Cutting seton for the treatment of cryptoglandular fistula-in-ano: a systematic review and meta-analysis.

BACKGROUND: The use of cutting seton (CS) for the management of cryptoglandular fistula-in-ano has remained controversial because of reports of fecal incontinence, postoperative pain, and extended healing time. The aim of this review was to provide the first synthesis of studies investigating the use of CS for the treatment of cryptoglandular fistula-in-ano. METHODS: MEDLINE, Embase, and CENTRAL were searched up to October 2022. Randomized controlled trials and observational studies comparing CS with alternative interventions were included, along with single-arm studies evaluating CS alone. The primary outcome was fistula-in-ano recurrence, and secondary outcomes included incontinence, healing time, proportion with complete healing, and postoperative pain. Inverse variance random-effects meta-analyses were used to pool effect estimates. RESULTS: After screening 661 citations, 29 studies were included. Overall, 1513 patients undergoing CS (18.8% female, mean age: 43.1 years) were included. Patients with CS had a 6% (95% CI: 3-12%) risk of recurrence and a 16% (95% CI: 5-38%) risk of incontinence at 6 months. CS patients had an average healing time of 14.6 weeks (95% CI: 10-19 weeks) with 73% (95% CI: 48-89%) of patients achieving complete healing at 6 months postoperatively. There was no difference in recurrence between CS and fistulotomy, advancement flap, two-stage seton fistulotomy, or draining seton. CONCLUSIONS: Overall, this analysis shows that CS has comparable recurrence and incontinence rates to other modalities. However, this may be at the expense of more postoperative pain and extended healing time. Further comparative studies between CS and other modalities are warranted.

Burden of Silicosis among stone crushing workers in India.

BACKGROUND: In North India, the mining industry is disorganized and profit-driven. It predisposes its workers towards the development of silicosis. Haryana, a major North Indian state, has developed a compensation-rehabilitation policy for mining workers. AIMS: This study is the review of the policy's functioning and limitation from the first 4 years of implementation. METHODS: The labour department does surveillance of workers in the mining industry. All suspected cases of silicosis are evaluated by a multidisciplinary team. Based on the final diagnosis, the compensation is decided. RESULTS: Nearly 5000 workers were screened, and 729 appeared before the medical board. Of these 729, 465 were having silicosis, and their data are presented here (data of 7 patients were missing). All workers were males. The mean age was 44.54 ± 9.6 years, and the mean exposure (work experience) was 17.25 ± 6.7 years. Most of the workers were between the age of 40 and 50 years and had exposure for 10-20 years. Chest radiography examination showed that progressive massive fibrosis (large size type C opacities) was the most common type of presentation (23%). Smaller opacities (p, q, r and s, t, u) were combined for further analysis, given their similar prognostic significance. It was found that age and experience both had a linear and significant correlation with the severity of lung involvement. CONCLUSIONS: Nearly a quarter of subjects were suffering from the worst type of lung involvement at screening itself. The policy has laid a foundation for the welfare of workers, but there is still a long way to go.

SDH-deficient renal cell carcinoma: a clinicopathological analysis highlighting the role of genetic counselling.

Succinate dehydrogenase (SDH)-deficient renal cell carcinoma (RCC) accounts for 0.05-2% of all RCCs. The majority of patients have germline mutations, most frequently in the SDHB gene. People with these mutations are predisposed to developing paragangliomas, phaeochromocytomas and gastrointestinal stromal tumours. Patients should be referred to genetic services for further workup and close surveillance imaging due to the risk of development of further tumours. We present a woman with SDH-deficient RCC and review the literature associated with this uncommon entity.

Assessment of the Non-Technical Skills for Surgeons (NOTSS) framework in the USA.

