In-theatre training of anaesthetists in a teaching hospital: has it changed over 10 years?

BACKGROUND: We wished to ascertain in what way recent changes such as Modernising Medical Careers (MMC) and the implementation of the Working Time Directive (WTD) have affected clinical training and experience for anaesthetists in a teaching centre, in particular the provision of training in specialized fields of anaesthesia provided in the teaching hospital. METHODS: Data were extracted from the computerized system for every operating theatre in this Trust. This provided a continuous record of all operations undertaken, and has previously been validated as an accurate record against individual anaesthetists' personal logbooks. We compared recent data with that of 10 yr ago. RESULTS: Comparing data for 1997 and 2008 showed that registrars and post-fellowship senior registrars (SRs) in anaesthesia continue to be well supervised directly by consultants (49% and 39%) and subspeciality training has been protected in our department. Average case numbers for SRs increased from 442 to 623 yr(-1), including an increase in emergency workload and theatre cases undertaken during the evening and at night. Although average case numbers for both SRs and consultants increased, we detected a small decrease in average case numbers from 394 to 353 yr(-1) for pre-fellowship registrars. CONCLUSIONS: In spite of many pressures on training in the clinical setting, the number of cases and senior supervision in specialist modules for trainee anaesthetists in our teaching hospital has been maintained. Continuous monitoring of in-theatre supervision is one way of confirming that training is not compromised as changes occur in hospital workload.

Use of isradipine in hypertension following coronary artery bypass surgery.

A dose-finding pilot study including six patients concluded that isradipine at an initial rate of 0.6 microgram/kg/minute, decreasing to 0.3 microgram/kg/minute with further adjustments as necessary, was safe for the treatment of post-aortocoronary bypass graft hypertension. A comparative study followed, comprising 20 patients randomly assigned to receive isradipine (starting at 0.6 microgram/kg/minute) or nitroprusside (initially 1 microgram/kg/minute) for the treatment of post-aortocoronary bypass graft hypertension. Both drugs produced a satisfactory reduction in arterial blood pressure accompanied by a decrease in systemic vascular resistance. Central venous pressure and mean pulmonary artery pressure decreased with nitroprusside, but both increased with isradipine. Pulmonary capillary wedge pressure was reduced, heart rate increased, and cardiac output was minimally changed with nitroprusside. However, wedge pressure was maintained with isradipine and there was no tachycardia. An increase in cardiac output was seen, associated with an increase in stroke index. Isradipine is a more specific treatment for post-aortocoronary bypass graft hypertension than nitroprusside because its systemic arterial dilating effect is associated with a minimum of other circulatory changes.

Minorities, women, and clinical cancer research: the charge, promise, and challenge.

Significant progress has been made since the war against cancer was launched. Discoveries in molecular medicine, genetics, and epidemiology have led to the recognition that certain cancers are potentially preventable and that elements of lifestyle, along with genetic, hormonal, and metabolic factors can be altered to reduce cancer risk. Advances in medical technology have led to the development of new imaging methods and computer technologies that can aid in efforts to detect, diagnosis, and treat cancer. Since the offensive against cancer was initiated, cancer treatments have become more powerful, more precise, less drastic, and safer. As a result, cancer incidence and mortality have begun to decline. Yet, while the nation boasts of the progress being achieved relative to cancer incidence and mortality, and federal research agencies retort that research applies to all populations, it is apparent that the declines do not translate to all populations in the United States. Clinical research is essential to cancer prevention and control. Within the oncology community, clinical cancer research trials are viewed as an efficient and economical way for patients to secure state-of-the-science medical care. Recognizing the need to improve access to state-of-the-science cancer treatment and control programs, minority and female participation in clinical cancer research trials has been encouraged. This recommendation is based on the belief that increased participation in well-designed clinical cancer research trials adhering to strict protocols and quality controls will, not only help validate the application of research findings to minority and female populations, but also result in better patient outcomes. Born out of a commitment to social equity, justice, beneficence, and the desire to ensure that data relevant to cancer prevention and control are both valid and generalizable to populations across the United States, several programs of research aimed toward increasing the representation of women and minorities in clinical cancer research have been pursued by the National Cancer Institute. This issue of the Annals of Epidemiology Minorities, Women, and Clinical Cancer Research presents issues and challenges that face the research community and descriptions of effective models, strategies, and practices that may be used to increase the participation of minorities and women in clinical cancer research trials and facilitate the conduct of research directed toward reducing the cancer burden within the United States.

