bluuebunny/crossref_metadata_2025 huggingface dataset:
PEPTIC DISEASE: CAN WE AFFORD CURRENT MANAGEMENT?
Authors: Fletcher D. R.
Published: January 2008

Background: While surgery has the potential to cure peptic disease (ulceration and reflux), the development in the 1970s of H2 receptor antagonists saw them replace surgery in the management of peptic symptoms, controlling disease while the medication was taken. Medical cure at least in the case of a duodenal ulcer is now also possible by the use of anti‐Helicobacter therapy.

Methods: Australian Pharmaceutical Benefits Scheme (PBS) and Medicare data on the treatment of peptic disease were reviewed.

Results: The data showed that medical cure of duodenal ulcer is rarely attempted. While elective surgical treatment for duodenal ulcer, highly selective vagotomy, has decreased 10‐fold in 10 years, prescriptions for antisecretory agents (H2 and proton pump) are doubling every 2 years (increasing from 6.7 to 7.8% of PBS budget). Meanwhile upper gastrointestinal endoscopy rates are doubling every 5 years. By comparison, the most appropriate treatment, unti‐Helicobacter therapy, is prescribed at 1/50th the rate of antisecretory agents and over 2 years decreased to 1/80th. Antisecretory treatment has not been effective in reducing mortality from duodenal ulcer, at least not in New South Wales.

Conclusions: If the principle of treatment is to decrease cost and prevent complications by curing duodenal ulcer, then current practice is a failure. A management algorithm for peptic symptoms which has the potential to relieve symptoms, cure ulcer when present, minimize surgery and reduce complications and cost is proposed for the purpose of debate.
DUCTAL CARCINOMA IN SITU PART I: DEFINITION AND DIAGNOSIS
Authors: Delaney Geoff , Ung Owen , Bilous Michael , Cahill Stephen , Greenberg Merle , Boyages John
Published: January 2008

The frequency of diagnosis of ductal carcinoma in situ (DCIS) has increased in Australia, largely because of the national screening programme. Ductal carcinoma in situ presents a dilemma because of problems with its diagnosis and variations in reporting pathological and radiological findings, making it difficult to define optimal treatment and communicate information in a way that helps the patient understand the problems and make decisions. There is considerable inter‐observer variation, particularly in differentiating low‐grade DCIS from ductal hyperplasia, with or without atypia, but pathologists who participate in regular pathological review sessions vary less in their opinions. Mammography remains the main investigative tool for DCIS and the American College of Radiology has recommended standardized reports. A team approach is required for the removal and diagnosis of possible DCIS. Although the team may be best co‐located in the one facility, this is not practical in many community hospital settings which lack on‐site radiology and pathology services. The decision about how much breast tissue to remove will need to be made for each patient and depends on the size of the microcalcification and how suspicious the mammogram is for DCIS. We recommend the use of synoptic reports for DCIS, and we document the minimum factors that should be reported by pathologists. The evaluation and management of DCIS by a multidisciplinary team will allow the patient access to information required to make often difficult treatment decisions. In this paper, we review the literature about the natural history, pathology, cytology and radiology of DCIS and document the 20 critical steps required for the diagnosis of impalpable, mammographic microcalcifications suspected to be DCIS.
FOCAL TENOSYNOVIAL AMYLOID DEPOSITION AS A RARE CAUSE OF MEDIAN NERVE COMPRESSION AT THE WRIST
Authors: Subramaniam P. , De La Harpe D. , Corlett R. J.
Published: January 2008

Although certain local and systemic aetiologies for the carpal‐tunnel syndrome are known, a large number of cases of this syndrome do not have a conclusive aetiology. We present a case of histologically proven focal tenosynovial deposition of amyloid presenting as a rare cause of median nerve compression at the wrist.
PORT‐SITE RECURRENCE AFTER THORACOSCOPIC RESECTION OF OESOPHAGEAL CANCER
Authors: Dixit A. S. , Martin C. J. , Flynn P.
Published: January 2008

We report a case of thoracoscopic port‐site recurrence after a thoracoscopically assisted total oesophagectomy for squamous cell carcinoma. The tumour was not extracted through the port site.
DUCTAL CARCINOMA IN SITU PART 2: TREATMENT
Authors: Delaney Geoff , Ung Owen , Cahill Stephen , Bilous Michael , Boyages John
Published: January 2008

