British journal of surgery.

Incorporating European Journal of Surgery.

The medical department of the United States Army in the world war .../

Editor-in-chief: Col. Charles Lynch.

Deregulation, competition policy and intra-professional contests in medical education

This paper investigates how government policy directions embracing deregulation and market liberalism, together with significant pre-existing tensions within the Australian medical profession, produced ground breaking change in the funding and delivery of medical education for general practitioners. From an initial view between and within the medical profession, and government, about the goal of improving the standards of general practice education and training, segments of the general practice community, particularly those located in rural and remote settings, displayed increasingly vocal concerns about the approach and solutions proffered by the predominantly urban-influenced Royal Australian College of General Practitioners (RACGP). The extent of dissatisfaction culminated in the establishment of the Australian College of Rural and Remote Medicine (ACRRM) in 1997 and the development of an alternative curriculum for general practice. This paper focuses on two decades of changes in general practice training and how competition policy acted as a justificatory mechanism for putting general practice education out to competitive tender against a background of significant intra-professional conflict. The government's interest in increasing efficiency and deregulating the 'closed shop' practices of professions, as expressed through national competition policy, ultimately exposed the existing antagonisms within the profession to public view and allowed the government some influence on the sacred cow of professional training. Government policy has acted as a mechanism of resolution for long standing grievances of the rural GPs and propelled professional training towards an open competition model. The findings have implications for future research looking at the unanticipated outcomes of competition and internal markets.

Impact of a comprehensive nutrition and lifestyle education intervention on body weight and health-related outcomes in morbidly-obese Hispanic-Americans following laparoscopic Roux-en-Y gastric bypass

As morbid obesity increasingly affects Hispanic-Americans, the incidence of Roux-en-Y gastric bypass procedures (RYGB) among this population rises. Prospective research on the impact of postoperative educational interventions focused on Hispanic- Americans is needed to prevent premature weight loss plateau, weight regain, nutritional deficiencies, and relapse of obesity-related comorbidities. This randomized-controlled study evaluated the impact of a comprehensive nutrition and lifestyle education intervention (6 biweekly postoperative sessions that incorporated motivational strategies for behavioral change) as compared to a non-comprehensive approach (printed guidelines for healthy lifestyle). The variables to consider are body weight, obesity-related comorbidities (depression, diabetes, dyslipidemia, and others), nutrient status, physical activity, and eating habits in 144 morbidly-obese adult Hispanic-Americans 6 to 12 months following RYGB. Patients were randomly assigned to either the comprehensive intervention (n=72) or the comparison group (n=72). Participants (mean age 44.5 ± 13.5 years) were mainly Cuban-born females (83.3%). Intervention sessions attendance was 64%. At 12 months, both groups lost weight significantly, but those in the comprehensive intervention experienced greater excess weight loss than those in the comparison group (80% vs. 64% from preoperative excess weight, P<.001). Intervention participants were significantly more involved in physical activity (+ 14 min/week vs. – 4 min/week), had decreased depression, joint illness, and required less medication for comorbidities than comparison participants. Additionally, those in the comprehensive intervention had sustained supplement intake experiencing less folate deficiency (P=.014). The non-comprehensive intervention group significantly decreased their protein and supplement intake compared to the intervention group. Patients in the comprehensive intervention had significantly better eating habits reflected by fewer episodes of dumping syndrome, constipation, and night eating, than those in the comparison group who reported greater eating in response to negative emotions (P=.003). These findings support the importance of a comprehensive educational approach to achieve more effective weight reduction and health-related outcomes to prevent relapse of obesity-related comorbidities and nutritional deficiencies in Hispanic-Americans 6 to 12 months following RYGB.