Minority recruitment in the prostate cancer prevention trial.

PURPOSE: African American men have a higher prostate cancer risk profile than that of other men in the United States. The purpose of this manuscript is to summarize the challenges associated with enrolling and randomizing African American and other minority participants in the Prostate Cancer Prevention Trial (PCPT). METHODS: The PCPT is a randomized trial of finasteride versus placebo for preventing prostate cancer in healthy men age 55 years and older; it is coordinated by the Southwest Oncology Group. The manuscript describes demographic and lifestyle characteristics of the PCPT randomized sample (18,882 men) by four racial and ethnic groups (Caucasian, African American, Hispanic, and other). African American men comprised 4% of the total randomized sample compared to our goal of 8%. Minority recruitment was emphasized through the Study Manual and training that occurred at trial activation. Supplemental minority recruitment activities were initiated a year after study activation and continued through the end of the accrual period. Minority recruitment was emphasized as follows: minority recruitment presentations at PCPT training seminars (held during twice yearly Southwest Oncology Group meetings); distribution of additional minority recruitment materials; engagement of four consultants for minority recruitment; production of a Minority Recruitment Manual; and a small pilot study involving minority outreach recruiters at five PCPT sites. RESULTS: The consultants were helpful in implementing the pilot project and in suggesting and reviewing materials for minority recruitment. The five-site pilot project did not increase either enrollment or randomization of minorities (with a possible exception at one site). CONCLUSIONS: We suggest that a long-term perspective is required for successful recruitment of minority participants in clinical trials. Likewise, extensive minority recruitment efforts must be ready to implement at trial activation.

Time-course of free radical activity during coronary artery operations with cardiopulmonary bypass.

Myocardial and pulmonary impairment after cardiopulmonary bypass may be caused by oxygen free radicals produced by reperfusion and by activated neutrophils. Free radical activity was assessed by assays for lipid peroxidation (thiobarbituric acid-reactive material) and phospholipid-esterified diene conjugation (18:2[9,11]/18:2[9,12] molar ratio) in 25 patients during coronary artery operations. Arterial blood samples were obtained before, during the ischemic period, and for 24 hours thereafter. There were no significant changes in free radical indices during the ischemic periods, but after cessation of bypass they increased significantly. Ten minutes after bypass thiobarbituric acid-reactive material rose from 96 (median; range 65 to 145) nmol/gm albumin to 138 (85 to 200) nmol/gm albumin (p < 0.001), and molar ratio rose from 2.23% (0.45% to 7.70%) to 2.51% (0.39% to 7.93%) (p < 0.02). Values of thiobarbituric acid-reactive material subsequently decreased, but molar ratio reached a peak at 4 hours after bypass, 2.64% (0.55% to 10.08%) (p < 0.001), thereafter returning to baseline. The postoperative increases in thiobarbituric acid-reactive material and in molar ratio were correlated (r = +0.53; p = 0.006). These increases in thiobarbituric acid-reactive material and in molar ratio were not related to age, preoperative left ventricular function, or the number of grafts performed. Increase in thiobarbituric acid-reactive material correlated with the duration of cardiopulmonary bypass (r = +0.43; p = 0.03). In 10 patients in whom cardiopulmonary bypass was performed using a bubble oxygenator, the increases in thiobarbituric acid-reactive material were significantly greater than in the 15 in whom a membrane oxygenator was used (p < 0.02). These data show that after apparently uncomplicated coronary operations with bypass there is an increase in lipid peroxidation and diene conjugation, indicating increased free radical activity. This increase varies between patients and does not relate to patient or surgical factors but may depend on the type of oxygenator employed during bypass.