Several dilemmas exist when treating a patient with ductal carcinoma in situ (DCIS): the high rate of inter‐observer variation for pathologists who must diagnose these tumours; the potential for over‐and under‐treatment; and the uncertainty about the best way to inform a patient who must often make a decision between breast conservation and mastectomy. Mastectomy is nearly 100% curative, is expedient, but may represent over‐treatment for many women, particularly those with asymptomatic mammographically detected lesions. Axillary dissection is not recommended as a routine except for patients with lesions over 5 cm in whom the risk of micro‐invasion and lymph node involvement increases. Conservative surgery (CS) alone is associated with a local recurrence rate of ˜ 20%, and half of these recurrences (10% overall) are invasive, with a potential long‐term cure rate of at least 90%. The addition of radiation to CS reduces the risk of local recurrence to ˜ 10%, half of these recurrences (5%) are invasive for a potential long‐term cure rate of 95%. Several randomized trials comparing CS with or without radiation therapy (RT) are in progress. The factors that increase the rate of local recurrence after CS alone for DCIS include close or involved margins, and the presence of necrosis or high‐grade tumours. Patients with these features should have radiation therapy if breast conservation is preferred. Patients with low‐grade tumours (without necrosis) up to 15 mm, with clear margins of at least 10 mm, who agree to be closely observed may be good candidates for CS alone. A critical review of the literature is presented.
LAPAROSCOPIC CHOLECYSTECTOMY: THE MISSED DIAGNOSIS
Authors: Hanney Richard M. , Bond Geoff , de Costa Alan
Published: January 2008

Background: All 534 laparoscopic cholecystectomies performed by five surgeons at a single institution over a 3‐year period were reviewed as part of a quality assurance process. The aim of the review, which has previously been published in this journal, was to identify and quantify complications of the procedure. Five cases in this series were recognized where major intra‐abdominal pathology not identified at the time of laparoscopic cholecystectomy required laparotomy shortly thereafter. These five cases are reported here because there has been little discussion in the literature of this problem associated with laparoscopic cholecystectomy.

Methods: The records of all 534 patients having a laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed and entered into a computer database (Microsoft Access). This data collection and recording have subsequently become an ongoing process of quality assurance.

Results: Five of 534 patients treated by laparoscopic cholecystectomy failed to have resolution of their symptoms post‐operatively. A laparotomy was subsequently required within 3–12 months which demonstrated causative pathology present, but not detected at, the time of laparoscopic cholecystectomy. Where possible, treatment of these laparotomy findings resolved the initial presenting symptoms of colicky epigastric pain.

Conclusions: The rate of ‘missed diagnosis’ is found to be < 1%. Laparoscopic cholecystectomy is a therapeutic, rather than diagnostic, procedure, and pre‐operative discussion should include the possibility of further procedures being required subsequently, particularly when symptoms and signs are atypical.
ENDOTOXIN LEVELS IN DONORS AND RECIPIENTS DURING ORTHOTOPIC LIVER TRANSPLANTATION
Authors: Pillay S. P. , Wynter C. , Lynch S. , Wall D. , Balderson G. , Strong R.
Published: January 2008

Background: The hypothesis being tested in this paper is that endotoxin levels in donors and in recipients during liver transplantation influences postoperative outcome.

Methods: Endotoxin levels in systemic venous and portal venous blood were measured in 46 adult donors and 44 adult recipients (47 liver transplants) during the period 1992–95. Endotoxin was measured using a modification of the Limulus amoebocyte lysate (LAL) assay.

Results: In the donor, systemic endotoxin levels were above normal levels at 10.0 ± 1.3 pg/mL from the start and rose to 15.8 ± 2.9 pg/mL after dissection of the hilar structures, but fell to 10.6 ± 0.8 pg/mL just prior to the removal of the liver (control = 7.8 pg/mL). The mean portal venous endotoxin levels were 18.2 ± 3.4 pg/mL after dissection of the hilar structures and 12.6 ± 0.9 pg/mL after cannulation of the portal vein. In the recipients, the highest level in the portal venous blood occurred at the end of the anhepatic phase (46.5 ± 6.7 pg/mL). The systemic venous samples in the recipients were elevated to start with, but fell rapidly to 19.3 ± 1.5 pg/mL 24 h postoperatively, and to 13.2 ± 1.0 pg/mL by day 7. The endotoxin concentrations were higher in recipients who developed complications.

Conclusions: Endotoxin is elevated throughout the recipient transplantation procedure and up to 7 days postoperatively. High levels of endotoxin at induction, the anhepatic phase and at certain time points correlated with patients who developed postoperative complications.
LAPAROSCOPIC APPENDECTOMY IN PAEDIATRIC PATIENTS: OPTIMIZATION WITH A NEW METHOD OF PORT INSERTION
Authors: Yip K. F. , Yeung C. K. , Lee K. H. , Lau W. Y.
Published: January 2008

Background: Conventional methods of port insertion for laparoscopic appendectomy often result in poor surgical access, especially when a pelvic appendix is encountered or when mobilization of the caecum becomes necessary. The relatively small antero‐posterior diameter of the peritoneal cavity in children further aggravates this problem.

Methods: We have modified the procedure by inserting only one 10‐mm port at the sub‐umbilical position, and two 5‐mm ports at the lower abdomen beneath the ‘bikini line’. The videoscope is inserted via the left lower abdominal port, and the sub‐umbilical port and the right lower abdominal port are used as the working ports.

Results: Very satisfactory results have been achieved. The bottom of the caecum can be well visualized and caecum mobilization becomes easy. A pelvic appendix is well visualized. Dissection of a high retrocaecal appendix could be carried out without being obscured by the caecum. Better cosmetic results were also achieved. The method has been applied in 66 patients (aged 4–14). The mean operation time was 62 min.