Towards guidelines for curriculum design and development in English language teacher education in Cambodian higher education institutions

In the current Cambodian higher education sector, there is little regulation of standards in curriculum design of undergraduate degrees in English language teacher education. The researcher, in the course of his professional work in the Curriculum and Policy Office at the Department of Higher Education, has seen evidence that most universities tend to copy their curriculum from one source, the curriculum of the Institute of Foreign Languages, the Royal University of Phnom Penh. Their programs fail to impose any entry standards, accepting students who pass the high school exam without any entrance examination. It is possible for a student to enter university with satisfactory scores in all subjects but English. Therefore, not many graduates are able to fulfil the professional requirements of the roles they are supposed to take. Neau (2010) claims that many Cambodian EFL teachers do not reach a high performance standard due to their low English language proficiency and poor background in teacher education. The main purpose of this study is to establish key guidelines for developing curricula for English language teacher education for all the universities across the country. It examines the content of the Bachelor‘s degree of Education in Teaching English as a Foreign Language (B Ed in TEFL) and Bachelor‘s degree of Arts in Teaching English to Speakers of Other Languages (BA in TESOL) curricula adopted in Cambodian universities on the basis of criteria proposed in current curriculum research. It also investigates the perspectives of Cambodian EFL teachers on the areas of knowledge and skill they need in order to perform their English teaching duties in Cambodia today. The areas of knowledge and skill offered in the current curricula at Cambodian higher education institutions (HEIs), the framework of the knowledge base for EFL teacher education and general higher education, and the areas of knowledge and skill Cambodian EFL teachers perceive to be important, are compared so as to identify any gaps in the current English language teacher education curricula in the Cambodian HEIs. The existence of gaps show what domains of knowledge and skill need to be included in the English language teacher education curricula at Cambodian HEIs. These domains are those identified by previous curriculum researchers in both general and English language teacher education at tertiary level. Therefore, the present study provides useful insights into the importance of including appropriate content in English language teacher education curricula. Mixed methods are employed in this study. The course syllabi and the descriptions within the curricula in five Cambodian HEIs are analysed qualitatively based on the framework of knowledge and skills for EFL teachers, which is formed by looking at the knowledge base for second language teachers suggested by the methodologists and curriculum specialists whose work is elaborated on the review of literature. A quantitative method is applied to analyse the perspectives of 120 Cambodian EFL teachers on areas of knowledge and skills they should possess. The fieldwork was conducted between June and August, 2014. The analysis reveals that the following areas are included in the curricula at the five universities: communication skills, general knowledge, knowledge of teaching theories, teaching skills, pedagogical reasoning and decision making skills, subject matter knowledge, contextual knowledge, cognitive abilities, and knowledge of social issues. Additionally, research skills are included in three curricula while society and community involvement is in only one. Further, information and communication technology, which is outlined in the Education Strategies Plan (2006-2010), forms part of four curricula while leadership skills form part of two. This study demonstrates ultimately that most domains that are directly and indirectly related to language teaching competence are not sufficiently represented in the current curricula. On the basis of its findings, the study concludes with a set of guidelines that should inform the design and development of TESOL and TEFL curricula in Cambodia.

A longitudinal interpretive phenomenological investigation into latent entrepreneurial learning processes: Key implications for entrepreneurial education.

The effectiveness and value of entrepreneurship education is much debated within academic literature. The individual’s experience is advocated as being key to shaping entrepreneurial education and design through a multiplicity of theoretical concepts. Latent, pre-nascent and nascent entrepreneurship (doing) studies within the accepted literature provide an exceptional richness in diversity of thought however, there is a paucity of research into latent entrepreneurship education. In addition, Tolman’s early work shows the existence of cases whereby a novel problem is solved without trial and error, and sees such previous learning situations and circumstances as “examples of latent learning and reasoning”, (Deutsch, 1956, pg115). Latent learning has historically been the cause of much academic debate however, Coon’s (2004, pg260) work refers to “latent (hidden) learning … (as being) … without obvious reinforcement and remains hidden until reinforcement is provided” and thus, forms the working definition for the purpose of this study.

