bluuebunny/crossref_metadata_2025 huggingface dataset:
Excess mortality in winter in Finnish intensive care
Authors: Reinikainen M. , Uusaro A. , Ruokonen E. , Niskanen M.
Published: June 2006

Background:  In the general population, mortality from acute myocardial infarctions, strokes and respiratory causes is increased in winter. The winter climate in Finland is harsh. The aim of this study was to find out whether there are seasonal variations in mortality rates in Finnish intensive care units (ICUs).

Methods:  We analysed data on 31,040 patients treated in 18 Finnish ICUs. We measured severity of illness with acute physiology and chronic health evaluation II (APACHE II) scores and intensity of care with therapeutic intervention scoring system (TISS) scores. We assessed mortality rates in different months and seasons and used logistic regression analysis to test the independent effect of various seasons on hospital mortality. We defined ‘winter’ as the period from December to February, inclusive.

Results:  The crude hospital mortality rate was 17.9% in winter and 16.4% in non‐winter, P= 0.003. Even after adjustment for case mix, winter season was an independent risk factor for increased hospital mortality (adjusted odds ratio 1.13, 95% confidence interval 1.04–1.22, P= 0.005). In particular, the risk of respiratory failure was increased in winter. Crude hospital mortality was increased during the main holiday season in July. However, the severity of illness‐adjusted risk of death was not higher in July than in other months. An increase in the mean daily TISS score was an independent predictor of increased hospital mortality.

Conclusion:  Severity of illness‐adjusted hospital mortality for Finnish ICU patients is higher in winter than in other seasons.
Oscillometric brachial mean artery pressures are higher than intra‐radial mean artery pressures in intensive care unit patients receiving norepinephrine
Authors: Pytte M. , Dybwik K. , Sexton J. , Straume B. , Nielsen E. Waage
Published: June 2006

Background:  Norepinephrine is frequently used in intensive care unit (ICU) patients to raise and maintain an adequate mean arterial pressure (MAP). Conflict arises as to which MAP should guide vasopressor dose, as oscillometric MAP in the brachial artery often diverges from intra‐radial MAP. We wanted to estimate the magnitude of this difference in ICU patients receiving norepinephrine, and to see whether the patient age, norepinephrine dose, age of radial catheter, ventilation treatment or severity of illness influenced the difference.

Methods:  Prospective observational study comparing oscillometric MAP and intra‐radial MAP performed in a central hospital‐based surgical ICU during the period from February 2002 through to October 2003. Sixty‐eight consecutive patients who received a norepinephrine infusion to maintain MAP above 70 mmHg were included. The mean arterial blood pressure was measured both oscillometrically and in the ipsilateral radial artery.

Results:  Oscillometric MAP was on average 6.6 mmHg higher (95% CI 5.3–7.9) than intra‐radial MAP in the 134 sets of measurements (P < 0.001). The patient’s age (P = 0.319), norepinephrine dosage (P = 0.959) the age of the radial catheter (P = 0.992) were not significant. The difference in MAP was marginally greater in ventilated patients (P = 0.061) and significantly greater as the simplified acute physiology score (SAPS) score increased (P = 0.022).

Conclusions:  MAP measured oscillometrically over the brachial artery directly in the radial artery gave different results in an ICU population receiving norepinephrine. In more than one of four patients this difference is so large, and increases with illness severity, that the selection of any one method would influence treatment.
Coloured chlorhexidine cotton pads may help to identify cerebrospinal fluid during epidural or spinal anaesthesia
Authors: Knudsen K.
Published: June 2006

Background:  During complicated technical conditions in epidural or spinal anaesthesia, it may be difficult to safely identify the epidural space. The confirmation or exclusion of the presence of cerebrospinal fluid (CSF) during the procedure of regional anaesthesia is helpful to determine the position of the epidural needle in order to proceed with the anaesthetic block.

Methods:  We have examined how CSF and different anaesthetic solutions change the colour of yellowish phenol red absorbed in cotton pads.

Results:  Sodium chloride and local anaesthetic agents do not change the colour of yellowish phenol red. However, CSF immediately changes the colour from yellow to pink or red. Letting a drop of fluid from the epidural/spinal needle fall on to the cleaning pads filled with phenol red will enable the anaesthesiologist to immediately confirm the presence or absence of CSF. The higher pH of CSF relative to that of sodium chloride and local anaesthetic agents explains the different colour reaction.