Conclusion: We recommend this approach to be used as the standard procedure for laparoscopic appendectomy in children.
LAPAROSCOPY: THE ULTIMATE DIAGNOSTIC TOOL FOR A BLEEDING MECKEL'S DIVERTICULUM
Authors: Crosthwaite Gary L. , Leather Andrew J. M.
Published: January 2008

Laparoscopy is useful in the diagnosis and treatment of a complicated Meckel's diverticulum. A case is presented describing the technique.
BUERGER'S DISEASE IN HONG KONG: A REVIEW OF 89 CASES
Authors: Lau Hung , Cheng Stephen W. K.
Published: January 2008

Background: A retrospective analysis of 103 case records from 1978 to 1996 with a provisional diagnosis of Buerger's disease was undertaken at the Department of Surgery, University of Hong Kong, Queen Mary Hospital. The aim of the study was to elucidate the clinical course and evaluate the results of surgical intervention of Buerger's disease in Hong Kong Chinese people.

Methods: Fourteen patients were subsequently excluded from the study because of inability to fulfil our diagnostic criteria. Data on clinical presentation, investigations, indications and results of surgical intervention were reviewed. Sympathectomies and arterial reconstructions were performed on 42 and four patients, respectively, for critical ischaemia or rest pain. Outcome was analysed with respect to the rate of ulcer healing, pattern of recurrence and limb loss.

Results: The patients were all young male heavy smokers with a mean age of 36.5 years. The majority of patients (80%) presented with ischaemic ulceration or gangrene. Vascular reconstruction was undertaken in four patients and satisfactory long‐term results were obtained in three patients. Sympathectomy was able to relieve symptoms in 87% of operated patients and ischaemic ulceration healed in 2.6 (mean) ± 1.7 (SD) months after the operation. If the patient continued to smoke, surgical intervention did not exempt the patient from a relapse or amputation.

Conclusion: Sympathectomy provides short‐term pain relief and promotes ulcer healing in patients with Buerger's disease but carries no long‐term benefit. Complete abstinence from smoking is the only means of arresting the progression of the disease.
PRE‐OPERATIVE HISTOLOGICAL DIAGNOSIS OF BREAST CANCER
Authors: Serpell Jonathan W. , Johnson William R.
Published: January 2008

Background: A concordant triple assessment (clinical, mammographic and cytological) diagnosis of breast malignancy allows for pre‐operative planning of surgery and may also allow for one‐stage surgery. However, while the accuracy of cytology is high, it is unable to distinguish invasive cancer from ductal carcinoma in situ (DCIS). A malignant mass may be due to pure in situ cancer and hence axillary dissection may be avoided if pre‐operative histology is available.

Methods: A consecutive series of 300 cases of breast cancer treated over the last 5 years by the two authors was analysed to determine: the method of achieving pre‐definitive operation histology; the number of stages of surgery required; and the number of cases of mass‐forming DCIS which could be susceptible to over‐treatment.

Results: Of 289 patients undergoing local definitive surgery for breast cancer, 12 (42%) had clinical masses predominantly due to DCIS and in most of these patients axillary dissection was avoided. Histology was obtained prior to definitive surgery in 272 (94.1%) patients, by intra‐operative frozen section in 159 (55.0%), incisional biopsy in 37 (12.8%), needle localization biopsy in 62 (21.5%) and core biopsy in 14 (4.8%). A total of 189 patients (65.4%) underwent one‐stage surgery only. Breast conservation was achieved in 210 (72.7%) patients. Those requiring mastectomy were significantly more likely to have required two stages of surgery as were those with lesions detected by screening.

Conclusions: Mass‐forming DCIS cannot be predicted pre‐operatively by triple assessment alone; and therefore pre‐operative histology is required to avoid axillary dissection. Pre‐operative histology may be obtained by core biopsy or intra‐operative frozen section to identify DCIS and distinguish it from invasive disease, but both allow a one‐stage surgical procedure in the majority of cases.
HANDLEBAR INJURIES IN CHILDREN: PATTERNS AND PREVENTION
Authors: Clarnette Thomas D. , Beasley Spencer W.
Published: January 2008

Background: Bicycle handlebar injuries in children are a significant cause of abdominal trauma. The present study documents 32 children with handlebar injuries who were managed at the Royal Children's Hospital over a 5‐year period, and suggests a design change to bicycle handlebars which may reduce the severity of injury.

Methods: A retrospective review of all the children admitted to the Royal Children's Hospital with handlebar injuries between January 1990 and January 1995 was undertaken. The age, sex, nature of injury, length of hospital stay and management were recorded.

Results: Thirty‐two children with blunt abdominal trauma or lacerations resulting from handlebar injuries were identified. Injuries included: splenic trauma (9); liver trauma (4); traumatic pancreatitis (3); transection of the pancreas (2); renal contusions (2); duodenal haematoma (1); and bowel perforation (3). In addition, there were three urethral injuries and five lacerations involving the abdominal wall and inguino‐scrotal region. The presence of external bruising was a poor indicator of underlying organ damage. Thirteen operations were performed and the mean hospital stay for the series was 9 days.

