%) of 14 patients with all of these characteristics were discharged alive. Increased intervention was generally associated with increased mortality. Overall survival rates replicate previous reports and may reflect the effects of diagnosis-related groups policies on the average illness severity of the in-patient population, rather than failure of current CPR methods to improve the probability of survival. Use of the data as baseline for future studies and as a source of hypotheses for research on decision making are discussed.

A methodological framework for the design of research on the evaluation of residents.

This paper describes a construct validation framework for research on the selection and evaluation of residents. The application of the proposed methodology to surgery residents is described. The need to measure non-cognitive and neuropsychological factors in addition to cognitive knowledge and technical ability is emphasized, and a research strategy that integrates theory formulation, internal validation, and external validation is presented. In this context, residents' competence is viewed as a multivariate construct that requires validation through longitudinal empirical studies and the use of multivariate statistical approaches.

Ratings of surgical residents by self, supervisors and peers.

Ratings by self, supervisors and peers of surgical residents were compared and contrasted, and the correlation between these ratings and the scores on the American Board of Surgery In-Training Examination (ABSITE) were studied. In addition, comparisons were made between ratings by residents of their peers (n = 32) and of attending surgeons (n = 61) with whom they had worked. The ratings consisted of scores from 1 to 5 in each of ten areas of clinical competence. Results indicated that over-all ratings by peers and supervisors were highly intercorrelated (r = 0.92; p less than 0.001) and that the average of over-all ratings by peers and supervisors correlated moderately with the total raw score on ABSITE (r = 0.58; p less than 0.01). Factor analyses suggested that the dimensions underlying the three sets of ratings differed considerably. It appeared that ratings by supervisors were influenced primarily by the interpersonal skills of the residents and secondarily by ability. In contrast, self-ratings by the residents were apparently mainly influenced by their perceptions of their own ability, followed by interpersonal skills and effort. Ratings by peers, on the other hand, seemed to reflect the over-all impression of the peers of the resident being rated. Comparisons between ratings of peers and attending surgeons by residents revealed that residents view attending surgeons as having a more balanced level of competence, across areas of both ability and interpersonal skills. Ratings of peers were lower than were the ratings of attending physicians by the residents in the areas of technical ability, knowledge of basic science and clinical knowledge.(ABSTRACT TRUNCATED AT 250 WORDS)

In-hospital cardiopulmonary resuscitation during asystole. Therapeutic factors associated with 24-hour survival.

The most recent American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) during asystole include ventricular defibrillation, intubation, and the administration of epinephrine and atropine. This study reports results from a retrospective analysis of clinical, demographic, and treatment data collected during in-hospital CPR efforts in 123 patients in whom the initial rhythm was asystole. Twenty-eight (22.8 percent) of these patients were alive 24 h after CPR initiation. Patients who received norepinephrine drip (N = 43) were more likely to survive than those who did not (39.5 percent vs 14.1 percent; p less than .01), and those who received lidocaine drip were more likely to survive than those who did not (47.6 percent vs 18.2 percent; p less than .01). The best survival rate (57.1 percent) occurred among those who received both norepinephrine and lidocaine (N = 14). Survivors did not differ significantly from nonsurvivors in terms of age, gender, primary diagnosis, location of arrest, or duration of CPR efforts. The results suggest that aggressive resuscitation efforts which include the addition of norepinephrine and lidocaine drips to the AHA-recommended regimen of epinephrine and atropine may substantially increase the number of 24-h survivors. A pharmacologic mechanism involving norepinephrine-induced myocardial irritability and peripheral vasoconstriction, combined with lidocaine-induced suppression of abnormal automaticity, is offered as a possible explanation of the obtained results.