BACKGROUND: Surgeons' non-technical skills are important for patient safety. The Non-Technical Skills for Surgeons assessment tool was developed in the UK and recently adapted to the US surgical context (NOTSS-US). The aim of this study was to evaluate the reliability and distribution of non-technical skill ratings given by attending (consultant) surgeons who underwent brief online training. METHODS: Attending surgeons across six specialties at a large US academic medical centre underwent a 10-min online training, then rated 60-s standardized videos of simulated operations. Intraclass correlation coefficient (ICC), and mean(s.d.) values for NOTSS-US ratings were determined for each non-technical skill category (score range 1-5, where 1 indicates poor, 3 average and 5 excellent) and for total NOTSS-US score (range 4-20; sum of 4 category scores). Outcomes were adjusted for rater characteristics including sex, specialty and clinical experience. RESULTS: A total of 8889 ratings were submitted by 81 surgeon raters on 30 simulated intraoperative videos. The mean(s.d.) total NOTSS-US score for all videos was 9·5(4·8) of 20. The within-video ICC for total NOTSS-US score was 0·64 (95 per cent c.i. 0·57 to 0·70). For individual non-technical skill categories, the ICC was highest for social skills (communication/teamwork: 0·63, 95 per cent c.i. 0·56 to 0·71; leadership: 0·64, 0·55 to 0·72) and lowest for cognitive skills (situation awareness: 0·54, 0·45 to 0·62; decision-making: 0·50, 0·41 to 0·59). Women gave higher total NOTSS-US scores than men (adjusted mean difference 0·93, 95 per cent c.i. 0·44 to 1·43; P = 0·001). CONCLUSION: After brief online training, the inter-rater reliability of the NOTSS-US assessment tool achieved moderate strength among trained surgeons rating simulated intraoperative videos.

ANTECEDENTES: Las habilidades no técnicas de los cirujanos (Non-Technical Skills for Surgeons, NOTSS) son importantes para la seguridad del paciente. La herramienta de evaluación de habilidades no técnicas para cirujanos se desarrolló en el Reino Unido y se adaptó recientemente al contexto quirúrgico de los Estados Unidos (NOTSS-US.). El objetivo de este estudio fue evaluar la fiabilidad y distribución de las calificaciones de habilidades no técnicas obtenidas por cirujanos adjuntos de cirugía (consultores) que recibieron una breve formación online. MÉTODOS: Cirujanos adjuntos de 6 especialidades en un gran centro universitario de Estados Unidos recibieron una formación online de 10 minutos de duración y seguidamente puntuaron vídeos estandarizados de operaciones simuladas de 60 minutos de duración. Se calcularon el coeficiente de correlación intraclase (intraclass correlation coefficient, ICC), la media y la desviación estándar (standard deviation, SD) para la puntuación de cada categoría de habilidad no técnica del NOTSS-US (rango 1-5, siendo 1 = pobre, 3 = promedio, 5 = excelente) y para la puntuación global de NOTSS-US (rango 4-20, suma de las puntuaciones de las cuatro categorías). Los resultados se ajustaron de acuerdo con las características del evaluador, incluyendo sexo, especialidad, experiencia clínica. RESULTADOS: En 30 videos intraoperatorios simulados, 81 cirujanos evaluadores proporcionaron 8.889 puntaciones. La puntuación media global de NOTSS-US para todos los vídeos fue de 9,5 sobre 20 (SD 4,8). El ICC de los vídeos para la puntuación global de NOTSS-US fue 0,64 (i.c. del 95% 0,57-0,70). Para las categorías individuales de habilidades no técnicas, el ICC más alto fue para las habilidades sociales (comunicación / trabajo en equipo: 0,63, (i.c. del 95% 0,56-0,71); liderazgo, 0,64 (i.c. del 95% 0,55-0,72)) y el más bajo para las habilidades cognitivas (conciencia de la situación 0,54 (i.c. del 95% 0,45-0,62); toma de decisiones 0,50 (i.c. del 95% 0,41-0,59)). Las evaluadoras femeninas presentaron puntuaciones globales de NOTSS-US más altas que los evaluadores masculinos (diferencia 0,93, i.c. del 95% 0,44-1,43; P = 0,001)). CONCLUSIÓN: Después de una breve formación online, la fiabilidad de la herramienta de evaluación NOTSS-US mostró una correlación moderada entre los cirujanos que puntuaron vídeos de simulaciones de intervenciones quirúrgicas.

Development and evaluation of the General Surgery Objective Structured Assessment of Technical Skill (GOSATS).

