Spectrum of general surgery in rural America.

OBJECTIVES: To define the types of surgery performed by rural surgeons, to compare their experience to that of graduating US surgical residents and to document rural surgical mortality. DESIGN: Prospective registry of consecutive cases recorded by 7 rural general surgeons working in one department of surgery from December 31, 1994, through March 30, 1996. Comparison with the 1995 Report C (Resident Operative Logs) of the Residency Review Committee. National survey of surgical residency programs regarding formal gynecology experience. SETTING: Nine rural community hospitals in the Midwest. PATIENTS: Patients undergoing surgery in 9 cities with populations of fewer than 10000. MAIN OUTCOME MEASURES: Type of surgery and postoperative (30-day) mortality. RESULTS: Two thousand four hundred twenty procedures were performed by 7 surgeons practicing in 9 cities with populations of 1500 to 8000. There were 6 (0.25%) postoperative deaths. Case types are as follows: endoscopy, 686 (28.3%); gynecology, 498 (20.6%); hernia, 241 (10%); colorectal, 194 (8%); biliary, 183 (7.6%); cesarean sections, 130 (5.4%); breast, 129 (5.3%); orthopedic, 115 (4.8%); carpal tunnel, 63 (2.6%); otolaryngology, 35 (1.4%); and endocrine, 1 (0.4%); for a total of 2420 (100%). Report C indicated 1995 graduating chief residents averaged 8 obstetric and and gynecologic and 5.3 orthopedic cases during their residency. Of 204 surgical residency programs surveyed, 106 (52%) offered no obstetrics and gynecology rotation. CONCLUSIONS: A large volume of surgery was performed with low mortality by 7 rural general surgeons. The operative experience of 1995 residency graduates differed from our rural surgeons. We recommend a rural surgical track in selected training programs to prepare graduates better for rural practice. Senior level rotations in endoscopic, gynecologic, obstetric, and orthopedic surgery and mentorship with rural surgeons would be optimal.

[Amplitude modulation following response (AMFR)--a method for objective frequency specific audiologic diagnosis]. / Amplitude Modulation Following Response (AMFR)--Eine Methode zur objektiven frequenzspezifischen audiologischen Diagnostik.

BACKGROUND: The objective evaluation of the hearing threshold below 1kHz by means of early auditory potentials leads to problems caused by the discrepancy between the required steep rise edge of stimulus and the frequency specificity of the potentials. Therefore the aim of this study was to evaluate the potential role of the AMFR as a diagnostic tool for the assessment of hearing below 1 kHz. METHOD: The threshold of the AMFR was compared to the behavioral threshold in 13 normal hearing subjects and 46 patients with hearing loss. The stimulus used was an amplitude-modulated tone at the carrier frequencies of 0.5 and 1 kHz, a modulation frequency of 40 Hz; the modulation depth was 80%. The introduction of an empiric detectibility criterion based on spectral analysis of the response curve allowed the investigator to minimize the examination time and objectify the interpretation of the response. Additional investigations by means of highpass-masking took place to estimate the frequency specificity of the AMFR. RESULTS: The results show a good correspondence of the AMFR threshold to the behavioral threshold. Depending on hearing loss the mean values of differences between AMFR threshold and behavioral threshold are 3 dB - 13 dB. The degree of correspondence was highest in the patients with the most severe hearing loss. An influence of underlying cause of the hearing loss could not be found. Additionally the frequency specificity of the response potential was proven with high-pass masking in normal hearing subjects. Masking with cut-off frequencies above the carrier frequencies had no influence on the response while masking at the carrier frequency resulted in a strong reduction of the response curve. CONCLUSIONS: The results show that the 40 Hz-AMFR is a suitable method for the objective frequency-specific assessment of hearing in adults. Problems in the clinical use of the AMFR are caused by the long investigation time and the dependence of the potentials on the state of wakeness.