Conclusion:  This colour reaction quickly identifies the presence of CSF and thus the intradural space during the procedure of spinal or epidural anaesthesia.
Can remifentanil be a better choice than propofol for colonoscopy during monitored anesthesia care?
Authors: Akcaboy Z. N. , Akcaboy E. Y. , Albayrak D. , Altinoren B. , Dikmen B. , Gogus N.
Published: June 2006

Background and objective:  This prospective, randomized trial was designed to test the hypothesis that continuous infusion of low‐dose remifentanil can provide effective analgesia, sedation, amnesia, patient comfort and stable recovery profile without respiratory depression when compared with propofol infusion during colonoscopy.

Methods:  One hundred patients were randomly assigned to receive either remifentanil (group R, 0.5 μg/kg followed by 0.05 μg/kg/min, n= 50) or propofol (group P, 0.5 mg/kg followed by 50 μg/kg/min, n= 50). Supplemental doses of remifentanil 12.5 μg in group R and propofol 10 mg in group P were given to treat complaints of moderate to severe pain and discomfort. Hemodynamic and respiratory data, pain, discomfort and sedation scores, patient and gastroenterologist satisfaction and recovery profiles were recorded.

Results:  The duration of colonoscopy was longer in group P. The mean arterial pressure, heart rate and end‐tidal CO2 remained stable during the procedure and were comparable between the groups. After bolus injection of the study drugs, the respiratory rate and oxygen saturation values were lower in group R than in group P. Only one patient in group R required airway support. Pain and discomfort scores were better in group R than in group P. Sedation levels were higher in group P than in group R. Group P needed more supplemental doses than group R. The time to reach an Aldrete score of nine or more was shorter in group R, but discharge times were similar in the two groups. Amnesia was better in group P. Nausea and vomiting were more frequent in group R during the recovery phase.

Conclusion:  Low‐dose remifentanil infusion with intermittent bolus injections can provide adequate sedation, amnesia and better analgesia than propofol infusion during colonoscopy. However, remifentanil‐induced nausea and vomiting may be a problem during the recovery phase.
Reproductive tradeoffs and yolk steroids in female leopard geckos, Eublepharis macularius
Authors: Rhen T. , Crews D. , Fivizzani A. , Elf P.
Published: June 2006

Life history theory predicts tradeoffs among reproductive traits, but the physiological mechanisms underlying such tradeoffs remain unclear. Here we examine reproductive tradeoffs and their association with yolk steroids in an oviparous lizard. Female leopard geckos lay two eggs in a clutch, produce multiple clutches in a breeding season, and reproduce for several years. We detected a significant tradeoff between egg size and the number of clutches laid by females during their first two breeding seasons. Total reproductive effort was strongly condition-dependent in the first season, but much less so in the second season. Although these and other tradeoffs were unmistakable, they were not associated with levels of androstenedione, oestradiol, or testosterone in egg yolk. Female condition and egg size, however, were inversely related to dihydrotestosterone (DHT) levels in egg yolk. Finally, steroid levels in egg yolk were not directly related to steroid levels in the maternal circulation when follicles were developing, indicating that steroid transfer to eggs is regulated. These findings suggest that maternal allocation of DHT could mitigate tradeoffs that lead to poor offspring quality (i.e. poor female condition) and small offspring size (i.e. small egg size).
Ecological significance of microsatellite variation in western North American populations of Bromus tectorum
Authors: RAMAKRISHNAN ALISA P. , MEYER SUSAN E. , FAIRBANKS DANIEL J. , COLEMAN CRAIG E.
Published: June 2006

Bromus tectorum (cheatgrass or downy brome) is an exotic annual weed that is abundant in western USA. We examined variation in six microsatellite loci for 17 populations representing a range of habitats in Utah, Idaho, Nevada and Colorado (USA) and then intensively sampled four representative populations, for a total sample size of approximately 1000 individuals. All loci were homozygous, indicating that the species is strongly selfing. Populations consisted of a few common genotypes and variable numbers of rare genotypes. Small sample sizes (n = 10 individuals) were adequate for distinguishing among populations, but larger sample sizes were needed to characterize more diverse populations, particularly in terms of genotype. Large populations contained more genetic diversity than small populations in terms of both number of alleles per locus and number of genotypes. Genetic distance among survey populations was much more strongly correlated with ecological distance (habitat) than with geographical distance, and was also strongly correlated with a suite of adaptively significant seed germination traits. This suggests that similar habitats across the range of B. tectorum in western USA select for specific self‐pollinating lines from an array of widely distributed genotypes. Because all traits are effectively linked in this selfing organism, the distribution of adaptively significant genetic variation can be successfully inferred from an examination of microsatellite marker variation.
Reproductive biology and pollination ecology of the rare Yellowstone Park endemicAbronia ammophila(Nyctaginaceae)
Authors: SAUNDERS N. ELIZABETH , SIPES SEDONIA D.
Published: June 2006