BACKGROUND: Technical skill acquisition is important in surgery specialty training. Despite an emphasis on competency-based training, few tools are currently available for direct technical skills assessment at the completion of training. The aim of this study was to develop and validate a simulated technical skill examination for graduating (postgraduate year (PGY)5) general surgery trainees. METHODS: A simulated eight-station, procedure-based general surgery technical skills examination was developed. Board-certified general surgeons blinded to the level of training rated performance of PGY3 and PGY5 trainees by means of validated scoring. Cronbach's α was used to calculate reliability indices, and a conjunctive model to set a pass score with borderline regression methodology. Subkoviak methodology was employed to assess the reliability of the pass-fail decision. The relationship between passing the examination and PGY level was evaluated using χ2 analysis. RESULTS: Ten PGY3 and nine PGY5 trainees were included. Interstation reliability was 0·66, and inter-rater reliability for three stations was 0·92, 0·97 and 0·76. A pass score of 176·8 of 280 (63·1 per cent) was set. The pass rate for PGY5 trainees was 78 per cent (7 of 9), compared with 30 per cent (3 of 10) for PGY3 trainees. Reliability of the pass-fail decision had an agreement coefficient of 0·88. Graduating trainees were significantly more likely to pass the examination than PGY3 trainees (χ2  = 4·34, P = 0·037). CONCLUSION: A summative general surgery technical skills examination was developed with reliability indices within the range needed for high-stakes assessments. Further evaluation is required before the examination can be used in decisions regarding certification.

ANTECEDENTES: La adquisición de habilidades técnicas es importante en el entrenamiento especializado en cirugía. A pesar del énfasis en la capacitación basada en competencias, actualmente hay pocas herramientas disponibles para la evaluación directa de habilidades técnicas al finalizar el periodo de formación. El objetivo de este estudio fue desarrollar y validar un examen simulado de habilidades técnicas para postgraduados en formación en cirugía general (5º año postgraduado). MÉTODOS: Se desarrolló un examen simulado de habilidades técnicas de procedimientos de ocho estaciones. Cirujanos generales certificados y ciegos respecto al nivel de formación puntuaron la actuación de 10 postgraduados de tercer año (PGY3) y 9 postgraduados de quinto año (PGY5) usando una puntuación validada. Se utilizó el coeficiente alfa de Cochrane para calcular los índices de fiabilidad, y un modelo conjuntivo para establecer la nota de paso del examen mediante un método de regresión borderline. La fiabilidad de la decisión pasar/no pasar el examen se evaluó usando la metodología Subkoviak. La relación entre pasar el examen y el nivel PGY se analizó mediante la prueba de ji al cuadrado. RESULTADOS: La fiabilidad entre estaciones fue de 0,66 y la fiabilidad entre evaluadores de 0,92, 0,97 y 0,76. Se estableció una puntuación para pasar el examen de 176,8/280 (63,1%). La tasa de paso del examen para postgraduados PGY5 fue del 78% (7/9) en comparación con el 30% (3/10) para los posgraduados PGY3. La fiabilidad de la decisión pasar/no pasar fue pₒ= 0,88. Los postgraduados PGY5 presentaban una probabilidad significativamente superior de pasar el examen en comparación con los postgraduados PGY3 (χ2 = 4,34, P = 0,037). CONCLUSIÓN: Se desarrolló un examen sumatorio de habilidades técnicas de cirugía general con índices de fiabilidad dentro del rango necesario para este tipo de valoraciones. Se requiere una evaluación adicional antes de que el examen se pueda utilizar en las decisiones de certificación.

Flow cytometric osmotic fragility test and eosin-5'-maleimide dye-binding tests are better than conventional osmotic fragility tests for the diagnosis of hereditary spherocytosis.