Predictive modelling : parents’ decision making to use online child health information to increase their understanding and/or diagnose or treat their child’s health

Abstract Background The quantum increases in home Internet access and available online health information with limited control over information quality highlight the necessity of exploring decision making processes in accessing and using online information, specifically in relation to children who do not make their health decisions. Objectives To understand the processes explaining parents’ decisions to use online health information for child health care. Methods Parents (N = 391) completed an initial questionnaire assessing the theory of planned behaviour constructs of attitude, subjective norm, and perceived behavioural control, as well as perceived risk, group norm, and additional demographic factors. Two months later, 187 parents completed a follow-up questionnaire assessing their decisions to use online information for their child’s health care, specifically to 1) diagnose and/or treat their child’s suspected medical condition/illness and 2) increase understanding about a diagnosis or treatment recommended by a health professional. Results Hierarchical multiple regression showed that, for both behaviours, attitude, subjective norm, perceived behavioural control, (less) perceived risk, group norm, and (non) medical background were the significant predictors of intention. For parents’ use of online child health information, for both behaviours, intention was the sole significant predictor of behaviour. The findings explain 77% of the variance in parents’ intention to treat/diagnose a child health problem and 74% of the variance in their intentions to increase their understanding about child health concerns. Conclusions Understanding parents’ socio-cognitive processes that guide their use of online information for child health care is important given the increase in Internet usage and the sometimes-questionable quality of health information provided online. Findings highlight parents’ thirst for information; there is an urgent need for health professionals to provide parents with evidence-based child health websites in addition to general population education on how to evaluate the quality of online health information.

Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients

BACKGROUND After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population. OBJECTIVE To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure. METHODS A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model. RESULTS The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01). CONCLUSION Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.

Immediate Breast Reconstructions in the Treatment of Breast Cancer

Breast cancer is the most common form of potentially fatal cancer in women in the Western world. Better understanding of the breast cancer disease process together with developments in treatments have led to improved survival and reduced risk of recurrence, significantly influencing the acceptance of breast reconstructions as part of breast cancer treatment. Skin-sparing mastectomy followed by immediate breast reconstruction has proved superior to other forms of breast reconstruction in terms of aesthetic outcome. However, due to the relatively recent introduction of skin-sparing mastectomy concerns on the surgical and oncological safety of the operation persist. The aim of the present study is to evaluate the surgical and oncological safety of skin-sparing mastectomy and immediate breast reconstruction in a consecutive patient series with ensuing follow-up. Subsequent aims of the study are to examine possibilities of reducing surgical complications of the operation and to assess the feasibility of sentinel node biopsy together with immediate breast reconstruction. The study population comprises a consecutive series of patients having undergone skin-sparing mastectomy followed by immediate breast reconstruction at the Helsinki University Central Hospital between 1992 and 2006. In Study I, the hospital records of 207 patients, operated between 1992 and 2001, were analyzed for surgical complications and recurrences of breast cancer during follow-up. In Study II, 60 consecutive patients were randomized into either conventional diathermy or radiofrequency coagulation groups to examine possibilities of reducing skin-flap complications. Study III consists of 62 consecutive breast cancer patients evaluated for the feasibility of sentinel node biopsy simultaneously with immediate breast reconstruction. In Study IV, hospital records were analyzed to examine local recurrence of breast cancer in a consecutive series of 146 patients with Stage I or II disease. Post-operative complications in Study I included native skin-flap necrosis (10.1%), hematoma (10.1%), anastomose thrombosis (5.3%), infection (3.4%), hernia (2.6%) and loss of one microvascular flap (0.7%). The Stage I and II patients in Study IV had a local recurrence rate of 2.7%, an isolated regional lymph node recurrence rate of 2.1% and a systemic recurrence rate of 2.7%, during a mean follow-up time of 51 months. The Stage III patients in study I had a locoregional recurrence rate of 31.3% during follow-up. Radiofrequency coagulation in Study II did not decrease skin-flap complications when compared with conventional diathermy. An increased skin-flap complication rate in Study II was associated with smoking and the type of skin incision used. In Study III, eleven patients had tumor positive sentinel nodes, nine of which were detected intraoperatively. Skin-sparing mastectomy followed by immediate breast reconstruction is a safe procedure both surgically and oncologically, especially for early stage breast cancer. Tennis racket type incision is associated with an increased skin-flap complication rate. Sentinel node biopsy with intraoperative assessment of sentinel node metastases is feasible in patients undergoing immediate breast reconstruction.