We examined the breeding system, reproductive output and pollination ecology ofAbronia ammophilaGreene, a rare and highly restricted endemic of Yellowstone National Park, Wyoming, USA. Floral morphology permits the automatic deposition of self‐pollen on the stigma of individual flowers, and male and female reproductive functions temporally overlap. In controlled hand‐pollination treatments, we found no significant difference among pollination treatments (unmanipulated, self‐pollinated or cross‐pollination). The species maintains a long reproductive season with high reproductive output (natural seed set ranged from 59 to 84%). Our results, along with pollinator observations, suggest thatA. ammophilaexhibits a mixed‐mating system: the species can produce seed without pollinators (via either autogamy or agamospermy), but is also visited by an array of pollinating insects that included moths, butterflies and bumblebees. However, noctuid moths were the most abundant pollinators. In contrast, otherAbroniaspecies are obligate outcrossers. The mixed‐mating system ofA. ammophilamay have evolved as a consequence of ecological pressures such as scarcity of mates or pollinators.
Reproductive biology of two Cattleya (Orchidaceae) species endemic to north‐eastern Brazil
Authors: SMIDT ERIC CAMARGO , SILVA‐PEREIRA VIVIANE , BORBA EDUARDO LEITE
Published: June 2006

The reproductive biology of the endemic Cattleya elongata and the endemic and critically endangered Cattleya tenuis (Orchidaceae) was studied in areas of ‘campo rupestre’ and ‘caatinga’ vegetation, respectively, in the Chapada Diamantina, north‐eastern Brazil. Floral visitors and their behavior were recorded, and experimental pollinations were carried out to determine the breeding systems of these species. The species have similar flower morphology, flower in synchrony and both are pollinated by queens of Bombus (Fervidobombus) brevivillus (Apidae, Bombina). Flowers of both species do not present nectar despite the presence of a nectary‐like cuniculus. Cattleya tenuis presented low natural fruit set (10%), while C. elongata presented a higher fruit set (25%). Both species are self‐compatible, and only C. tenuis presented inbreeding depression, expressed as reduced seed viability in self‐pollinations compared with cross‐pollinations. The species have a parapatric distribution and differences in their habitats probably act as the principal barriers to the formation of natural hybrids.
Dispersal by ants inCentaurea corymbosa(Asteraceae): What is the elaiosome for?
Authors: IMBERT ERIC
Published: June 2006

This paper reports on different observations and experiments examining the role of ants in the seed dispersal of the rare and endemic speciesCentaurea corymbosa. Direct observations of seed manipulation by ants in natural populations showed that dispersal distances are very limited, and many ants did not disperse seeds at all. Cafeteria experiments failed to demonstrate: (i) that the elaiosome represents the attractive part of the achene; and (ii) that seeds ofEuphorbia characias,a common species occurring in the same habitat, are more attractive than achenes ofC. corymbosadespite a 10‐fold difference in elaiosome size. However, ants show a foraging behavior to collect seeds ofC. corymbosabecause seed removal is greater at the foot of a fruiting plant than further away. Experiments in controlled conditions were also carried out to investigate the secondary benefits of seed manipulation by ants. Two independent experiments showed that, in contrast to many other myrmecochorous species, elaiosome removal decreases germination rate. Finally, the effects of burial at low depth (2 cm) on seed emergence are limited; however, as ants rarely move seeds to their nest, this secondary benefit of myrmecochory is unlikely. Therefore, it can be concluded that the functional role of an elaiosome in this species is not evident. However, ants clearly contribute to seed dispersal inC. corymbosa.
HYPERTENSIVE PRIMARY INTRAVENTRICULAR HEMORRHAGE DUE TO A PHAEOCHROMOCYTOMA
Authors: Rajendra Tiruchelvarayan , Kumar Krishan , Liang Loh Hwai
Published: June 2006

