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6 - Professionalism – including academic activities: clinical research, audit, consent and ethics
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- By Evangelos Mazaris, Hammersmith Hospital, London, Paris Tekkis, Chelsea and Westminster Hospital and The Royal Marsden Hospital, London, Vassilios Papalois, Hammersmith Hospital, London
- Edited by Andrew Kingsnorth, Douglas Bowley
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- Book:
- Fundamentals of Surgical Practice
- Published online:
- 03 May 2011
- Print publication:
- 17 March 2011, pp 94-102
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Summary
Introduction
Surgical practice of the highest standards has always been based on sound knowledge of applied anatomy, sharp clinical judgment and excellent operative skills. In modern times, surgical practice is also integrated with basic and translational research in which the surgeon has to be actively and creatively involved.
Tight monitoring of the outcomes of surgical practice and the development of evidence-based surgery is a central theme in modern surgery. Clinical audit is an important process for the continuous evaluation of care provided to patients, leading to the acknowledgement of drawbacks, and has become a driving force for future improvement. Thus, it is necessary for surgeons to familiarize themselves, as early as possible during their careers, with the basic principles.
Acquiring informed consent is a crucial part of the daily practice of a surgeon. In modern healthcare, the patients rightly have a very strong say regarding their care and medical-legal problems arise more frequently. Therefore, surgeons have to be trained properly regarding the width and depth of the information they need to provide to the patients and their families prior to surgery regarding the type of operation, the potential problems and alternative treatments and allow them sufficient time and space to ‘digest the information’, ask questions and finally consent without coercion.
Inflammatory bowel disease: ulcerative colitis
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 413-416
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Summary
Introduction
Ulcerative colitis is an inflammatory condition of the large bowel that typically presents with frequent bloody stools. In acute cases presentation may be with signs of sepsis, and perforation of the colon may have occurred or be imminent.
Incidence
Ten new cases per 100 000 population in developed countries. Less commonin Africa and Asia. Bi-modal age distribution with peak at 20–40 and a lesser peak at 60–80 years of age. Incidence is equal between the sexes.
Aetiology
The aetiology of ulcerative colitis remains unknown. Possible factors are genetic, as demonstrated by 15-fold increase in incidence in first-degree relatives. Other factors include infective organisms, psychosocial wellbeing, immunological, or defects in colonic mucus production. Smoking appears to have a protective effect.
Pathophysiology
The disease process usually begins in the rectum (proctitis), and spreads proximally. If the ileocaecal valve is incompetent, the terminal ileum may also be involved (backwash ileitis).Macroscopically there is diffuse inflammation with hyperaemia, pus and bleeding. Ulceration may be evident. In long–standing cases, inflammatory polyps (pseudopolyps) may occur in large numbers. In severe fulminant (toxic) colitis, a segment of the colon, most commonly the transverse, becomes acutely dilated and the wall thins and is at risk of perforation (toxic megacolon).
Microscopically, acute and chronic inflammatory cells invade the lamina propria and crypts, and there are crypt abscesses. Goblet cell mucin becomes depleted, and the crypts are present in reduced number and atrophic. With increased duration of the disease the cells undergo dysplastic changes and there is an increase in the risk of colorectal cancer.
Inflammatory bowel disease: Crohn's disease
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 409-412
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Summary
Introduction
Crohn's disease (CD) is an inflammatory condition that most commonly affects the small intestine. It may, however, affect any part of the GI tract from themouth to the anus. The colon (Crohn's colitis) or the perineum, with or without small-bowel involvement may be affected.
Incidence
Five new cases per 100 000 population per year in developed countries. The incidence is rising rapidly. Crohn's disease is most commonly diagnosed in 20–30 year olds, but shows a biphasic incidence, with a second peak in the sixth decade.
Aetiology
Unknown. Possible causes include infective (there are features that are similar to intestinal tuberculosis), immunological (there are suggestions of impaired cell-mediated immunity, and of autoantibody formation) and diet (possible causation of diet high in refined carbohydrates). In contrast to ulcerative colitis, smoking appears to be a risk factor.
Pathophysiology
Unlike ulcerative colitis, which is confined to the colon, CD can affect any part of the gastrointestinal tract. The disease is characteristically patchy in nature with normal segments of bowel between ‘skip lesions’ of disease. Macroscopically there is aphthous ulceration which progresses to deep fissuring ulcers. This leads to a cobblestone appearance and tight strictures or fistulae may develop. Microscopically there is chronic inflammation of all layers of the bowel wall, with ulceration, micro-abscesses and non-caseating granulomas.
Symptoms and signs
The presentation of CD can vary depending on the areas affected. The most common presenting features are diarrhoea, weight loss, abdominal pain and fever. There may be steatorrhoea if the small bowel is affected, or rectal bleeding in those with Crohn's colitis.
Inflammatory bowel disease: infective colitis
- Omer Aziz, Sanjay Purkayastha, Paraskevas Paraskeva
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- Book:
- Hospital Surgery
- Published online:
- 06 July 2010
- Print publication:
- 16 February 2009, pp 417-420
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Summary
Introduction: infective colitis is an inflammatory condition of the large bowel caused by the presence of pathogenic organisms, and may be primary or secondary.
Incidence: the incidence varies widely depending on the causative organism. The most common type, pseudomembranous colitis, occurs in up to 1%of hospitalized patients, and is almost exclusively associated with antibiotic use.
Causative organisms
A number of different organisms have been implicated, and these include:
▪ Clostridium difficile. This organism is responsible for pseudomembranous colitis. It is associated with the use of antibiotics, particularly the macrolides. Clinically a patient who may have been steadily improving suddenly deteriorates, with tachycardia and signs of hypovolaemia. There is profuse diarrhoea which is characteristically green in colour. Blood tests show a rising white count and inflammatory markers. If dehydration is severe then renal function may become compromised. The inflammatory process causes a fibrinous pseudomembrane to develop over the colonic mucosa. Treatment is with oral metronidazole or vancomycin. Parenteral antibiotics are not effective. If treatment is delayed toxic megacolon and/or perforation may occur. Mortality is reported to be as high as 30%.
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