Cancer incidence, mortality, and pregnancy outcome among women treated for cervical intraepithelial neoplasia

Cervical cancer develops through precursor lesions, i.e. cervical intraepithelialneoplasms (CIN). These can be detected and treated before progression to invasive cancer. The major risk factor for developing cervical cancer or CIN is persistent or recurrent infection with high-risk human papilloma virus (hrHPV). Other associated risk factors include low socioeconomic status, smoking, sexually transmitted infections, and high number of sexual partners, and these risk factors can predispose to some other cancers, excess mortality, and reproductive health complications as well. The aim was to study long-term cancer incidence, mortality, and reproductive health outcomes among women treated for CIN. Based on the results, we could evaluate the efficacy and safety of CIN treatment practices and estimate the role of the risk factors of CIN patients for cancer incidence, mortality, and reproductive health. We collected a cohort of 7 599 women treated for CIN at Helsinki University Central Hospital from 1974 to 2001. Information about their cancer incidence, cause of death, birth of children and other reproductive endpoints, and socio-economic status were gathered through registerlinkages to the Finnish Cancer Registry, Finnish Population Registry, and Statistics Finland. Depending on the endpoints in question, the women treated were compared to the general population, to themselves, or to an age- and municipality-matched reference cohort. Cervical cancer incidence was increased after treatment of CIN for at least 20 years, regardless of the grade of histology at treatment. Compared to all of the colposcopically guided methods, cold knife conization (CKC) was the least effective method of treatment in terms of later CIN 3 or cervical cancer incidence. In addition to cervical cancer, incidence of other HPV-related anogenital cancers was increased among those treated, as was the incidence of lung cancer and other smoking-related cancers. Mortality from cervical cancer among the women treated was not statistically significantly elevated, and after adjustment for socio-economic status, the hazard ratio (HR) was 1.0. In fact, the excess mortality among those treated was mainly due to increased mortality from other cancers, especially from lung cancer. In terms of post-treatment fertility, the CIN treatments seem to be safe: The women had more deliveries, and their incidence of pregnancy was similar before and after treatment. Incidence of extra-uterine pregnancies and induced abortions was elevated among the treated both before and after treatment. Thus this elevation did not occur because they were treated rather to a great extent was due to the other known risk factors these women had in excess, i.e. sexually transmitted infections. The purpose of any cancer preventive activity is to reduce cancer incidence and mortality. In Finland, cervical cancer is a rare disease and death from it even rarer, mostly due to the effective screening program. Despite this, the women treated are at increased risk for cancer; not just for cervical cancer. They must be followed up carefully and for a long period of time; general health education, especially cessation of smoking, is crucial in the management process, as well as interventions towards proper use of birth control such as condoms.

Aphasia rehabilitation and the strange neglect of speed.

Timing data is infrequently reported in aphasiological literature and time taken is only a minor factor, where it is considered at all, in existing aphasia assessments. This is not surprising because reaction times are difficult to obtain manually, but it is a pity, because speed data should be indispensable in assessing the severity of language processing disorders and in evaluating the effects of treatment. This paper argues that reporting accuracy data without discussing speed of performance gives an incomplete and potentially misleading picture of any cognitive function. Moreover, in deciding how to treat, when to continue treatment and when to cease therapy, clinicians should have regard to both parameters: Speed and accuracy of performance. Crerar, Ellis and Dean (1996) reported a study in which the written sentence comprehension of 14 long-term agrammatic subjects was assessed and treated using a computer-based microworld. Some statistically significant and durable treatment effects were obtained after a short amount of focused therapy. Only accuracy data were reported in that (already long) paper, and interestingly, although it has been a widely read study, neither referees nor subsequent readers seemed to miss "the other side of the coin": How these participants compared with controls for their speed of processing and what effect treatment had on speed. This paper considers both aspects of the data and presents a tentative way of combining treatment effects on both accuracy and speed of performance in a single indicator. Looking at rehabilitation this way gives us a rather different perspective on which individuals benefited most from the intervention. It also demonstrates that while some subjects are capable of utilising metalinguistic skills to achieve normal accuracy scores even many years post-stroke, there is little prospect of reducing the time taken to within the normal range. Without considering speed of processing, the extent of this residual functional impairment can be overlooked.