Primary intraventricular haemorrhage (IVH) is rare. We defined primary IVH as haemorrhage into the ventricles only as detected by computerized tomographic (CT) brain scan. This is in contrast with other intracerebral haemorrhages (e.g. basal ganglia/thalamic with intraventricular extension). The clinical condition of the patient ranges from minimal neurological defecits to coma/death. It also carries with it a poor prognosis of up to 80% when all four ventricles are involved. We present a 45‐year‐old Chinese female who presented with a hypertensive IVH which was managed successfully with ventricular drainage and intraventricular urokinase therapy. An adrenal phaeochromocytoma was diagnosed which was subsequently removed laproscopically. The patient has recovered well in all aspects. This case report will discuss management of IVH and the importance of searching for secondary causes of hypertension.
ADHERENCE TO GUIDELINES FOR PREVENTION OF POSTSPLENECTOMY SEPSIS. AGE AND SEX ARE RISK FACTORS: A FIVE‐YEAR RETROSPECTIVE REVIEW
Authors: Kotsanas Despina , Al‐Souffi Mohammed H. , Waxman Bruce P. , King Richard W. F. , Polkinghorne Kevan R. , Woolley Ian J.
Published: June 2006

Background:  Vaccination, education and use of long‐term antibiotics are recommended in expert guidelines for the prevention of infectious complications after splenectomy. However, studies outside Australia have shown poor adherence to the guidelines. The aim of this study was to determine overall adherence to the guidelines and to ascertain any independent risk factors for poor compliance with the guidelines.

Method:  A retrospective review of hospital records between 1999 and 2004 was carried out.

Results:  Indications for splenectomy of the 111 patients in this review included post‐trauma (32), haematological (32), cancer surgery (24), iatrogenic (12) and others (11). On multivariable analysis, age was associated with a 28% less likelihood to receive education (odds ratio (OR) 0.72; 95% confidence interval (CI) 0.56–0.92; P = 0.009) and 36% less likelihood to receive long‐term antibiotics (OR 0.64; 95% CI 0.52–0.80; P ≤ 0.001). Women were four times more likely to receive education (OR 4.03; 95% CI 1.16–14.0; P = 0.028) and patients who had undergone splenectomy in 2004 were 22 times more likely to have received education compared with those in 1999 (OR 22.53; 95% CI 3.12–162.34; P = 0.002).

Conclusions:  Education for prevention of sepsis after splenectomy is poorly documented and may be incomplete. Older age and male sex are risk factors in non‐adherence to guidelines for prevention of postsplenectomy sepsis. Strategies such as alert cards and information brochures may improve adherence to guidelines particularly in older patients.
DIAPHRAGMATIC HERNIAS COMPLICATING PREGNANCY
Authors: Eglinton Timothy W. , Coulter Grant N. , Bagshaw Philip F. , Cross Lauren A.
Published: June 2006

Background:  Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life‐threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non‐hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports.

Methods:  The presentation, management and outcomes of a series of three recent cases are described. A review of all other reported cases of diaphragmatic hernias complicating pregnancy was also carried out.

Results:  All three cases were emergency presentations in the third trimester of pregnancy, resulting from compression of thoracic contents. All cases required emergency laparotomy and one also required thoracotomy. Delivery was by Caesarean section at the time of emergency surgery in two cases and was delayed in the third case. There was one fetal and no maternal deaths. One mother suffered persistent pleural infection. One baby also had a diaphragmatic hernia requiring postnatal repair. Published reports showed only 36 previously reported cases of diaphragmatic hernias identified in pregnancy. There is a consensus that hernias presenting with evidence of strangulation represent a surgical emergency and mandate operative management, irrespective of fetal maturity. Elective management of asymptomatic hernias is more controversial and both conservative and operative approaches have been suggested.

Conclusion:  Diaphragmatic hernias can cause life‐threatening complications in pregnancy. Consideration should be given to operative repair in the second trimester if asymptomatic hernias are identified during pregnancy. If vaginal delivery is attempted in the presence of a hernia, this should only be carried out under closely monitored conditions.
PANCREATICODUODENECTOMY: DOES PREOPERATIVE BILIARY DRAINAGE, METHOD OF PANCREATIC RECONSTRUCTION OR AGE INFLUENCE PERIOPERATIVE OUTCOME? A RETROSPECTIVE STUDY OF 104 CONSECUTIVE CASES
Authors: Barnett Stephen A. , Collier Neil A.
Published: June 2006

Background:  Whether preoperative biliary drainage (PBD) is beneficial in reducing complications after pancreaticoduodenectomy is controversial. There remains a reluctance to consider pancreaticoduodenectomy in older patients. The major source of morbidity and potential mortality after pancreaticoduodenectomy is pancreatic fistula, which is caused by difficulties associated with the pancreatic anastomosis. The purpose of this study was to examine the effect of PBD, patient age and method of pancreatico‐enteric reconstruction on postoperative morbidity and mortality.

