Correlation between experience targets and competence for general surgery certification.

BACKGROUND: Working time restrictions and public expectation have stimulated competence-based assessment in surgery. Nevertheless, certification of completion of training, and board accreditation across the developed world, still rely on experiential models based on indicative numbers as markers of operative competence. This study assessed the correlation between trainer assessment of competence and completion of indicative numbers. METHODS: Analysis of UK Intercollegiate Surgical Curriculum Programme portfolios of general surgical trainees in a single Local Education and Training Board allowed comparison of Procedure Based Assessment (PBA) scores (level of competence) for cholecystectomy, segmental colectomy and Hartmann's procedure with operative numbers. RESULTS: Among 121 trainees, there was a positive correlation between operative numbers and 1058 PBA scores for cholecystectomy (rs = 0·532, P < 0·001), segmental colectomy (rs = 0·552, P < 0·001) and Hartmann's procedure (rs = 0·663, P < 0·001). Of those who completed the indicative numbers defined for each procedure to achieve certification of completion of training, only eight of 30 performing cholecystectomy, eight of 52 undertaking segmental colectomy and seven of 36 performing Hartmann's procedure had achieved three PBAs at the level considered to represent independent operating (level 4). More than half of all assessments (259 of 428, 60·5 per cent; 85 of 132 cholecystectomy, 140 of 217 colectomy and 34 of 79 Hartmann's) performed after trainees had completed their indicative numbers were scored below level 4. CONCLUSION: A minimum number of index procedures did not reflect competence in a significant proportion of trainees. A more reliable tool is required for certification.

Managing the open abdomen in a district general hospital.

INTRODUCTION: The need to manage an open abdomen is becoming more common in general surgical practice and a variety of methods of temporary abdominal closure (TAC) are available. The evidence for the efficacy of the various forms of TAC as well as the subsequent definitive fascial closure (DFC) rates and complications comes mainly from large trauma series in the US, which represent a different patient population to those in the UK in whom TAC is usually required. METHODS: All cases of open abdomen management in our hospital over a five-year period were reviewed to ascertain the methods of TAC used, our success in achieving DFC and the applicability of managing such cases in a district hospital environment. RESULTS: Nineteen patients underwent TAC, with two deaths (10.5%) and an overall DFC rate at hospital discharge of 12/17 (70.6%). The median lengths of critical care and hospital stays were 19.5 and 38.0 days respectively. Thirteen out of seventeen survivors had at least one significant complication. CONCLUSIONS: The management of the open abdomen can be achieved safely in a district general hospital setting with acceptable outcomes for the non-trauma patients commonly seen in UK practice but it is a resource intensive and expensive undertaking.

Sensorial differences according to sex and ages.

OBJECTIVE: To investigate age and sex differences in orofacial sensory detection. METHODS: One hundred and twenty-six (126) healthy subjects were divided into five groups according to their ages. They were assessed with a quantitative sensory testing protocol for gustative, olfactory, thermal (cold/warm), mechanical (tactile/vibration/electric), and pain (deep/superficial) detection thresholds. The corneal reflex was also evaluated. Data were analyzed with the one-way ANOVA, chi-squared, Fisher's exact, Mann-Whitney, and Kruskal-Wallis tests. RESULTS: The groups of subjects over 61 years old had higher olfactory (P < 0.001), gustative (sweet P = 0.004, salty P = 0.007, sour P = 0.006), thermal (warm P < 0.001, cold P < 0.001), and tactile (P < 0.001) detection thresholds than the others. The vibration detection threshold was high only for subjects over 75 years old (P < 0.001). The electric and deep pain detection thresholds were different for the 61-75 years old group (P ≤ 0.001). Women in all age groups had lower gustative (sweet P = 0.020, salty P = 0.002, sour P < 0.001, and bitter P = 0.002), olfactory (P = 0.010), warm (P < 0.001) and deep (P < 0.001), and superficial pain (P = 0.008) detection thresholds than men, and men from all age groups had lower vibratory detection thresholds (P = 0.006) than women. CONCLUSION: High sensory detection thresholds were observed in subjects over the 6th decade of life, and women had a more accurate sensory perception than men.