A dor no período pós-cirúrgico abdominal em doentes geriátricos

A dor é uma das principais causas do sofrimento humano, comprometendo a qualidade de vida dos indivíduos, em especial o idoso que, devido aos problemas cognitivos e à elevada medicação os torna mais suscetíveis aos efeitos adversos dos medicamentos utilizados para o alívio da dor. Neste contexto, o objetivo deste estudo é avaliar a dor na pós-cirurgia abdominal em doentes geriátricos; identificar a localização e a intensidade dolorosa utilizando a Escala Numérica; analisar a dor nas dimensões sensorial, afetiva e cognitiva, utilizando o Questionário para Dor de McGill; relacionar o processo álgico com a idade, sexo, religião e tipo de abordagem cirúrgica; saber se as intervenções autónomas de enfermagem contribuem para o alívio da dor pós-operatória. Trata-se de um estudo descritivo correlacional longitudinal, com abordagem quantitativa, desenvolvido entre 14 de fevereiro e 30 de março de 2012 num Hospital no Serviço de Cirurgia Geral. A amostra constou de 30 pacientes submetidos a cirurgias abdominais. Os dados que serviram de base a este estudo foram recolhidos através da aplicação da Escala Numérica e do Questionário de Dor de McGill. Os resultados mostraram que 60% eram homens, 50% dos doentes tinham 65 e 69 anos e todos (100%), eram católicos romanos. Na primeira avaliação, 60% apresentaram dor pós-operatória moderada, 30% severa e 10% leve. Os descritores escolhidos com maior frequência foram: fisgada (90%); fina, agulhada e pontada (70%); beliscão (60%); sensível (50%); cansativa (60%) e que incomoda (50%). Nas três avaliações seguintes houve diminuição da dor severa e moderada que, aos 180 minutos era de 0% e 3% respetivamente, aumentando a percentagem de pacientes com dor leve (7%). Não encontramos relação significativa entre a variável dor pós-operatória e o sexo mas, pelo contrário, a intensidade da dor pós-operatória e a idade. O índice de dor total e sensitiva é influenciado pelo sexo. A localização da dor é influenciada pelo tipo de cirurgia, pela idade e pelo sexo. A dor pós-operatória era, principalmente, de intensidade moderada. Mesmo nos doentes a quem não foi administrado fármaco (50%), a dor foi aliviada ao longo das quatro avaliações. Desta forma, podemos inferir que as que as intervenções autónomas de enfermagem contribuem para o alívio da dor. A informação/atualização permanente dos profissionais de saúde é indispensável para que seja possível evitar ou minimizar a ocorrência de dor.

Noninvasive monitoring of tissue hemoglobin using UV-VIS diffuse reflectance spectroscopy: a pilot study.

We conducted a pilot study on 10 patients undergoing general surgery to test the feasibility of diffuse reflectance spectroscopy in the visible wavelength range as a noninvasive monitoring tool for blood loss during surgery. Ratios of raw diffuse reflectance at wavelength pairs were tested as a first-pass for estimating hemoglobin concentration. Ratios can be calculated easily and rapidly with limited post-processing, and so this can be considered a near real-time monitoring device. We found the best hemoglobin correlations were when ratios at isosbestic points of oxy- and deoxyhemoglobin were used, specifically 529/500 nm. Baseline subtraction improved correlations, specifically at 520/509 nm. These results demonstrate proof-of-concept for the ability of this noninvasive device to monitor hemoglobin concentration changes due to surgical blood loss. The 529/500 nm ratio also appears to account for variations in probe pressure, as determined from measurements on two volunteers.