Methods:  A total of 104 consecutive patients undergoing pancreaticoduodenectomy between November 1992 and November 2004 were identified from a prospectively collected database. Multiple preoperative and intraoperative variables were examined and their relationship to postoperative outcome was analysed.

Results:  Postoperative mortality was <1%. Forty‐three patients (43%) suffered a total of 85 complications. Median length of stay was 12.5 days (range, 1–88 days). The group undergoing PBD did not have higher rates of infectious complication (12 vs 19%; P = 0.34) or overall complication (41 vs 42%; P = 0.88) compared with the undrained group. Rate of anastomotic leak (18 vs 4%; P = 0.045) and anaemia requiring transfusion (41 vs 9%; P = 0.001) were significantly higher in the pancreaticojejunostomy group compared with the pancreaticogastrostomy group. Patients over the age of 70 years did not have higher rates of complication (44 vs 41%, P = 0.5) or postoperative length of stay.

Conclusion:  Preoperative biliary drainage was not associated with increased postoperative complications. Pancreaticogastrostomy after pancreaticoduodenectomy is a safe and reliable method of reconstruction. Finally, pancreaticoduodenectomy can be carried out with acceptable rates of postoperative morbidity and mortality in selected patients over 70 years of age.
METASTECTOMY FOR NON‐COLORECTAL, NON‐NEUROENDOCRINE LIVER SECONDARIES
Authors: Teo Melissa C. , Tan Yu‐Meng , Chung Alex Y. , Chow Pierce K. , Cheow Peng C. , Soo Khee‐Chee C. , Hee Siew W. , Ooi London L.
Published: June 2006

Background:  The role of metastectomy for colorectal and neuroendocrine liver secondaries is well established. Significant palliation and survival have been reported after aggressive surgical resection. However, the role of liver resection for secondaries from other primary tumours is less well defined. In this study, we aim to describe our experience, including indications and selection criteria, operative strategy and clinical outcome of liver resection, for non‐colorectal, non‐neuroendocrine liver metastases.

Methods:  A review of prospectively collected operative database was conducted and patients who underwent liver resection of secondaries from non‐colorectal, non‐neuroendocrine primary tumours were studied. Eighteen patients were included in the study. There were 4 men and 14 women with a median age of 48 years (range, 37–78 years). Liver resection was carried out either for cure or for palliation of debilitating symptoms. Selection criteria included: (i) absence of extrahepatic disease and (ii) functional status of the liver and volume of remnant liver after hepatectomy. The median follow up was 24 months (range, 7–81 months) for 17 patients, excluding the one who defaulted after surgery. Cancer‐specific survival and recurrence‐free interval was calculated from the date of hepatectomy.

Results:  Liver resection was considered curative in 13 patients. There was no 30‐day mortality in this cohort of patients. The median recurrence‐free survival time was 13 months (95% confidence interval (CI), 8–18 months). The median follow‐up time for the 12 patients was 23.5 months (range, 7–35 months). Only five patients died due to cancer‐specific causes and one died from acute myocardial infarction. The median cancer‐specific survival time was 30 months (95% CI, 25–35 months). The 2‐year survival rate was 77.1% (95% CI, 48.9–100%).

Conclusion:  The results are encouraging and suggest that with appropriate selection criteria, there is a role for metastectomy of non‐colorectal, non‐neuroendocrine liver secondaries.
NEW ERA: PROPHYLACTIC SURGERY FOR PATIENTS WITH MULTIPLE ENDOCRINE NEOPLASIA‐2A
Authors: Gosnell Jessica E. , Sywak Mark S. , Sidhu Stan B. , Gough Ian R. , Learoyd Diana L. , Robinson Bruce G. , Delbridge Leigh W.
Published: June 2006

Background:  The surgical management of patients with multiple endocrine neoplasia‐2A (MEN‐2A) continues to evolve with specific genotype–phenotype correlations allowing for a more tailored approach. In this study, we report the surgical management of one of the largest MEN‐2A families with a rearranged during transfection (RET) codon 804 mutation.

Method:  This is a cohort study comprising all at‐risk kindred within a single known MEN‐2A family. Prophylactic total thyroidectomy with lymph node dissection was recommended to all mutation carriers aged 5 years and older.

Results:  There were a total of 48 at‐risk individuals in the MEN‐2A kindred, with 22 patients undergoing thyroidectomy after appropriate preoperative evaluation. A total of 9 patients had medullary thyroid cancer including 5 with a normal preoperative calcitonin level. A total of 11 patients had C‐cell hyperplasia and 7 showed histological evidence of parathyroid disease. Only the index case had a phaeochromocytoma.