Polysomnographic study of the prevalence of sleep bruxism in a population sample.

The goal of the current study was to estimate the prevalence of sleep bruxism (SB) in the general population using a representative sample of 1,042 individuals who answered questionnaires and underwent polysomnography (PSG) examinations. After PSG, the individuals were classified into 3 groups: absence of SB, low-frequency SB, and high-frequency SB. The results indicated that the prevalence of SB, indicated by questionnaires and confirmed by PSG, was 5.5%. With PSG used exclusively as the criterion for diagnosis, the prevalence was 7.4% regardless of SB self-reported complaints. With questionnaires alone, the prevalence was 12.5%. Of the 5.5% (n = 56) with confirmed SB, 26 were classified as low-frequency SB, and 30 as high-frequency. The episodes of SB were more frequent in stage 2 sleep, and the phasic bruxism events were more frequent than tonic or mixed events in all sleep stages in individuals with SB. A positive association was observed between SB and insomnia, higher degree of schooling, and a normal/overweight body mass index (BMI). These findings demonstrate the prevalence of SB in a population sampled by PSG, the gold standard methodology in the investigation of sleep disorders, combined with validated questionnaires.

Somesthetic, gustatory, olfactory function and salivary flow in patients with neuropathic trigeminal pain.

OBJECTIVES: To determine somesthetic, olfactory, gustative and salivary abnormalities in patients with burning mouth syndrome (BMS), idiopathic trigeminal neuralgia (ITN) and trigeminal postherpetic neuralgia (PHN). SUBJECTS AND METHODS: Twenty patients from each group (BMS, ITN, PHN) and 60 healthy controls were evaluated with a systematized quantitative approach of thermal (cold and warm), mechanical, pain, gustation, olfaction and salivary flow; data were analyzed with ANOVA, Tukey, Kruskal-Wallis and Dunn tests with a level of significance of 5%. RESULTS: There were no salivary differences among the groups with matched ages; the cold perception was abnormal only at the mandibular branch of PHN (P = 0.001) and warm was abnormal in all trigeminal branches of PHN and BMS; mechanical sensitivity was altered at the mandibular branch of PHN and in all trigeminal branches of BMS. The salty, sweet and olfactory thresholds were higher in all studied groups; the sour threshold was lower and there were no differences of bitter. CONCLUSION: All groups showed abnormal thresholds of gustation and olfaction; somesthetic findings were discrete in ITN and more common in PHN and BMS; central mechanisms of balance of sensorial inputs might be underlying these observations.

Post-craniotomy headache: a proposed revision of IHS diagnostic criteria.

Seventy-nine patients with intracranial aneurysms were evaluated in the presurgical period, and followed up to 6 months after surgery. We compare patients who fulfilled with those that did not post-craniotomy headache (PCH) diagnostic criteria, according to the International Classification of Headache Disorders. Semistructured interviews, headache diaries, Short Form-36 and McGill Pain Questionnaire were used. Seventy-two patients (91%) had headaches during the follow-up period. The incidence of PCH according to the International Headache Society diagnostic criteria was 40%. Age, sex, type of surgery, temporomandibular disorder, vasospasm, presence and type of previous headaches, and subarachnoid haemorrhage were not related to headache classification. There were no differences in the quality of life, headache frequency and characteristics or pain intensity between patients with headache that fulfilled or not PCH criteria. We proposed a revision of the diagnostic criteria for PCH, extending the headache outset after surgery from 7 to 30 days, and including the presence of headaches after surgery in patients with no past history of headaches, or an increase in headache frequency during the first 30 days of the postsurgical period followed by a decrease over time. Using these criteria we would classify 65% of our patients as having PCH.

Special care dentistry: Midazolam conscious sedation for patients with neurological diseases.