INTRODUCTION: Hereditary spherocytosis (HS) is the most common inherited hemolytic anemia with heterogeneous clinico-laboratory manifestations. We evaluated the flow-cytometric tests: eosin-5'-maleimide (EMA) and flow-cytometric osmotic fragility test (FOFT) and the conventional osmotic fragility tests (OFT) for the diagnosis of hereditary spherocytosis (HS). METHODS: One hundred two suspected HS patients underwent EMA, FOFT, incubated OFT (IOFT), and room temperature OFT (RT-OFT). In addition, 10 cases of immune hemolytic anemia (IHA) were included, and performance of the above 4 tests was evaluated. For EMA and FOFT, 5 normal controls were assessed together with the patients and cutoffs were calculated using receiver-operator-characteristics curve (ROC) analysis. RESULTS: The best cutoff for %EMA decrease was 12.5%, and for FOFT, %residual red cells (%RRC) was 25.6%. The sensitivity and specificity of RT-OFT was 62.06% and 86.3%, respectively, while that of IOFT was 79.31% and 87.67%, respectively. Both flow cytometric tests performed better. Sensitivity and specificity of EMA was 86.2% and 93.9% respectively, and that of FOFT was 96.6% and 98.63%, respectively. The combination of the FOFT with IOFT or EMA dye-binding test yields a sensitivity of 100%, but with EMA, it had a higher specificity. Hb/MCHC was a predictor of the severity of the disease while %EMA decrease and %RRC did not correlate with severity of the disease. CONCLUSION: Flow-cytometric osmotic fragility test is the best possible single test followed by EMA for diagnosis of HS. A combination of FOFT and EMA can correctly diagnose 100% patients. These tests are likely to replace conventional OFTs in future.

A novel thermal detection method based on molecularly imprinted nanoparticles as recognition elements.

Molecularly Imprinted Polymers (MIPs) are synthetic receptors that are able to selectively bind their target molecule and, for this reason, they are currently employed as recognition elements in sensors. In this work, MIP nanoparticles (nanoMIPs) are produced by solid-phase synthesis for a range of templates with different sizes, including a small molecule (biotin), two peptides (one derived from the epithelial growth factor receptor and vancomycin) and a protein (trypsin). NanoMIPs are then dipcoated on the surface of thermocouples that measure the temperature inside a liquid flow cell. Binding of the template to the MIP layer on the sensitive area of the thermocouple tip blocks the heat-flow from the sensor to the liquid, thereby lowering the overall temperature measured by the thermocouple. This is subsequently correlated to the concentration of the template, enabling measurement of target molecules in the low nanomolar regime. The significant improvement in the limit of detection (a magnitude of three orders compared to previously used MIP microparticles) can be attributed to their high affinity, enhanced conductivity and increased surface-to-volume ratio. It is the first time that these nanosized recognition elements are used in combination with thermal detection, and it is the first report on MIP-based thermal sensors for determining protein levels. The developed thermal sensors have a high selectivity, fast measurement time (<5 min), and data analysis is straightforward, which makes it possible to monitor biomolecules in real-time. The set of biomolecules discussed in this manuscript show that it is possible to cover a range of template molecules regardless of their size, demonstrating the general applicability of the biosensor platform. In addition, with its high commercial potential and biocompatibility of the MIP receptor layer, this is an important step towards sensing assays for diagnostic applications that can be used in vivo.

Widespread non-adherence to evidence-based maternity care guidelines: a population-based cluster randomised household survey.

OBJECTIVE: To assess the quality of maternity care in an Indian metropolitan city. STUDY DESIGN: Three-stage cluster randomised cross-sectional survey. SETTING: Sixty selected colonies of Delhi. POPULATION: One thousand eight hundred and one subjects (of 2286 eligible) were enrolled from 118 446 houses. Women who had delivered a live viable birth in the past 6 months were selected for the study. METHODS: In stage 1, 20 wards (of 150) were selected using a probability-proportionate-to-size systematic method. In stage 2, one colony from each income stratum (high, middle and low) was selected from each ward by simple random sampling. In stage 3, a house-to-house survey was conducted to recruit 30 women for administering a peer-reviewed and pilot-trialled questionnaire. MAIN OUTCOME MEASURES: Caesarean section rate, induction rate and episiotomy rate. RESULTS: National health targets such as iron supplementation advice (>96%), tetanus vaccination (>81%), and ≥3 antenatal visits (>90%) were largely achieved across health care facilities but not in home deliveries. Interventions were lower in public than private hospitals: caesarean section [23.7% (20.2-27.7) versus 53.8% (49.3-58.3)], induction [20.6% (17.5-24.25) versus 30.8% (26.8-33.2)] and episiotomy [57.8% (52.3-63.1) versus 79.4% (71.0-85.9)]. Private hospitals achieved better labour support rates [1.1% (0.5-2.2) versus 14.6% (8.5-24.1)] and pain relief [0.9% (0.4-2.0) versus 9.9 (6.5-14.8)]. Pubic hair shaving [16.2% (11.5-22.5) versus 36.4% (29.9-43.4)], enema [20.2% (15.5-26.0) versus 57.3% (49.5-64.8)], and IV fluids during labour [44.0% (36.2-52.2) versus 38.7% (29.3-49.1)] were widely prevalent in public and private hospitals. CONCLUSION: Present practices fall short of evidence-based guidelines, with relative overuse of interventions in private hospitals and deficiency of patient-centred practices such as labour support in public hospitals.