Conclusion:  Genetic testing for germline mutations in the RET proto‐oncogene has allowed precise identification of affected RET carriers and provided the opportunity for prophylactic or ‘preclinical’ surgery to treat and in fact to prevent medullary thyroid cancer. This concept of prophylactic surgery based on a genetic test is likely to be applied more widely as the tools of molecular biology advance.
OUTCOMES OF PATIENTS WITH ORTHOPAEDIC TRAUMA ADMITTED TO LEVEL 1 TRAUMA CENTRES
Authors: Urquhart Donna M , Williamson Owen D , Gabbe Belinda J , Cicuttini Flavia M , Cameron Peter A , Richardson Martin D , Edwards Elton R ,   on Behalf of the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) Project Group
Published: June 2006

Background:  Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres.

Methods:  Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post‐injury.

Results:  Of the 1303 patients recruited for VOTOR over a 12‐month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post‐injury. Patients reported ongoing pain (moderate‐severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone.

Conclusion:  A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long‐term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.
NO REST FOR THE WOUNDED: EARLY AMBULATION AFTER HIP SURGERY ACCELERATES RECOVERY
Authors: Oldmeadow Leonie B. , Edwards Elton R , Kimmel Lara A , Kipen Eva , Robertson Val J. , Bailey Michael J
Published: June 2006

Background: Level 3 evidence‐based guidelines recommend first walk after hip fracture surgery within 48 h. Early mobilization is resource and effort intensive and needs rigorous investigation to justify implementation. This study uses a prospective randomized method to investigate the effect of early ambulation (EA) after hip fracture surgery on patient and hospital outcomes.

Methods: Sixty patients (41 women and 19 men; mean age 79.4 years) admitted between March 2004 through December 2004 to The Alfred Hospital, Melbourne, for surgical management of a hip fracture were studied. Randomization was either EA (first walk postoperative day 1 or 2) or delayed ambulation (DA) (first walk postoperative day 3 or 4). Functional levels on day 7 post‐surgery, acute hospital length of stay and destination at discharge were compared.

Results: At 1 week post‐surgery, patients in the EA group walked further than those in the DA group (P = 0.03) and required less assistance to transfer (P = 0.009) and negotiate a step (P = 0.23). Patients in the EA group were more likely to be discharged directly home from the acute care than those in the DA group (26.3 compared with 2.4%) and less likely to need high‐level care (36.8 compared with 56%). A failed early ambulation subgroup had significantly more postoperative cardiovascular instability and worse results for all outcome measures.

Conclusion: EA after hip fracture surgery accelerates functional recovery and is associated with more discharges directly home and less to high‐level care.
ASSESSING SURGEONS’ DISCLOSURE OF RISK INFORMATION BEFORE CAROTID ENDARTERECTOMY
Authors: Middleton Sandy , Gattellari Melina , Harris John P , Ward Jeanette E
Published: June 2006

Background: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and ‘non‐treatment’ options. A survey was conducted to determine patients’ recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA).

Methods: A self‐administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self‐assessed estimates of stroke risk with and without surgery and receipt of written information before CEA.

Results: A significantly higher proportion of patients recalled that their surgeon discussed the short‐term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short‐term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long‐term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001).

Conclusions: Patients recalled discussions with their surgeon about short‐term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.
REGULATION OF FIBROGENESIS DURING THE EARLY PHASE OF COMMON BILE DUCT OBSTRUCTION
Authors: Engin Atilla , Dinçer Sibel , Ercan Sevim Z. , Memiş Leyla , Bukan Neslihan , Bozkurt Şükrü
Published: June 2006

Background:  Both nitric oxide (NO) and prostaglandins have been proposed as inhibitor substances involved in collagen deposition in the hepatic parenchyma. The possible reciprocal connections between NO and eicosanoids in the development of liver fibrosis were investigated during the initial phase of common bile duct obstructions.

Methods:  A total of 30 male albino guinea pigs were randomly and equally assigned to three groups. Group 1 underwent sham laparotomy. Group 2 and group 3 were subjected to permanent common bile duct ligature for 24 and 72 h , respectively. Changes in the liver prostaglandin E2 (PGE2), leukotriene C4, malondialdehyde contents and plasma nitrite plus nitrate concentrations were measured. To evaluate the extent of hepatic fibrosis, histological assessment of liver was confirmed with the equivalent hydroxyproline contents of liver.