AIM: Midazolam is used very often to control the anxiety of patients for dental treatment, especially in patients with special needs. The objective of this study was to evaluate the efficiency of Midazolam in patients with neurological diseases referred for dental treatment. STUDY DESIGN: Descriptive study. MATERIALS AND METHODS: Forty consecutive patients with neurological disorders (encephalopathy, autism, and epilepsy) were referred to dental treatment, and 45 sedations were performed; all were sedated with Midazolam (intramuscular 0.2-0.3 mg/kg or intravenous 0.1mg/kg) and all were anesthetised with lidocaine 2% (0.5-2 mL). During the dental procedure, their behavior was analysed and classified into 3 categories: A (indifferent), B (reacted but allowed treatment), and C (did not allow treatment). Data were tabbed and statistically analysed. RESULTS: The final patients' classification was: A 22 (49%), B 18 (40%) and C 5 (11%); the patients with encephalopathy had the best results of sedation according to the proposed classification (p<0.05). CONCLUSION: Midazolam demonstrated to be effective in 89% of this sample for dental procedures in patients with neurological and behavioral disturbances, but it was less effective for patients with autism (p<0.05).

The antitumoral, trypanocidal and antileishmanial activities of extract and alkaloids isolated from Duguetia furfuracea.

The alkaloid extract and five alkaloids isolated from subterranean stem bark of Duguetia furfuracea (Annonaceae) were investigated for the following activities: antitumoral, trypanocidal and leishmanicidal. Dicentrinone showed weak cytotoxicity, but it had the strongest leishmanicidal activity (IC(50) 0.01 microM). Duguetine and duguetine beta-N-oxide caused considerable antitumoral activity in every cell lines evaluated, although duguetine was more active against trypomastigote forms (IC(50) 9.32 microM) than other alkaloids tested.

Post-craniotomy headache: characteristics, behaviour and effect on quality of life in patients operated for treatment of supratentorial intracranial aneurysms.

We prospectively studied headache characteristics during 6 months after craniotomy performed for treatment of cerebral aneurysms in 79 patients. Semistructured interviews, headache diaries, the Hospital Anxiety and Depression Scale and the Epworth Sleepiness Scales, the Short Form-36 Health Survey (SF-36) and McGill Pain Questionnaire were used. Seventy-two patients had headaches, half before the fifth day after surgery. Changes were observed in headache diagnosis, side and site in the postoperative period. Headache frequency increased immediately after surgery and then decreased over time. Headache frequency was associated with depressive and anxiety symptoms. Pain intensity was higher in women and in patients with more anxiety symptoms. An incidence of post-craniotomy headache of 40% was observed according to International Headache Society classification criteria, 10.7% of the acute and 29.3% of the chronic type. The bodily pain domain of the SF-36 was worse in patients with more anxiety symptoms. Greater frequencies of headache were associated with lower scores on bodily pain and social functioning.

Masticatory problems after balloon compression for trigeminal neuralgia: a longitudinal study.

Idiopathic trigeminal neuralgia (ITN) is a chronic neuropathic pain that affects the masticatory system. The objective of this study was to identify orofacial pain and temporomandibular characteristics, including temporomandibular disorder (TMD), in a sample of 105 ITN patients treated with compression of the trigeminal ganglion. The evaluations occurred before, 7, 30 (1 month), 120 (3 months) and 210 days (7 months) after surgery. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), the Clinical Questionnaire (EDOF-HC) and Helkimo Indexes were used. Findings before neurosurgery were used as control for parameters. McNemar test and variance analysis for repetitive measurements were used for statistical analysis; 45.3% of the edentulous patients presented severe dental occlusion index; numbness was an important masticatory complaint in 42.6%; mastication became bilateral, but its discomfort continued during all period; headache and body pain reduced after surgery; TMD, present in 43.8% before surgery, increased but normalized after 7 months; jaw mobility compromise was still present, but daily activities improved after 7 months. We concluded that: (i) ITN relief reduced headache, body pain, depression and unspecific symptoms; and (ii) TMD before surgery and at 7 months suggests that this may be a contributory factor to patients' pain complaints.

Antineoplastic activity of selected constituents of Duguetia glabriuscula.

The cytotoxic effects of seven constituents isolated from Duguetia glabriuscula were evaluated against Hep2 human larynx carcinoma cells. The cytotoxicity exhibited by beta-sitosterol was as strong as that of cis-platin. (+)-Alloaromadendran-10,14beta-diol caused inhibition of cellular growth with IC50 values lower than 25 microg/ml, a feature that was considered as revealing significant activity. Polycarpol showed borderline cytotoxicity, whereas the other compounds were inactive.