Assessment of lingual nerve injury using different surgical variables for mandibular third molar surgery: a clinical study.

The objective of this study was to investigate the incidence of sensory impairment of the lingual nerves following lower third molar removal and to compare the outcome with various operative variables. A total of 1200 mandibular third molars were removed under local anaesthesia. Predictor variables were categorized as lingual flap retraction, tooth sectioning, and buccal guttering. The outcome variable was the presence or absence of lingual nerve impairment. Different operative techniques were performed to identify independent predictors. Of the 1200 patients, 67 (5.6%) experienced transient sensory impairment at the 1-week follow-up. In all cases this resolved completely during the study period, except for four (0.3%) patients who suffered permanent impairment of lingual nerve function. Factors that predicted lingual nerve injury were lingual flap retraction, tooth sectioning, and buccal guttering. The incidence of lingual nerve injury was greater when combinations of these operative variables were used.

Meta-analysis: efficacy of bovine lactoferrin in Helicobacter pylori eradication.

BACKGROUND: Several randomized-controlled trials (RCTs) have sought to determine the efficacy of bovine lactoferrin in Helicobacter pylori eradication with equivocal results. AIM: To evaluate the effect of bovine lactoferrin supplementation in H. pylori eradication. METHODS: Electronic databases, reviews, bibliographies, abstracts and conference proceedings were searched. Included trials had to be randomized or quasi-randomized and controlled, using bovine lactoferrin in the intervention group, treating Helicobacter-infected subjects and evaluating eradication of H. pylori as an outcome. RESULTS: The search identified five eligible RCTs (of 169). Data were available for 682 subjects (bovine lactoferrin group-n = 316; control group-n = 366). The pooled odds ratio (five studies) for eradication by intention-to-treat analysis was 2.22 (95% CI 1.44-3.44; P = 0.0003) using the fixed effects model (FEM) and 2.24 (95% CI 1.15-4.35; P = 0.0003) using the random effects model (REM) (Cochran's Q = 6.83; P = 0.145). The pooled risk difference was 0.11 (95% CI 0.05-0.16; P = 0.0001) by FEM (Cochran's Q = 6.67; P = 0.154) and 0.10 (95% CI 0.04-0.17; P = 0.0023) by REM. There was no significant difference in incidence of adverse effects. CONCLUSION: Bovine lactoferrin potentially improves H. pylori eradication rates without any impact on adverse effects, but available evidence is limited and further research is necessary to confirm the findings.

Elevation of carbohydrate antigen 19.9 in benign hepatobiliary conditions and its correlation with serum bilirubin concentration.

BACKGROUND: Carbohydrate antigen 19.9 (CA19.9), a tumor marker for malignancies of the hepatobiliary tract and pancreas, has frequently been shown to be deranged in a number of non-malignant conditions that are associated with jaundice. This study aims to demonstrate the correlation between CA19.9 and serum bilirubin concentration in patients with benign conditions and to determine the frequency of a false-positive increase in CA19.9 in patients being investigated for potential HPB malignancies. METHODS: This is a retrospective review of 83 consecutive patients presenting with an abnormal CA19.9 and radiological or clinical features suggestive of HPB malignancy subsequently shown to have benign disease. All patients were thoroughly investigated and followed up until the diagnosis of malignancy could be safely excluded. RESULTS: Serum bilirubin, sodium, lymphocyte count, neutrophil:lymphocyte ratio (NLR), beta-human chorionic gonadotrophin (HCG), and age were found to correlate with CA19.9 by Pearson's correlation (P = 0.001, P = 0.006, P = 0.006, P < 0.001, P = 0.012, and P = 0.049, respectively). In multivariate regression analysis, bilirubin was identified as an independent variable that may predict CA19.9 level (P = 0.028). CONCLUSION: CA19.9 level is significantly influenced by serum bilirubin and elevated levels have been observed in patients with non-malignant HPB conditions. Adjusting CA19.9 according to bilirubin levels is likely to improve the specificity of this antigen in the differential diagnosis of benign and malignant HPB diseases and its reliability in the monitoring of disease response to chemotherapy.