Results:  Twenty‐four hours after ligature, the amount of malondialdehyde and PGE2 and plasma nitrite plus nitrate concentrations increased significantly, whereas liver hydroxyproline contents did not change. However, 72 h after ligature (Group 3), lipid peroxidation and collagen deposition were significantly higher than that of the group 2 animals. The PGE2 : leukotriene C4 ratio peaked at 24 h and later decreased, whereas PGE2 : NO ratio remained unchanged in both group 2 and group 3 animals.

Conclusions:  The initiation of collagen synthesis occurred in portal tract as early as within the first 72 h of bile duct obstruction. The optimum function of reactive oxygen species on the stellate cell activation might be determined by the interaction between NO and PGE2.
MEDIAL PECTORAL PEDICLE: A CRITICAL LANDMARK IN AXILLARY DISSECTION
Authors: Nadkarni Mandar S. , Raina Sudeep , Badwe Rajendra A.
Published: June 2006

Surgery for breast cancer has evolved over the last century and has gone from limited to radical, extended radical and back to conservative surgery. Along this journey, one constant feature has been the necessity for a complete axillary dissection. In recent times, this concept has also been successfully challenged and now we are in an era of conservative or limited surgery in the axilla as well. These surgical procedures such as four‐node axillary sampling or the technology‐driven sentinel node biopsy are conservative axillary procedures and are often performed through very small incisions. With limited access to the surgical field, there is always an increased chance of inadvertent and unnecessary injury to surrounding vital anatomical structures such as nerves or blood vessels. A well‐designed road map can definitely prevent such mishaps. This paper describes a simple technique of axillary surgery, which is step‐wise and makes use of a relatively constant landmark, namely the medial pectoral pedicle, present within the axilla. Such a regimented systematic approach not only allows us to minimize the risks of complications during axillary surgery, but also enables us to train beginners easily and efficiently.
FIFTY YEARS OF VASCULAR SURGERY IN AUSTRALIA AND NEW ZEALAND
Authors: Gurry John F.
Published: June 2006

Over the 50 years that vascular surgery has been practised in Australia and New Zealand there have been major advances and refinements of surgical techniques, particularly with the advent of endovascular surgery, spurred on especially with the introduction of endovascular aortic aneurysm stent grafting. At the same time, there has been a revolution in medical imaging, with the introduction of ultrasound, computed tomography scanning and magnetic resonance scanning. Vascular surgery in Australia and New Zealand was initially an interest of either general or cardiothoracic surgeons, but was recognized as a subspecialty of general surgery with the formation of the Section of Vascular Surgery within the Division of General Surgery of the Royal Australasian College of Surgeons in 1972. In 1981, a 2‐year training programme in vascular surgery was established and in 1983 an Australian and New Zealand Chapter of the International Society for Cardiovascular Surgery was formed. In 1995, vascular surgery was recognized as a specialty in its own right with the formation of the Division of Vascular Surgery within the College. There has been a separate examination for Fellowship of the Royal Australasian College of Surgeons (Vascular) since 1997. In 2001, the Chapter changed its name to The Australian and New Zealand Society for Vascular Surgery and in 2002 it amalgamated with and took over the functions of the Division of Vascular Surgery, which was formally dissolved.
SCEDOSPORIUM PROLIFICANS: AN UNCOMMON CAUSE OF SEPTIC ARTHRITIS
Authors: Dalton Philip A. , Munckhof Wendy J. , Walters David W.
Published: June 2006

Septic arthritis due to fungal infection is uncommon, but when it does occur it can have a devastating effect. Scedosporium prolificans is an emerging fungal pathogen that appears to have a predilection for bone and cartilaginous surfaces. This fungus is resistant to most commonly prescribed antifungal agents. We report the successful treatment of Scedosporium prolificans septic arthritis with a combination of surgery and new antifungal agents.
Calcium‐regulated potassium currents secure respiratory rhythm generation after loss of glycinergic inhibition
Authors: Zhao Ming‐Gao , Hülsmann Swen , Winter Stefan M. , Dutschmann Mathias , Richter Diethelm W.
Published: June 2006