Clinical evaluation of tinnitus in patients with sleep bruxism: prevalence and characteristics.

Evaluation of the prevalence and characteristics of tinnitus in a Brazilian series of sleep bruxism patients. In this descriptive study, 100 patients (80 women and 20 men) were selected through the self-report of grinding teeth during sleep, confirmed by room mate or family member. They were evaluated according to a systematized approach: a questionnaire for orofacial pain and the Portuguese version of the Research Diagnostic Criteria for Temporomandibular Disorders. The patients were divided into two groups: group A, 54 patients with complaint of tinnitus and group B, 46 patients without tinnitus complaint. The mean age was 37.85 (13-66 years) and 34.02 years (20-59 years), respectively, for groups A and B (P = 0.1164). There was statistically significant difference between the two groups, with higher prevalence for the group A, in relation to: presence of chronic facial pain (P = 0.0007); number of areas painful to palpation in the masticatory and cervical muscles (P = 0.0032); myofascial pain in the masticatory muscles (P = 0.0003); absence of teeth without prosthetic replacement (P = 0.0145) and indices of depression (P = 0.0234). Structural alterations of the TMJ, like disc displacement and vertical dimension loss did not differ for the two groups. Tinnitus frequency was higher in patients with sleep bruxism and chronic facial pain. Myofascial pain, number of areas painful to palpation in the masticatory and cervical muscles, higher levels of depression and tooth absence without prosthetic replacement were more frequent in the group with tinnitus.

Bilateral facial pain from cardiac origin. A case report.

A case of a 65-year-old female patient is reported. Her chief complaint was facial pain, so she sought care from her general dental practitioner for evaluation of a suspected temporomandibular disorder, after repeated visits to the emergency department due to excruciating facial pain associated with exertion. The dental examination revealed an edentulous upper and lower jaw. Radiographs of the facial bones revealed no abnormalities. Eventually, she was referred for cardiological evaluation, as her pain radiated to the chest and there was a medical history of myocardial infarction. Cardiac pain may radiate to the face and lead patients to seek dental care. In these settings, dentists may contribute to the diagnosis of ischemic heart disease and refer patients for cardiological evaluation.

[Acute facial pain associated with mandibular motion damage: considerations on a clinical sample]. / Dor facial aguda associada a alteração motora mandibular: considerações sobre uma amostra clínica.

The authors present a sample of five patients, 3 women and 2 men, with history of the dislocation of the mandible. The period ranged between 7 days and 7 months and all the patients looked for medical treatment, but did not have a correct diagnostic. The initial diagnostic was tetanus, sequela for VCA, food intoxication. The younger patient was 23 years old and the older was 63 years old. The first male patient was 23 years old and his first complaint was facial pain, rigidity, difficulty in speaking, chewing and the diagnosis received was Tetan, after 7 days. The second female patient was 61 years old and her first complaint was difficulty in speaking and chewing. The diagnosis was food intoxication after 7 month. The third patient was 54 years old. The first complaint was idiopathic, after 1 month. He did'nt managed to shut up his mouth--diagnosis idiopathic cause. The fourth patient was 63 years old and his first complaint was assimetric and facial pain due a neurological remains, after 4 month. And finally the fifth patient. He was 56 years old and the first complaint was an intense difficulty in speaking and shut out his mouth--hemiplegia in the left face due neurological remain, after 3 month. The authors make a review about the criteria for a diagnosis of dislocation of mandible and the benefits of immediate treatment.

Metal complexes of anhydrotetracycline. 1. A spectrometric study of the Cu(II) and Ni(II) complexes.