Formation of silver nanoparticles in poly(perfluorosulfonic) acid membrane.

The formation of silver nanoparticles by chemical reduction of Ag+-loaded Nafion-117 membrane with NaBH4 was studied using radioactivity tagged ions. The counterion-exchange method (Ag(m)+ <--> Na(s)+) was used to obtain a membrane sample with a varying proportion of Ag+ ions. The X-ray elemental mapping across the thickness of the membrane by energy-dispersive X-ray spectrometer attached to the environmental scanning electron microscope (ESEM/EDAX) indicated that Na+ and Ag+ were uniformly distributed in the membrane samples before reduction. The average size of nanoparticles formed after reduction was found to be 15 +/- 3 nm, irrespective of the concentration of silver ions present in the membrane before reduction. Energy-dispersive X-ray fluorescence (EDXRF) analyses of the membrane samples, carried out before and after reduction, indicated that the Ag concentration on the membrane surface was considerably increased after reduction. EDXRF measurements of the membrane samples, obtained from reduction carried out in a dead end cell, indicated that Ag nanoparticles were formed only on the membrane surface exposed to NaBH4 solution. Reduction carried out with NaBH4 tagged with 22Na showed that the formation of Ag nanoparticles involved exchange of Ag+ ions from ion-exchange sites in the interior of the membrane with Na+ ions, followed by reduction of Ag+ ions with BH4- ions at the surface of membrane. The study of self-diffusion of water, Na+, and Cs+ ions in the membrane loaded with Ag nanoparticles indicated that formation of Ag nanoparticles did not affect the diffusional transport properties of the membrane. The ion-exchange capacity and water uptake capacity were also not affected by the formation of Ag nanoparticles in the membrane. The spatial distribution of Ag nanoparticles across the thickness of the membrane obtained by ESEM/EDAX showed that Ag nanoparticles were confined to a few-micrometer surface layer of the membrane. Based on these observations, an attempt has been made to explain the mechanism of the formation of Ag nanoparticles in the membrane.

Groundnut as the commonest foreign body of tracheobronchial tree in winter in Northern India. An analysis of fourteen cases.

In Northern India, in an institution like ours which receives quite a number of patients from surrounding rural areas, we found groundnut as the most common foreign body of tracheobronchial tree in children particularly in winter months of October to January. This article attempts to address the potential hazard of groundnut inhalation in children. In Northern India, in an institution like ours which receives quite a number of patients from surrounding rural areas, we found groundnut as the most common foreign body of tracheobronchial tree in children particularly in winter months of October to January. This article attempts to address the potential hazard of groundnut inhalation in children.

Faculty development and support needed to integrate the learning of prevention in the curricula of medical schools.

Comprehensive coverage of prevention-related topics in the curricula of medical schools is important for the training of future physicians; however, the changes needed in educational programs to include such topics are likely to challenge many institutions. Faculty members are central to the successful adoption of any new curricular paradigm, yet many of the impediments to change are also likely to be found within the faculty ranks. Achieving major curricular change requires institution leaders to define a new vision and allocate sufficient resources to support faculty efforts. Appropriate steps should be taken to actively involve the faculty early in the process of change and to recruit stakeholders from within the faculty ranks to play prominent roles. The educational models should be based on educationally and scientifically sound underpinnings that will facilitate acceptance of the models by the faculty, and faculty members must be offered appropriate opportunities to develop the skills to successfully implement the models. A school-wide faculty development program should address organizational development, instructional development, and personal development. The expertise needed to design and implement these activities may be secured from within or outside the institution. Individuals who have played key roles in the curricular change process must be rewarded and given appropriate recognition for their contributions. These steps will help in the successful integration of prevention-related topics into the curriculum, which will add a much-needed dimension, resulting in students' being better prepared to address the needs of their patients and the community.

Paraganglionoma of extrahepatic biliary tract causing obstructive jaundice.