Conclusions: Handlebar injuries are a significant cause of both blunt abdominal trauma and lacerations to the contact area. The infrequent finding of external bruising in the presence of major organ damage suggests that, although the velocity at impact may be relatively low, the small cross‐sectional area of the end of the handlebar is a major factor contributing to organ damage. Moreover, we suspect that the high proportion of lacerations observed in this type of trauma result from the sharp metallic end of the handlebar cutting through the soft rubber handle. Manufacturers of bicycles should be made aware of these findings and should adjust the design of the handlebars accordingly.
THE RESULTS OF CORACO‐CLAVICULAR SLINGS FOR ACROMIO‐CLAVICULAR DISLOCATION
Authors: Clayer M. , Slavotinek J. , Krishnan J.
Published: January 2008

Background: Treatment of type 3 acromio‐clavicular (A‐C) dislocations is controversial. There have been over 60 different surgical procedures as well as a variety of conservative measures used to treat this injury.

Methods: The outcome of a coraco‐clavicular (C‐C) sling for grade 3–4 A‐C dislocation was studied. A dissolvable sling of braided 1 polydioxanone (PDS, Ethicon) was used with or without excision of the distal end of the clavicle in six patients. The clinical and radiological outcome of the braid and acromio‐clavicular joint were studied by clinical examination, plain and stress radiographs and magnetic resonance imaging (MRI).

Results: All patients reported good‐excellent results from 6 months after surgery. Radiological examination demonstrated some superior clavicular migration in all patients within 1 month of the procedure, although never more than that seen with a grade 2 dislocation. This migration was clinically evident only in patients with a thin build. At 1 month, the MRI demonstrated partial replacement of the braid by granulation tissue. From 6 months on, the braid was absent and fibrous tissue was noted between the coracoid and the clavicle and the acromion and clavicle.

Conclusions: The coraco‐clavicular sling did not maintain operative reduction of the dislocated clavicle. This did not diminish the functional result but was a cosmetic complication in patients with a thin build.
SAFETY OF SILICONE LIQUID IN THE POSTOPERATIVE MANAGEMENT OF DUPUYTREN'S CONTRACTURE
Authors: Thurston Alan J.
Published: January 2008

Background: Recently the New Zealand Department of Health expressed concerns about the safety of applying silicones to open wounds and banned their use. For 30 years silicone liquid has been used for the management and rehabilitation of the injured hand. It has been reported that the application of silicone fluids to the skin and ordinary handling over a period of years of various methyl and phenyl polymers by laboratory workers caused no skin disorders or sensitization, nor was absorption observed. There are no reports in the literature of the safety of the use of silicones applied to open wounds.

Methods: In the present study, 116 hands that had been mobilized in silicone liquid following surgery for Dupuytren's contracture over the last 12 years were reviewed. In the cases of 64 hands, the patients could be traced and contacted, and 47 patients (hands) agreed to attend for a clinical review. The hands were examined for areas of inflammation, granuloma formation and abnormal scar formation.

Results: No patient showed any evidence of adverse effects from the use of silicone liquid.

Conclusions: There is no evidence that the use of silicone liquid, in contact with open wounds of the hands, for the mobilization of the hand following surgery for Dupuytren's contracture has any of the adverse effects reported as being associated with implanted silicone prostheses.
TYPHOID ENTERIC PERFORATION
Authors: Talwar Sachin , Sharma Rakesh K. , Mittal Dinesh K. , Prasad P.
Published: January 2008

Background: Perforation of the bowel is the most serious complication of typhoid fever. The role of early limited surgery in managing these patients needs to be assessed.

Methods: The records of 110 cases of typhoid enteric perforation treated at JLN Hospital, Ajmer between 1990 and 1995 were reviewed.

Results: A total of 42.7% of the patients were in the 21—30‐year age group, and 83.6% were male. All patients presented with the classic features of typhoid enteric perforation. A total of 83.6% were operated on within 36 h of perforation. Surgical management consisted of primary closure of the perforation (74.5%), closure with omental graft (14.5%), resection and anastomosis (3.6%), and only drainage (7.3%). A total of 79.1% of patients developed wound infection and 10% of patients developed faecal fistula. The overall mortality rate was 16.4%. Increasing the time interval between perforation and operation significantly increased the mortality (P < 0.05). The mortality was least with early primary closure of the perforation. Patients with postoperative faecal fistula had higher mortality rates (P < 0.001).

Conclusions: Early limited surgery with thorough peritoneal lavage provides optimal results, faecal fistula is a grave complication, and the use of the McBurney incision may provide better results in terms of subsequent wound healing.
PERCUTANEOUS MICROCOIL EMBOLIZATION OF INTRAPERITONEAL INTRAHEPATIC AND EXTRAHEPATIC BILIARY FISTULAS
Authors: Hunt J. A. , Gallagher P. J. , Heintze S. W. D. F. , Waugh R. , Shiel A. G. R.
Published: January 2008

Background: Persistent intraperitoneal biliary fistulas are associated with significant morbidity and mortality. Percutaneous drainage, stenting, and endoscopic sphincterotomy or embolization of biliary radicals have largely replaced the need for hepatic resection or biliary reconstruction in managing such fistulas. When endoscopy is contraindicated, a previously undescribed technique of percutaneous embolization of intrahepatic and extrahepatic biliary fistula following penetrating liver trauma, and orthotopic liver transplant and its application in three patients, will be discussed.