African-American men. Perceptual determinants of early cancer detection and cancer risk reduction.

Research has shown that African-American men have a higher incidence, a higher death rate, and a lower survival rate for most cancers. But currently there are few studies addressing factors influencing the health care trends of this high-risk population. A study focused on identifying factors that contribute to early cancer detection and cancer risk-reduction health behavior in African-American men was therefore implemented. There is evidence to support the conclusion that perceptions do significantly contribute to the health behavior of African-American men. Those having the greatest impact were related to methods of early cancer screening. Clearly, if the National Cancer Institute's goal to reduce the mortality from cancer in the general population by 50% from the base rate in 1984 is to be met by the year 2000, there must be an increase in programs targeting African-American men. Every day African-American men can take steps to help protect themselves from cancer. Our charge as health care clinicians, educators, and researchers is to pinpoint ways to encourage them to do so.

Obstacles to cancer care: focus on the economically disadvantaged.

PURPOSE/OBJECTIVES: To provide additional documentation of the unmet cancer prevention and control needs of poor Americans. DESIGN AND SETTING: Qualitative analysis of testimony provided at American Cancer Society hearings on cancer and the poor. SAMPLE: 46 economically disadvantaged individuals with personal experiences with cancer. METHODS: Review of transcription of oral testimony and qualitative analysis for recurrent themes to identify common obstacles to cancer care. FINDINGS: Six major obstacles were identified: care was deferred because of costs; care was described as "fragmented," "impersonal," and "symptomatic;" patients were discouraged from worrying about bodily changes; patients were discouraged from seeking state-of-the-art care; poor patients experienced difficulty communicating their needs and concerns; and poverty interfered with efforts to participate in volunteer activities. CONCLUSIONS: Testimony is suggestive of the problems that poor patients with cancer face. Challenges to improve the situation include expanding and extending diagnostic, treatment, and rehabilitative services to the poor; facilitating education and prevention; and further research to document the scope of the problem. IMPLICATIONS FOR NURSING PRACTICE: Nurses should engage in the debate over healthcare reform and take advantage of the opportunities to define and participate in the development of procedures, strategies, and systems for removing obstacles to quality cancer prevention and care for the poor.

Increasing nursing involvement in cancer prevention and control among the economically disadvantaged: the nursing challenge.

The American Cancer Society sponsored a series of hearings to document the magnitude of the problems faced by the poor in seeking cancer care. The findings reflected that economically disadvantaged Americans are often forced to accept substandard health care services and face numerous problems when seeking preventive care and treatment. The glimpse from inside the circle of poverty (statements from the hearings) provides an opportunity to better understand the problems faced by the poor in accessing health care and to better recommend strategies for effecting a positive change.

Development of a cancer prevention and early detection program for nurses working with African Americans.

BACKGROUND: Many health care institutions expect nurses to assume leadership roles in the provision of cancer education and screening. However, all too often, nurses lack the knowledge and skills needed to effectively inform, screen, and counsel their clients. The challenges may be compounded when they are expected to provide cancer care to clients from cultural, racial, and ethnic backgrounds different from their own. METHOD: The Cancer Prevention and Early Detection Program for Nurses Working with African Americans was developed to help fill this void. The program provides nurses with theoretical, clinical, and practical information regarding cancer prevention and early detection for use within clinical and community settings. RESULTS AND CONCLUSIONS: The Cancer Prevention and Early Detection Program for Nurses Working with African Americans enhanced participants' abilities to provide cancer education, screening, and follow up, and it heightened their sensitivity and understanding of issues and trends influencing cancer prevention and early detection among African Americans.

