Weaving women's health across clinical clerkships

Clerkship directors have an opportunity to develop consensus on learning objectives for women's health issues and to develop curricula that cross disciplinary boundaries. A collaborative interdisciplinary approach assures proper sequencing of knowledge and skill acquisition, conserves educational resources, and reflects the values of connectedness and patient-centeredness that are central to women's health. The informal networks and the institutional structures that bring clerkship directors together for discussion of a variety of educational issues promote such collaboration. The authors describe three approaches to designing and implementing women's health curricula and discuss how each might be applied to the topic of domestic violence: adding free-standing courses to existing curricula, often as electives; delegating pieces of the women's health curriculum to existing courses; and creating new interdisciplinary curricula that then are integrated into the general curriculum. Each has advantages and disadvantages. Ideally, models for curriculum design will reflect the collaborative patient-centered models upon which the field of women's health is based. Such models enhance program effectiveness by taking advantage of discipline-based expertise while allowing for the sharing of both educational responsibilities and educational resources.

Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

BACKGROUND AND AIMS

Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach for hospitalized patients who require TPN.

METHODS

One hundred and two hospitalized patients (age range, 18-88 years) who required TPN were prospectively randomized to receive therapy via a centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied.

RESULTS

Complication-free delivery rate (without the need to remove or replace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P<0.05). The overall infection rate was 4.9 per 1000 catheter days and was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the direct institutional costs for insertion and maintenance of PICC lines (US$22.32+/-2.74 per day) was greater than that for subclavian lines (US$16.20+/-2.96 per day;P<0.05).

CONCLUSION

PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.

Characteristics of women surgeons in the United States

BACKGROUND

Women surgeons are becoming increasingly prevalent. Despite this, there have been few studies of personal or professional characteristics of US surgeons of either gender.

METHODS

Data were taken from the Women Physicians' Health Study, a nationally representative random sample (n = 4,501 respondents) of US women physicians, and data were analyzed in SUDAAN.

RESULTS

Surgeons were younger, and more likely to be US born, white, unmarried, and childless than were other women physicians; their personal health behaviors were similar to those of others. They worked significantly more clinical hours and call nights, but were not more likely to report feeling that they worked too much, had too much work stress, or had less control of their work environment. Their career satisfaction was similar to that of other women physicians, and satisfaction with their specialty was greater. They were less avid preventionists than were primary care practitioners, and somewhat less avid than other specialists.

CONCLUSIONS

Women surgeons differ in interesting and important ways from other women physicians.

The role of platelet-activating factor in conscious, normotensive endotoxemia

The effects of endotoxin have been postulated to be mediated in large part by release of endogenous platelet-activating factor (PAF) due to the similarity of their hemodynamic and gastric effects in anesthetized animals, and to the ability of PAF inhibitors to ameliorate endotoxin's effects. We chose to examine the relationship with doses that would not produce circulatory shock, in unrestrained conscious animals, in order to mimic clinical situations. Adult male rats were prepared with vascular access, hemodynamic and temperature monitors, and gastric strain gauge transducers. After an overnight fast, rats received a 4-hr infusion of saline (0.5 ml/hr), endotoxin (12.5 mg/kg/hr), PAF (36 micrograms/kg/hr, or 600 ng/kg/min), or endotoxin plus the PAF inhibitor CV 3988 (1 mg/kg/hr, after an initial pretreatment of 1 mg/kg). Rats were killed, stomachs were harvested, and contents were analyzed at the end of the infusions. Blood pressure was not affected by any treatment, but all treated groups developed diarrhea and vasodilatation. Endotoxin and PAF infusions decreased heart rate and body temperature to a similar extent, although the PAF effect on temperature was delayed. The PAF inhibitor did not prevent the body temperature effect, but did reverse it. Gastric secretions were affected by PAF to a lesser extent than by endotoxin, and the PAF inhibitor did not decrease endotoxin's gastric secretory effects. PAF has similar systemic and gastric effects to endotoxin in conscious, unrestrained, normotensive animals. The systemic effects of endotoxin at 12.5 mg/kg/hr were prevented or reversed by the PAF inhibitor CV-3988 at 1 mg/kg/hr, but not the gastric secretory effects.

Pancreatic enzyme elevations after blunt trauma

BACKGROUND

Elevations in levels of the pancreatic enzymes amylase and lipase occur frequently after trauma. The purpose of this prospective study was to examine the incidence of these enzyme elevations in patients suffering blunt trauma, their natural history, and their relationship to posttraumatic pancreatitis.

METHODS

One hundred consecutive trauma patients were studied on admission to the surgical intensive care unit with daily serum amylase and lipase measurements, which were blinded to the clinical service. If the enzyme levels were elevated after 3 days, the patient was enrolled in the study and observed and examined daily, and enzyme levels were measured every other day. These patients were fed enterally by the clinical service if no symptoms of clinical pancreatitis were present.