Methods: Embolization procedures were performed by an interventional radiologist. Percutaneous trans‐hepatic cholangiography via a standard right‐side approach or via tube cholangiography was initially performed and the fistula defined. Coaxial catheter systems were used (5 Fr angiography catheters and Tracker 18 infusion catheters), and were positioned within the biliary tree as close as possible to the origin of the fistula. Embolization was performed using vascular Embolization 28 coils (WA Cook) 2–3 mm × 2 cm coils, straight Hilal 18 embolization coils (WA Cook) 5–7 cm, as well as Gelfoam (Upjohn) 1 mm pellets, and Histoacryl (B. Braun) 0.25–1 mL. Occlusion of the duct was confirmed by a selective intrahepatic cholangiogram. In cases of multiple fistulas several embolizations were performed at subsequent procedures. Follow‐up is over 13 months without adverse event.

Results: The technique was used in the three cases and was successful in all. A peripheral biliary fistula required embolization twice and two cystic leaks were cured after a single attempt.

Conclusions: Percutaneous embolization of biliary fistulas provides a management option in cases where conservative treatment has failed and other techniques are relatively contraindicated. The technique is effective and safe in skilled hands, and avoids major surgery. The long‐term effect of microcoils in the biliary tree is unknown.
THE EFFECT OF ARTERIAL CLAMP DURATION ON ENDOTHELIAL INJURY: AN EXPERIMENTAL STUDY
Authors: Margovsky A. I. , Lord R. S. A. , Chambers A. J.
Published: January 2008

Background: Arterial clamp‐related endothelial damage was investigated in an animal model to quantify the surface area of endothelial disruption. The influence of the duration of clamp application on this damage was evaluated.

Methods: Four identical angled DeBakey vascular clamps were applied on each of eight carotid arteries in four heparinized adult sheep for durations of 15, 30, 45 and 60 min. The applied clamping forces were measured and kept constant. After the last clamp was removed, the areas of endothelial loss were identified by in vivo staining with Evan's blue dye. The vessels were excised and the blue stained areas measured by computer‐assisted analysis. The morphological appearance of the specimens was assessed by scanning electron microscopy.

Results: Endothelial damage following clamping for 15 min (10.6 ± 4.3 mm2) was significantly less than for 30 min (19.0 ± 4.7 mm2), 45 min (19.8 ± 4.6 mm2) and 60 min (20.7 ± 4.9 mm2; P= 0.005), but there were no significant differences between the areas of endothelial loss observed for 30, 45, and 60 min. These results corresponded to the damage seen using scanning electron microscopy, which showed partial disruption of endothelium at 15 min compared to more complete destruction at longer durations.

Conclusion: Evan's blue staining combined with computer‐assisted surface area measurement is an accurate method for quantifying endothelial damage. The extent of damage caused by vascular clamps is partly time‐dependent, being less for 15 min than for 30 min of clamping, but not significantly increasing for durations greater than 30 min.
THE LOWER TRAPEZIUS ISLAND MYOCUTANEOUS FLAP FOR RECONSTRUCTION OF SOFT TISSUE OF THE LATERAL SKULLBASE AND NECK
Authors: Cole Ian
Published: January 2008

Background: The lower trapezius island myocutaneous flap (LTIMF) has been described as a method of reconstruction after excision of carcinoma of the head and neck. A high rate of failure and confusion regarding the nomenclature of its vascular supply has been reported in the literature.

Methods: The data on six patients whose lateral skullbase and upper neck were reconstructed with an LTIMF were assessed prospectively.

Results: There was one major flap loss, and one previously irradiated patient had a minor dehiscence. One patient had a small haematoma at the donor site. All wounds were closed primarily and preservation of the accessory nerve to the superior fibres of the trapezius muscle enabled almost normal abduction of the arm.

Conclusions: The anatomy and complications of the LTIMF are reviewed and certain recommendations are made to improve its reliability.
TEACHING NORMAL PHYSICAL EXAMINATION IN A LARGE‐GROUP INTERACTIVE USING ARTISTS’ MODELS
Authors: Hardman D. T. A. , Patel M. I. , Delbridge L.
Published: January 2008

Background: The innovative use of artists’ models within the context of a large‐group interactive teaching session, at Royal North Shore Hospital is reviewed.

Methods: The models were used to teach normal physical examination skills to a group of junior medical students, during their surgical rotation. This same group of students were also exposed to traditional bedside tutorials. The students evaluated both teaching experiences.

Results: In the four areas of evaluation (interaction, explanation, presentation, and organization), the large‐group interactive sessions were consistently rated higher than the bedside tutorials (P < 0.001).

