RESUMO
OBJECTIVE: To learn about the effects of cranial base surgery. DESIGN: Cohort study with a mean follow-up of 30 months. SETTING: Population-based. PATIENTS: A consecutive sample of 183 patients who underwent cranial base surgery; 118 patients had malignant skull base tumors, the majority of which were previously treated; 50 had benign tumors; 9 had congenital malformations of the skull base; 3 had inflammatory lesions, and 3 had traumatic defects of the skull base. MAIN OUTCOME MEASURES: Disease-free interval, overall survival, and rate of complications and functional status. INTERVENTION: Cranial base surgery was followed by radiotherapy (in previously untreated patients). RESULTS: After completion of follow-up (mean, 30 months), 30 (25.4%) patients had died of their malignant tumors and 8 (6.8%) had died of other causes. One patient (0.84%) was lost to follow-up. The overall cancer survival rate without regard to histologic type was 67% (63% with no evidence of disease). Among the patients who were treated for benign neoplasm, 72% had no evidence of disease at a mean follow-up of 39 months. The group of patients with congenital malformations and inflammatory and traumatic lesions demonstrated successful correction of their presurgical problem with skull base surgery. One patient (who had invasive aspergillosis) died of disease. The overall surgical-medical mortality rate was 2%; the complication rate was 33%, and the Karnofsky performance score was improved or unchanged after surgery in 83% of patients. The average duration of surgery, number of blood transfusions used, and length of the hospital stay were 10 hours, 3 units, and 15 days, respectively. CONCLUSIONS: Cranial base surgery is a valid surgical technique for treatment of cranial base afflictions. In this study it was found to be beneficial in controlling benign and malignant disease and to be the treatment of choice for selected congenital malformations, trauma, and inflammatory lesions.
Assuntos
Neoplasias Cranianas/cirurgia , Crânio/cirurgia , Adolescente , Adulto , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Crânio/anormalidades , Neoplasias Cranianas/mortalidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Prescription-writing skills are often overlooked in resident education. The present study evaluates a method of improving prescription-writing skills over a 2-year period. METHODS: This was a prospective, nonblinded, nonrandomized trial of an educational method to improve prescription-writing abilities of a class of 12 family practice residents. The intervention included evaluation and feedback of prescription writing by a clinical pharmacist using copies of prescriptions written over a 2-year period and applying previously defined criteria for determining prescription-writing errors. RESULTS: The baseline prescription-writing error rate was 14.4%. Over the 2-year intervention, prescription-writing errors by all residents decreased to 6.0% (P = .0002). Error rates decreased 58% from the baseline during the last 6 months of the intervention (P = .001). CONCLUSIONS: Continuous evaluation and feedback improved prescription-writing skills and improved communication with pharmacists and patients.
Assuntos
Prescrições de Medicamentos , Medicina de Família e Comunidade/educação , Internato e Residência , Redação , Estudos de Avaliação como Assunto , Retroalimentação , Hospitais Comunitários , Humanos , Erros de Medicação , Ambulatório Hospitalar , Farmacêuticos , Estudos ProspectivosRESUMO
OBJECTIVE: To assess the long-term effect of an extensive rheumatology curriculum on graduates of family practice residencies. DESIGN: Cohort analytic study using a mailed survey and a multiple-choice test based on clinical vignettes that were administered 3 to 7 years after graduation from residency training. PARTICIPANTS: Practicing family physicians who had graduated from a community hospital family practice residency with an extensive rheumatology curriculum (trained) were compared with graduates from a similar program without specific rheumatology training (untrained). MAIN OUTCOME MEASURES: Total test scores, results of individual test questions, practice style, and attitudes toward rheumatology training and practice. RESULTS: We received 39 (85%) responses from 46 potential respondents in the trained group and 25 (89%) responses from 28 potential respondents in the untrained group. Physicians in the two groups had similar backgrounds and practice styles. The trained physicians scored higher on the multiple-choice test (mean +/- SD, 25 +/- 5 vs 22 +/- 6; P < .03). The clinical significance of these differences is a matter of individual interpretation. One hundred percent of the trained physicians believed that the quality of their rheumatology training was good to excellent compared with 25% of the untrained physicians. Seventy-six percent of the untrained physicians wished that they knew more about rheumatology. No variables other than rheumatology training accounted for the differences between the two groups. CONCLUSIONS: The difference in rheumatology knowledge, evident during and soon after residency between trained and untrained physicians, persists for 3 to 7 years.
Assuntos
Currículo , Medicina de Família e Comunidade/educação , Internato e Residência , Reumatologia/educação , Adulto , Estudos de Coortes , Feminino , Humanos , MasculinoRESUMO
Two hundred and thirty-three patients underwent cholecystectomy at Mercy Hospital of Pittsburgh during the popularization of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was performed in 167 of these patients while the remaining 66 patients had an open cholecystectomy. A statistically significant increase in the incidence of morbidity was observed with advancing age (p < 0.001, odds ratio 2.33) as well as in patients with higher ASA classes (p < 0.001, odds ratio 2.31). Overall, laparoscopic cholecystectomy was associated with a markedly lower incidence of morbidity than the open procedure (7% versus 47%, p < 0.001). A multiple logistic regression model was applied to the study population due to the fact that those patients who underwent open cholecystectomy tended to be older individuals with more clinically significant associated medical conditions than those individuals who underwent the laparoscopic procedure. When the logistic regression model was applied to control for the differences in age, associated illnesses, and ASA class between the two groups; a seven fold increase in the risk of morbidity was found in the open group as compared to the laparoscopic group (p < 0.001, odds ratio 7.31). These findings favor the use of laparoscopic cholecystectomy over open cholecystectomy in all eligible patients, especially elderly patients and those patients in higher ASA classes.
Assuntos
Colecistectomia Laparoscópica/estatística & dados numéricos , Colecistectomia/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças dos Ductos Biliares/cirurgia , Colecistectomia/efeitos adversos , Colecistectomia/economia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Colecistite/cirurgia , Colelitíase/cirurgia , Doença da Artéria Coronariana/complicações , Custos e Análise de Custo , Doença/classificação , Feminino , Humanos , Hipertensão/complicações , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Atelectasia Pulmonar/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
A multicenter, double-blind, randomized, placebo-controlled trial was conducted to determine whether the addition of penicillin was superior to patient education and anti-inflammatory drug therapy for relief of the acute discomforts of pharyngitis caused by group A beta-hemolytic streptococcus (GABHS). One hundred seventy-eight patients, aged 4 to 29 years, received appropriate symptomatic therapy, including specific doses of aspirin or acetaminophen, plus penicillin (91 patients) or placebo (87) for the initial 48 hours of illness. All had 24-hour office and 48-hour telephone reevaluations. In 123 patients (57 with clinically severe pharyngitis), throat cultures yielded GABHS. Penicillin provided a margin of 20% improvement over anti-inflammatory therapy for the complaint of sore throat only after 48 hours of treatment (for the 123 patients with GABHS, p = 0.01; for the 57 with both severe pharyngitis and GABHS, p = 0.05). No significant improvement was noted for fever, malaise, odynophagia, exudate, adenitis, or pharyngitis. The failure of penicillin to provide much additional benefit makes its routine early prescription specifically for symptomatic relief questionable.