We report a young woman with paraganglionoma arising from the extrahepatic bile duct presenting with acute obstructive jaundice. The patient underwent excision of the gall bladder and extrahepatic bile duct with the tumor, and Roux-en-Y hepaticojejunostomy. She is asymptomatic 9 months later, with normal biochemical investigations and imaging.

The normal breast epithelium of women with breast cancer displays an aberrant response to estradiol.

Breast epithelial response to estradiol may play an important role in breast cancer etiology. We have examined the relationship between serum estradiol and progesterone levels and normal breast epithelial expression of estrogen receptor (ER) alpha, progesterone receptor (PgR), and epithelial proliferation (as reflected by the Ki-67 labeling index) in 121 women (50 newly diagnosed breast cancer cases and 71 benign breast disease controls). Simultaneous samples of grossly normal breast tissue and venous blood were obtained from women undergoing breast surgery. Serum estradiol and progesterone levels were measured by radioimmunoassay; breast epithelial ER, PgR, and Ki-67 expression was measured by immunohistochemistry. Linear regression, controlled for patient age and ductal and lobular composition of the tissue, showed that the breast epithelium of control women displayed an inverse correlation between serum estradiol and ER-alpha, which was not seen in case women (P for the difference in regression slopes = 0.001). PgR expression displayed a significant positive correlation with serum estradiol in cases, but not in controls. Epithelial proliferation had no relationship to either estradiol or progesterone in both cases and controls but showed an inverse relationship with ER in controls and a direct relationship in cases (P for the difference in regression slopes = 0.066). These results suggest a dysregulation of hormonal response in the normal breast epithelium of high-risk women, with lack of regulation of ER by estradiol, increased estrogen responsiveness as reflected by PgR expression, and a dissociation of ER expression and proliferative response.

A new educational role for plastic surgery in the fourth year of medical school.

At most medical schools, students are offered limited or sporadic experiences in plastic surgery. This is unfortunate because all physicians need to possess the knowledge and skills to evaluate skin lesions and participate in wound management. Also, students who are considering a career in plastic surgery do not have adequate information to make informed decisions. With the restructuring of plastic surgery training programs, career decisions of individuals interested in plastic surgery are being made earlier than ever before in the education continuum, and the aforementioned problem assumes greater magnitude both for the students and the faculty. At MCP-Hahnemann School of Medicine, basic plastic surgery experiences have been integrated into the third-year surgery clerkship as a requirement for all students, and a Plastic Surgery Pathway has been designed in conjunction with the school's pathway system for fourth-year students. The Pathway provides a framework for the student to select a combination of rotations that will best provide an appropriate broad-based education in preparation for training in plastic surgery, and it provides extensive guidance by faculty members in the discipline to assist with career decisions, rotation selection, and preparations for the residency application process. Students in the Plastic Surgery Pathway are required to take rotations in medicine, neurology, and plastic surgery. The remaining rotations are selected from a list of options based on the student's individual learning needs, interests, and career aspirations. Early experience with the Plastic Surgery Pathway has shown that it has been well received by students and faculty, has assisted students with their career decisions, and has led to an increased student awareness of the importance and relevance of the specialty.

Redesigning the surgery clerkship at MCP Hahnemann School of Medicine to address the educational needs of generalists.

This article describes how the surgery clerkship at MCP Hahnemann School of Medicine was redesigned to provide all students a well-rounded general professional education and to address the specific educational needs of generalists. During the 12-week clerkship, students spend eight weeks on two different general surgery rotations, which include significant experiences in outpatient settings. The evaluation and management of common general surgical problems, as well as the holistic approach to patient care, are emphasized. A nurse educator, recruited through funding obtained from The Robert Wood Johnson Foundation's Generalist Physician Initiative, provides formal instruction in holistic care and teaches bedside procedures. Two weeks are devoted to focused surgical subspecialty experiences addressing common conditions and are conducted primarily in outpatient settings. The remaining two weeks include an integrated musculoskeletal disease rotation, including orthopaedic surgery, rheumatology, physiatry, and radiology. Didactic teaching includes criteria for referral of patients from generalists to specialists. The new clerkship model has been well received by the students. Review of student logs for the first six months indicates the breadth of surgical experience has been maintained and appropriate balance achieved between simple and complex surgical cases. Further evaluation of the model will continue through longitudinal follow-up.