Conclusions: The teaching technique is presented as an effective way of delivering quality clinical training to a group of junior medical students in an environment where access to good teaching material is becoming increasingly difficult.
KENNETH FITZPATRICK RUSSELL: THE FIRST READER TO THE GORDON CRAIG LIBRARY
Authors: Burke Peter F.
Published: January 2008

A review of the life and achievements of Kenneth Fitzpatrick Russell, whose death in his 76th year robbed us of a civilized gentleman who was at the zenith of his creative output, would be a daunting task, if only because of the breadth of his hobbies and interests: art and medical literature; reading; sinology and seal carving; numismatics, medical philately; bookbinding, collecting bookplates; carpentry; metal work, including pewter casting and silversmithing; model ship building and cooking. Yet these various interests were simply a backdrop to his public career at the University of Melbourne and the Royal Australasian College of Surgeons, where he laid the foundations of an international reputation as scholar and collector.
NOM ET LUMIÈRE ENLIGHTENMENT THROUGH NOMENCLATURE (THE 1996 KENNETH F. RUSSELL MEMORIAL LECTURE)
Authors: Pearn John
Published: January 2008

The classification of living things is both an acknowledgement of biological relationships and an identification of their differences. When Linnaeus, in 1735, published Systema Naturae, he set in place a system of biological classification that saw its apogee in the invention of binomial nomenclature: the description of every living thing being embodied simply in two names, (i.e. a genus and the species within it). Linnaeus built on the work of scientific forebears, of whom Nehemiah Grew (1641–1712) was one of the most influential. Grew was a surgeon‐physician whose passionate interest was plant anatomy; his work led to the discovery and documentation of sexual dimorphism in plants. Grew's life and works are a witness to that philosophy which views nature as a continuum, a broad holistic entity in which discoveries in one biological field have ramifications in other areas. Grew allowed his scientific curiosity full rein, manifested the courage to publish his work and possessed the self‐discipline to stand by the audit of his peers. Modern biological research and contemporary clinical practice owes much to the enlightenment engendered by the classification and nomenclature that developed from his work.
BENEFICENCE, TEMPERANCE AND MEDICAL SCIENCE
Authors: Cramond Tess
Published: January 2008

John Coakley Lettsom (1744–1815) founded the Medical Society of London and played a key role in the development of the Royal Humane Society. His Quaker background underpinned his interest in social reform. He established dispensaries and soup kitchens for the poor, recognized the need for public health measures in the control of disease, and advocated prison reform and education of the poor.
WILLIAM CHESELDEN (1688–1752): HUMANE ANATOMIST AND MASTER SURGEON
Authors: Guest James
Published: January 2008

William Cheselden (1688–1752) as a young man had a considerable reputation as an anatomist. He was one of the first to give a regular series of lecture/demonstrations and he incorporated this material into a basic text The Anatomy of the Humane Body, which was extremely popular and was in print for 100 years. He was even better known as a surgeon, being on the staff of three teaching hospitals and recognized as the most skilful lithotomist of his time. His achievements are on record and he must be regarded as one of the greatest of British surgeons. Perhaps his greatest impact was his strong advocacy for the separation of surgeons from the Barber‐Surgeons' Company. He realised how much this long‐established relationship was delaying the advancement of surgeons and surgery, and his vigorous action resulted in an Act of Parliament that severed the old ties and established in 1745 the Corporation of Surgeons, forerunner of the Royal College of Surgeons of England.
COLORECTAL SURGERY IN THE ELDERLY: AN AUDIT OF SURGERY IN OCTOGENARIANS
Authors: Isbister William H.
Published: January 2008

Background: Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors.

Methods: All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately.

Results: Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1: 0.79 in the < 80 group and 1: 1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty‐two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty‐six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%).

Conclusions: Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.
QUALITY OF LIFE AFTER BREAST CONSERVATION OR MASTECTOMY: A SYSTEMATIC REVIEW
Authors: Irwig Les , Bennetts Anna
Published: January 2008

Background: For early breast cancer, survival after breast conservation is similar to that after mastectomy. Some women may not have a clear preference and wish to have further information about quality of life experienced after the alternative treatments. This paper describes a systematic review of randomized trials on mastectomy versus breast conservation for which there are data on quality of life or psyehosocial outcomes.

Methods: Literature was reviewed to find all randomized controlled trials comparing breast conservation to mastectomy, with quality of life or psychological effects as an outcome. Studies were then critically appraised by two reviewers independently and any disagreements about their quality and results resolved by discussion.

Results: A total of six randomized trials met our inclusion criteria. In general, they are of poor quality. Women who had breast conservation had a more favourable body image of themselves than those who had mastectomy in all five studies in which it was examined. The evidence was statistically inconclusive for all the other dimensions measured, namely perceptions of psychological health, sexual health, physical health, fear of the future and global quality of life. Radiotherapy may be a determinant of poorer psychological health and body image.