Breast cancer screening among African American women: addressing the needs of African American women with known and no known risk factors.

Breast cancer is the single most common form of cancer observed in African American women. Yet, in spite of the advances that have been made in the area of breast cancer detection and treatment, breast cancer continues to be their leading cause of cancer death. Many experts believe that breast cancer mortality among African American women could be significantly reduced if breast cancer screening recommendations were more effectively used. However, little is known about the breast cancer screening behaviors of women with known and no known risk factors. An exploratory study was therefore undertaken to gain a broader understanding of the breast cancer screening behaviors of African American women. Attempts were also made to determine if age, type of medical services used, breast cancer risk factors, or provider discussions influenced compliance with screening guidelines. Breast cancer screening procedures were found to be markedly under-used by the African American women in the study sample. However, the data suggested that if health care providers provide women with information regarding their personal breast cancer risk and make a personalized recommendation for their breast cancer screening, greater compliance with screening guidelines would occur.

Influence of changing work patterns on training in anaesthesia: an analysis of activity in a UK teaching hospital from 1996 to 2004.

BACKGROUND: We aimed to assess the influence of reduced working hours on training in a UK teaching hospital as the specialist registrar grade was introduced in 1996, the New Deal was implemented in 2001 and the Working Time Directive (WTD) took effect for doctors in training in 2004. METHODS: We analysed data from operating theatres in our hospital looking at grade of anaesthetist, time of day, emergency category, and specialty for more than 50,000 cases. RESULTS: Although direct supervision of trainees increased from 32 to 37 to 47%, senior house officer (SHO) and specialist registrar (SpR) caseload reduced by 20 and 21%, respectively, while that of the consultants rose. CONCLUSIONS: The reduction in total operating theatre cases for our trainees was evident across the epochs analysed, case numbers fell after introduction of the New Deal as well as more recently following the WTD, particularly for SHOs who are now doing a larger proportion of their work at night. SHOs and SpRs are doing more obstetric cases than in previous times but these are regional and not general anaesthetics.

Enhancing the delivery of cancer care to the disadvantaged: the challenge to providers.

Few attempts have been made to document and highlight the challenges faced by professionals who work with medically and economically disadvantaged persons seeking cancer care. This report analyzes and summarizes the testimony presented by such professionals at a series of nationwide hearings in 1989 sponsored by the American Cancer Society. The purpose of the hearings was to document the effects of economic and medical disadvantage on the development of cancer and cancer care. Among those presenting testimony were persons with personal cancer experiences, family members, and partners of cancer patients, healthcare providers, and related community liaisons. Professionals who worked with disadvantaged persons shared their experiences during the hearings. They suggested that the beliefs and attitudes of their peers were a major deterrent to providing cancer care. Processes and systems discouraged referrals. Lack of access to resources to serve the needs of the disadvantaged was the greatest obstacle to care.

Sick sinus syndrome manifest after spinal anaesthesia.

A case of sick sinus syndrome which presented as a cardiac arrest following spinal anaesthesia is reported. The diagnosis of sick sinus syndrome, the cardiovascular effects of spinal anaesthesia and the anaesthetic management of patients with the syndrome are discussed.

A detailed analysis of theatre training activity in a UK teaching hospital.

We examined the placement of anaesthetists in our department over a 2 yr period. Data were collected from an in-theatre system to provide details of caseload and supervision for 34,856 operations. There was wide variation between anaesthetic sub-specialties with overall supervision levels of 35% of cases for senior house officers (SHOs) and 32% for specialist registrars (SpRs). The consultant data showed the size and areas of teaching reserve in the department. We then examined individual logbooks in order to validate our data, and departmental rotas to put these data into perspective with previous attempts to quantify trainee supervision. Supervision data derived from the rota allocations showed that 86% of SHO lists and 62% of SpR lists were scheduled to be supervised. This study has described our training activity and facilitated departmental changes, as well as highlighting the need for great care in interpreting trainee supervision data acquired from different sources, particularly when comparisons are being made.