Anhydrotetracycline (AHTC), one of the major toxic decomposition products of the antibiotic tetracycline, contains several potential binding sites to metal ions. The acidity constants of the ligand were calculated in aqueous medium (I = 0.1 M) at 25 and 37 degrees C. We found pKa1 = 3.23 +/- 0.08, pKa2 = 5.94 +/- 0.09, and pKa3 = 8.48 +/- 0.02 at 25 degrees C and pKa1 = 3.12 +/- 0.09, pKa2 = 5.86 +/- 0.03, and pKa3 = 8.38 +/- 0.04 at 37 degrees C. The coordination of AHTC to Cu(II) and Ni(II) ions was studied in the solid state as well as in buffered aqueous solution at pH 10.0. At this pH, the formation of the two CuL2 and CuL species was indicated (log beta 1 = 8.41 +/- 0.04 and log beta 2 = 12.55 +/- 0.05), but only the formation of the NiL complex (log beta = 5.74 +/- 0.04) was identified. Spectroscopic data confirm the previous assignment of the C11 and C12 oxygens as the coordination sites, yielding six-membered ring chelates and excluding complexation through any of the potential binding positions on ring A.

[Myocardial lesions after snake bites by the Crotalus durissus terrificus species (rattlesnake). A case report]. / Lesão miocárdica em acidente ofídico pela espécie Crotalus durissus terrificus (cascavel). Relato de caso.

Extensive and severe myocardial lesions are reported in a patient who died due to snakebite (Crotalus Durissus Terrificus). These lesions are documented by clinical, electrocardiographic, enzymatic and histological evidences. The main pathological features are represented by sarcoplasmatic vacuoles, densely clumped myofibrils and amorphous acidophilic mass into the cardiac fibers. These lesions are identical to those which have already been described in skeletal muscle after snakebite. This seems to be the first case report that shows undoubt myocardial lesions due to snakebite with anatomopathological documentation.

Repeated mass treatment of schistosomiasis mansoni: experience in hyperendemic areas of Brazil. 3. Techniques for assessment and surveillance.

Severe morbidity due to schistosomiasis mansoni is now quite rare in Brazil; thus it is proposed that surveillance plus selective and multidisciplinary intervention limited to areas at high risk be the next step. Such a policy has to be carried out periodically and on a state-wide scale, and therefore will have to rely upon cheap and time-saving sampling procedures. Clinical features cannot at present be used as indicators, with the exception of grossly enlarged livers, which are more frequent in areas at high risk. Overall prevalence rates for a county or even city may also be misleading, even if broken down into units of smaller size. Thus, egg counts in the young age groups remain the best indicators for the detection of areas at high risk (i.e., the main foci of transmission). Egg counts performed on pooled specimens adequately reflect the risk rating of a particular neighbourhood, and have a favourable cost-benefit ratio. In addition, it is suggested that field personnel be trained in the empirical recognition of potential foci; such 'screening by suspicion' has been tested and found to be reliable.

T cell phenotype alterations in hepatosplenic schistosomiasis mansoni normalize after chemotherapy.

Peripheral blood T cell phenotypes, CD3-induced mitogenesis and soluble IL 2 receptor and CD8 in sera were studied in intestinal and hepatosplenic Schistosomiasis mansoni before and three to six months after therapy with praziquantel. Fifteen pairs matched for intensity of infection were analyzed and compared with local, non-infected age-matched controls. CD3+ cell counts were lower in untreated hepatosplenic schistosomiasis (median 1040 cells/microliters; 95% confidence interval 608-1269) compared to controls (1534; 1264-1620). This difference was largely accounted for by immature CD1+/CD3-cells circulating in these patients (median 388/microliters, 252-474). The frequency of CD1+ T cells in circulation decreased drastically after chemotherapy. Similar, but less marked, alterations were seen in intestinal schistosomiasis. Lymphocyte proliferation initiated by agonistic anti-CD3 monoclonal antibody was severely impaired in hepatosplenic patients, who had suffered haemorrhagic complications, but not in the cases of incipient hepatomegaly. Soluble CD8 antigen circulated in increased amounts in hepatosplenic schistosomiasis. Remarkably, a negative correlation between CD3-induced mitogenesis and circulating levels of CD8 was noted in these patients. Whereas CD3-induced mitogenesis in hepatosplenic schistosomiasis normalized after therapy, circulating IL 2R and CD8 antigen in hepatosplenic patients still exceeded control levels. The results demonstrate disturbances of CD3 and CD8 expression and/or T cell maturation in hepatosplenic schistosomiasis. Imbalanced CD4/CD8 ratios and an increased IL 2R/CD8 turnover may reflect an inhibitory circuit within the T cell compartment.