Conclusions: Apart from body image, it is unclear whether breast conservation or mastectomy results in better psychosocial outcomes. Moreover, the studies were done before evidence was available to inform women about the equivalence of survival with these alternative treatments. Therefore there is inadequate information available to help many women decide about their choice of treatment in the future. Preference trials should be conducted, using standardized quality‐of‐life measures, in which women who are uncertain about which treatment to choose are randomized to breast conservation or mastectomy.
BREAST CANCER: AETIOLOGICAL FACTORS AND ASSOCIATIONS (A POSSIBLE PROTECTIVE ROLE OF PHYTOESTROGENS)
Authors: Stephens F. O.
Published: January 2008

Background: In spite of many known and suspected factors associated with the risk of breast cancer there has until recently been no explanation for its continuing increase in women of Western societies over recent decades or why there has not been an equivalent increase in women of most Asian and other less Westernized societies. It has long been suspected that a significant factor has been an increasing change of diet in Western societies from one predominantly vegetarian to one with a high content of meat and dairy products as well as ‘refined’ foods. Although diet has long been suspected there has otherwise been no real explanation as to the mechanism of the change in incidence of breast cancer.

Methods: A comprehensive literature review has been made of aetiological factors and associations concerning breast cancer to determine whether any consistent trend can explain the rising incidence in Western societies.

Results: There are a number of likely contributory factors but there is now accumulating evidence that the single most important difference is that people having a vegetarian diet have a high intake of legumes and other plant foods containing a variety of lignans and isoflavonoids. These appear to have an important role as nature'sex hormone modulators. These agents appear to be biologically active in a number of ways not yet completely understood but they do have both a weak oestrogenic effect and an anti‐oestrogenic competitive effect, thus reducing the potential carcinogenic action of prolonged oestrogen activity. A probable additional benefit of such diets could be the role of dietary fibre.

Conclusions: A major problem of Western diets may not be the presence of meat or dairy products in the diet but the absence of desirable ingredients of vegetarian diets, namely dietary fibre and certain plant lignans and isoflavonoids. A modification of diet to include a greater proportion of fibre and soy or other leguminous plant food should be studied. Alternatively addition of more fibre and lignans and especially isoflavonoids to traditional Western diets would seem worthy of serious investigation. Such influences appear to have their greatest impact early in life and therefore could be especially important for girls and young women in Western societies.
BREAST CANCER IN YOUNG WOMEN
Authors: Gillett David , Kennedy Catherine , Carmalt Hugh
Published: January 2008

Background: It is believed that cancer of the breast is more difficult to diagnose in young women and it has long been disputed whether breast cancer occurring in women aged 40 years is more aggressive than that occurring later in life. A number of reports in the literature suggest that the disease is of similar aggressiveness in the young patients and older age groups, while other reports suggest that it is more aggressive and carries a higher mortality in young women.

Methods: To address these aspects of breast cancer we have undertaken a review of the cases treated at The Strathfield Breast Centre between 1989 and 1996 and compared the disease in the young and old groups with particular reference to the modes of diagnosis, the pathological staging and types of tumour and the outcomes of treatment.

Results: The accuracy of ultrasound and fine needle aspiration biopsy were similar in both groups, but the false negative rate of mammography in the young patients was 15% or 50% greater than that which was observed in the older patients. The incidence of histopathological type, bilaterality, size of lesion and receptor positivity were the same in both groups. In the young group, 40% had Grade 3 tumours compared with 27% in the older group. Nineteen per cent of young patients had 4 or more lymph nodes involved while only 10% of the older patients had similar lymph node involvement. Overall 5‐year survival was 79% in the older patients compared with 90% in the young patients.

Conclusions: The spectrum of disease is similar in both the young and older patient and the prognosis is no worse for the young group but mammography is less effective in the diagnosis of the young patient.
PROSTATE CANCER MORTALITY IN NEW ZEALAND: THE PAST AND PROJECTIONS FOR THE FUTURE
Authors: Cohen Ronald J. , Robinson Elizabeth , McRae Colin U.
Published: January 2008

Background: Ageing male populations and improved diagnosis of early stage disease have contributed to the increasing incidence of prostate cancer observed in many Western countries. The clinical significance of these diagnosed cancers is, however, currently unclear. The aim of this study is to examine trends over time in prostate cancer mortality as an indicative measure of clinically significant disease during a 29‐year period (1965–93) which preceded the extensive use of early cancer diagnostic techniques or radical therapy protocols.

Methods: Age‐specific and age‐standardized rates were calculated for each year during the study period, using routinely collected mortality and demographic data. A Poisson regression model was used to describe trends in the age‐specific rates over time to predict numbers of prostate cancer deaths and the lifetime risk of death over the next 20 years.

Results: Significant annual increases ranging from 1 to 2.6% were found for age‐specific prostate cancer mortality rates over the 29‐year time period, with the largest increases experienced in the younger age groups at risk. Based on projected population ageing and growth alone, annual numbers of prostate cancer deaths are predicted to increase from 487 in 1993 to 664 by the year 2006 and then to 833 by the year 2016. Continuation of the observed increases in age‐specific mortality rates would result in a predicted 797 deaths by the year 2006, while an expected 1115 deaths is calculated for the year 2016. This would correspond with an increase in the lifetime risk of death from prostate cancer from a present 3.7 to 4.5% in 10 years and 6.2% in 20 years.