Intramuscular injections through indwelling cannulae.

A study was performed to establish the feasibility of an indwelling intramuscular cannula for the administration of post-operative analgesic and anti-emetic medication. One-hundred cannulae were inserted for periods up to 7 days (mean = 2.4). A mean of five and maximum of 15 injections were made through each cannula with a maximum volume in any patient of 29 ml. On 18 occasions cannulae were removed for minor complications; no serious complications were seen. This technique may be useful for administration of intramuscular analgesic and anti-emetic medications in the post-operative period.

Isradipine and the coronary circulation.

Isradipine has been shown to be an effective vasodilator in different vascular beds. Experimental evidence suggests that isradipine is a potent coronary vasodilator, and this is supported by clinical studies in both cardiology and cardiac surgery. Furthermore, in these studies, coronary vasodilation was not accompanied by evidence of any significant effect on cardiac contractility or conduction. It can be concluded that the cardiac effects of isradipine will ultimately prove to be beneficial in patients undergoing myocardial revascularization.

Veiled yet vulnerable. Breast cancer screening and the Muslim way of life.

OBJECTIVES: While multiple reports have been published in the literature that describe the effect of religion and spirituality on healthcare practices, few have been reported that attempt to describe the effect of the fundamental beliefs and customs of the followers of Islam. A qualitative study aimed toward gaining an understanding of the degree to which Islamic beliefs and customs influence followers' breast cancer screening practices was, therefore, undertaken. MATERIALS AND METHODS: The study was designed with semistructured focus groups as the primary means of gathering data. A purposefully selected sample of nine Muslim women were recruited to participate in the study. Throughout the focus group, attempts were made to engage the women in a manner that stimulated in-depth discussion of the beliefs and customs influencing breast cancer screening. RESULTS: Data revealed that the religious beliefs and customs of the Muslim women participating in the focus group significantly influenced their participation in breast cancer screening. Despite their knowledge of the benefits of regular breast cancer screening, the women indicated that they choose not to participate in available breast cancer screening programs, given that they were not structured in a manner that was consistent with the beliefs and customs of Islam. CONCLUSIONS: This study illustrates the manner and degree to which Islamic beliefs and customs can influence the breast cancer screening behavior of Muslim women and the importance of carefully designing breast health programs tailored to the needs of this population of women.

Anaesthesia for myocardial revascularisation. A comparison of fentanyl/propofol with fentanyl/enflurane.

We studied the effects on myocardial performance and metabolism of fentanyl/propofol and fentanyl/enflurane anaesthesia in 20 patients before coronary artery bypass grafting. Anaesthesia was induced with fentanyl 20 micrograms.kg-1 and pancuronium 0.15 mg.kg-1. Patients received, by random allocation, either propofol by infusion, 6 mg.kg-1.h-1 reduced by half after 10 min then adjusted as necessary (mean rate 2.8 mg.kg-1.h-1), or enflurane 0.8% inspired concentration for 10 min reduced to 0.6% and adjusted as required (mean 0.7%). Measurements were made before induction, after tracheal intubation, after skin incision and after sternotomy. There were no significant differences between the groups in any haemodynamic variables during the study. Following intubation both groups showed a rise in heart rate (p < 0.01) and cardiac index (p < 0.05). Systemic vascular resistance decreased after intubation (p < 0.05) then returned to baseline during surgery; stroke index was unchanged after intubation but was reduced during surgery (p < 0.01) as systemic vascular resistance increased. Regional and global coronary blood flow were maintained in both groups, as were myocardial oxygen consumption and lactate extraction ratio. However, lactate production did occur in one patient receiving enflurane and Holter monitoring confirmed ischaemia. One patient receiving propofol showed lactate production not accompanied by any ECG changes. This study suggests that propofol may be a suitable alternative to enflurane as an adjunct to opioids in anaesthesia for coronary artery bypass grafting.