RESULTS

In 17% of patients persistent pancreatic enzyme elevations developed. These patients more frequently had had hypotension, higher Injury Severity Scores, and were more likely to have had severe head injuries than those whose enzyme levels remained normal. Five percent of those studied displayed evidence of clinical pancreatitis, and none of these patients had only isolated head injuries. Lumbar spine injuries and retroperitoneal hematomas were present more frequently in the group in whom symptomatic pancreatitis developed.

CONCLUSIONS

After blunt trauma 17% of patients displayed persistent pancreatic enzyme elevations, but the majority remained asymptomatic despite enteral feeding. Retroperitoneal injury may identify patients at risk for pancreatitis. Patients with isolated head injuries should be fed enterally.

Emergency surgery for pancreatic pseudocysts

Pancreatic pseudocysts are a frequent complication of acute and chronic pancreatitis. The management of acute surgical emergencies associated with pseudocysts is unique. In a series of 117 patients with one or more pancreatic pseudocysts, 32% required urgent operation because of a cyst-related complication. The mean day of pseudocyst diagnosis was 7.8. Thirty percent of the patients had operation on the day of admission, while 70% required operation during cyst maturation because of an increase in size of the cyst or suspected rupture or infection. Twelve patients were found to have mature cysts at operation and had internal drainage, and external drainage was used in 56%. A pancreatic fistula developed in 22% of the patients, and septic complications occurred in 27% of surviving patients. The overall mortality was 18.9%. Mortality was 18% and 19%, respectively, for patients who had operation on the day of admission or during cyst maturation.

Hyperosmolar glucose prevents stress ulceration in the rat restraint model despite inhibition of endogenous prostaglandins

Stress ulceration continues to be a problem in critically ill surgical patients and occasionally occurs even when prophylaxis is attempted with standard agents. Tube feedings protect against ulceration in clinical settings. Many tube feeding formulas and intragastric 25 per cent glucose alone prevent gastric lesions in the rat restraint model. Endogenous cytoprotective prostaglandin release is stimulated by the application of hyperosmolar sugar solutions to the gastric mucosa. To determine whether all or part of the protection afforded by 25 per cent glucose is mediated through stimulation of endogenous prostaglandins, hyperosmolar glucose was tested in restrained rats with and without concurrent cyclo-oxygenase blockade. Intragastric hyperosmolar glucose protected against gross and microscopic gastric lesions, raised the blood glucose level and elevated the gastric mucosal pH. Although cyclo-oxygenase blockade alone worsened the lesions produced by restraint, blocking cyclo-oxygenase in the rats given 25 per cent glucose did not lessen the protective effect of hyperosmolar sugar. We conclude that endogenous prostaglandins are useful in gastric mucosal defense but are not necessary for the protection afforded by 25 per cent glucose. It is likely that providing glucose directly to the stressed gastric mucosa enhances several aspects of gastric mucosal defense.

Presentation of pancreatic pseudocysts: implications for timing of surgical intervention

A review of 115 patients with pancreatic pseudocysts treated surgically between 1976 and 1984 showed four patterns of presentation: pseudocyst alone, pseudocyst and acute pancreatitis, acute pancreatitis alone, or neither apparent on hospital admission. These patterns of presentation were associated with differences in the clinical course and ultimate surgical outcome of each group of patients. Emergency procedures greatly increased the morbidity and mortality of surgery for pseudocysts. A preoperative delay for pseudocyst maturation was expected to decrease the morbidity and mortality of elective pseudocyst drainage, but no benefit was found either for the series as a whole or for any subgroup. We conclude that an arbitrary preoperative delay for pseudocyst maturation (in the absence of acute pancreatitis) exposes patients to the risks of preoperative complications, increases the expense of care for pancreatic pseudocysts, and fails to improve surgical outcome.

Do diagnosis-related groups accurately reflect the disease? Pancreatic pseudocyst: a case in point

Diagnosis-related groups (DRGs) have been mandated by the federal government to promote fiscal responsibility and insure cost containment. A retrospective analysis of demographic and cost data was conducted on 115 patients operated on for pancreatic pseudocyst. The DRG 191 criteria are as follows: major pancreas, liver plus shunt procedure; mean length of stay (LOS), 20.8 days; outlier cutoff LOS, 41 days; hospital reimbursement, $11,367.82; and day outlier rate, $86.57. The overall LOS was 34.6 days (range, one to 138 days). Sixty-six percent of the patients exceeded the DRG LOS and 37% exceeded the day outlier cutoff of 41. The number of days from admission to surgery varied from one to 65 (mean, 15.7 days). Hospital charges and DRG reimbursement were compared in 23 patients. In nine patients with a LOS of 19.9 days, DRG reimbursement exceeded charges by $34,308. In 14 patients whose charges exceeded reimbursement, the loss was $142,156. Hospital costs and LOS seem to be related to the natural history of the disease and its necessary treatment, rather than to unnecessary diagnostic procedures. Unless surgeons assess and establish medical standards, economic pressures will have a negative impact on patient care and physicians' practice.