Conclusions: The changing pattern of prostate cancer mortality described in this study is likely to represent a significant increase in the incidence of clinically significant disease. This will have a significant impact on the ageing New Zealand male population, and important implications for the provision of effective treatment and preventive strategies.
PREVIOUS INTRAVENOUS CHEMOTHERAPY DOES NOT ALTER RESPONSE RATE OR SURVIVAL TIME OF PATIENTS WITH HEPATIC METASTASES FROM COLORECTAL CANCER TREATED BY HEPATIC ARTERY CHEMOTHERAPY
Authors: Morris David L. , Zhao Jing , Clingan Philip R.
Published: January 2008

Background: The present paper addressed the issue of whether pretreatment with intravenous (IV) chemotherapy affects response rate or survival in patients receiving hepatic artery chemotherapy (HAC).

Methods: Case note reviews of 164 patients treated in a teaching hospital from June 1990 to July 1996 were carried out.

Results: The response rate and carcino‐embryonic antigen (CEA) fall in the two groups was almost identical. There was a nonsignificant survival advantage in the non‐pretreatment group.

Conclusions: Previous administration of IV chemotherapy did not affect the CEA response of patients receiving HAC.
BENIGN ANTERIOR KNEE CYST IN EARLY CHILDHOOD
Authors: Liew S. M. , Menelaus M. B.
Published: January 2008

Background: Anterolateral knee cysts are not uncommon in the first 7 years of life, but have not been described in the literature.

Methods: Four patients presenting with an asymptomatic lump on the anterolateral joint line were reviewed.

Results: The lump remains asymptomatic.

Conclusions: Anterolateral knee cysts of childhood are benign and do not require treatment. Their cause is conjectural.
THE VALIDITY OF SURGICAL WOUND INFECTION AS A CLINICAL INDICATOR IN AUSTRALIA
Authors: McLaws Mary‐Louise , Murphy Cathryn , Keogh Greg
Published: January 2008

Background: Evidence‐based medicine and measurement of outcome have become the foremost strategy of departments of health and quality care in Australia in the 1990s. The Australian Council of Healthcare Standards (ACHS), formed in 1974, has introduced a Clinical Indicators Programme which monitors a number of clinical outcomes, including rates of specific nosocomial infections. It is the only formal system in Australia which attempts to monitor nosocomial infection in hospitals, and the ACHS acknowledges that the data provided to them are collected using a variety of sources and definitions.

Methods: The present study discusses the validity of the present definitions of nosocomial surgical wound infection used for accreditation, how validity may be improved and the attempts by some international systems to improve their own data.

Results: The ACHS definitions of nosocomial surgical wound infection lack validity, and the rates provided lack generalizability. Several international surveillance systems have resources in place to provide members with standardized training for practitioners, and support for methodology, data analysis and reporting, which assists in improving the quality of the data collected.

Conclusion: It is our belief that the validity of surgical wound infections will be improved by adoption of National Nosocomial Infection Surveillance (NNIS) definitions, stratification of surgical wound infections by anatomical site of infection for sentinel procedures. The ACHS system must adopt the proposed changes if the rates are to be used as a local and national indicator.
PULMONARY RESECTION FOR METASTATIC BREAST CANCER
Authors: Simpson Richard , Kennedy Catherine , Carmalt Hugh , McCaughan Brian , Gillett David
Published: January 2008

Background: A patient with a solitary pulmonary metastasis who had breast cancer in the past may benefit from pulmonary resection.

Methods: Between 1984 and 1996, 17 patients underwent metastatectomy for metastatic breast cancer. There were 15 females and two males whose average age was 59 (range: 40–74 years). The median tumour‐free interval after the primary breast‐cancer operation was 5.1 years (range: 8 months‐18.2 years). Sixteen patients had complete resections, which included six lobectomies and 10 lesser resections.

Results: The postoperative mortality was nil and the morbidity rate was 6%. Follow‐up was complete in all patients. Recurrent disease developed in four patients and two patients died of their disease. The 5‐year survival was 62%.

Conclusion: An aggressive surgical approach is warranted in patients with isolated resectable pulmonary metastases from breast cancer.
IMMUNOTHERAPY, INCLUDING GENE THERAPY, FOR METASTATIC MELANOMA
Authors: O'Rourke Michael G. E. , Schmidt Christopher W. , O‘rourke Thomas R. , Ellem Kay A. O.
Published: January 2008

Current standard therapy for distant metastatic melanoma is ineffective and often compromises the quality of a patient's life. Immunotherapy is briefly reviewed in relation to its many forms: from local non‐specific to the more recent specific vaccines, including those using specific melanoma peptides (e.g. from the proteins encoded by melanoma‐associated gene (MAGE)) and those involving genetically transduced autologous melanoma cells using retroviral vectors in vitro. The mode of action of genetically transduced melanoma cells incorporating the granulocyte macrophage colony stimulating factor (GM‐CSF) gene (GVAX) is presented as a paradigm for cytokine‐mediated strategies. Trials of GVAX and other cytokine gene strategies are under way in Brisbane, Boston and Amsterdam, and some interim perspectives on the clinical outcomes and immunological mechanisms involved are sketched. Some of the compounding problems in immunotherapeutic strategies for cancer are identified, and possible adjunct manoeuvres for overcoming them are discussed.