Mutant oscillator mice (Glra1spd –/–) are characterized by a developmental loss of glycinergic inhibition. These mice die during the third postnatal week presumably due to gradually increasing disturbances of breathing and motor behaviour. Some irregular rhythmic respiratory activity, however, is persevered until they die. Here we analysed cellular mechanisms that compensate for the loss of glycinergic inhibition and contribute to the maintenance of the respiratory rhythm. In a medullary slice preparation including the pre‐Bötzinger complex we performed a comparative analysis of after‐hyperpolarizations following action potentials (AP‐AHP) and burst discharges (burst‐AHP) in identified respiratory neurons from oscillator and control mice. Both AHP forms were increased in neurons from oscillator mice. These changes were combined with an augmented adaptation of firing frequency. Assuming that oscillator mice might upregulate calcium‐activated K currents (BKCa) in compensation for the loss of glycinergic inhibition, we blocked the big KCa conductances with iberiotoxin and verified that the respiratory rhythm was indeed arrested by BK channel blockade.
Ultrastructural organization of medial prefrontal inputs to the rhinal cortices
Authors: Apergis‐Schoute John , Pinto Aline , Paré Denis
Published: June 2006

Accumulating evidence suggests that the medial prefrontal cortex (mPFC) plays a critical role in the formation, retrieval and long‐term storage of hippocampal‐dependent memories. Consistent with this, there are direct hippocampal projections to the mPFC. Moreover, the mPFC sends robust projections to the perirhinal and entorhinal cortices, two interconnected cortical fields that funnel information into and out of the hippocampus. However, the significance of the latter projection remains unclear because no data are available regarding the rhinal targets of mPFC axons. This question was examined in the present study using a combination of anterograde tracing with Phaseolus vulgaris leucoagglutinin and pre‐embedding γ‐aminobutyric acid (GABA) immunocytochemistry in guinea pigs. Following Phaseolus vulgaris leucoagglutinin injections in the mPFC, anterogradely labeled axons were seen in the perirhinal (mainly superficial layers) and lateral entorhinal (mainly deep layers) cortices. In the electron microscope, the synaptic articulation of anterogradely labeled mPFC axon terminals with perirhinal and entorhinal neurons was found to be nearly identical. In these two rhinal fields, mPFC axon terminals only formed asymmetric synapses, typically with GABA‐immunonegative spines (≈70%) but occasionally with dendritic profiles (≈30%), half of which were GABA immunopositive. In the light of earlier observations, these findings indicate that mPFC inputs exert mainly excitatory effects in the rhinal cortices, prevalently on principal neurons. Thus, these results suggest that the mPFC may affect hippocampal‐dependent memories by enhancing impulse traffic into and out of the hippocampus at the level of the rhinal cortices.
Neonatal resuscitation courses for pediatric residents: comparison between Khartoum (Sudan) and Padova (Italy)
Authors: TREVISANUTO DANIELE , IBRAHIM SALAH A. , DOGLIONI NICOLETTA , SALVADORI SABRINA , FERRARESE PAOLA , ZANARDO VINCENZO
Published: June 2006

Background:  The efficacy of a Neonatal Resuscitation Program (NRP) has been previously evaluated in developed countries, but there is a lack of information regarding the impact of this teaching program in developing countries. Our aim was to compare the knowledge gained by University of Khartoum (Sudan) and University of Padova (Italy) pediatric residents following participation in the NRP course.

Methods:  An 80‐item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was given to participants before and after the course.

Results:  Twenty‐five Sudanese and 26 Italian pediatric residents answered the pre‐ and postcourse questionnaire. The percentages of correct answers significantly improved from before to immediately after the course for both Sudanese (51.9 ± 10.5% vs 84.9 ± 5.8%; P < 0.01) and Italian (64.3 ± 8.1% vs 94.0 ± 3.9%; P < 0.01) pediatric residents. During the entire study, the scores obtained by Italian pediatric residents were higher than those reached by their Sudanese colleagues (P < 0.01).

Conclusions:  The trend of the knowledge attainment of both Sudanese and Italian pediatric residents was similar after NRP course participation. An NRP is effective in teaching neonatal resuscitation in developing countries.
Sedation for children with metachromatic leukodystrophy undergoing MRI
Authors: MATTIOLI CRISTINA , GEMMA MARCO , BALDOLI CRISTINA , SESSA MARIA , ALBERTIN ANDREA , BERETTA LUIGI
Published: June 2006

Background:  Metachromatic leukodystrophy (MLD) is a lysosomal storage disease with infantile and juvenile onset with a poor prognosis and magnetic resonance imaging (MRI) plays a fundamental role in its diagnosis. Procedural sedation is needed to carry out MRI on children. Very few case reports have been published on anesthesia or sedation for MLD patients.

Methods:  We prospectively studied 18 MLD patients undergoing sedation for brain MRI. Twenty consecutive similar‐aged ASA I children undergoing MRI during the same time span for suspected seizures and exhibiting no MRI brain alteration healthy (HLT) patients were also studied for comparison. In patients up to 3 years of age (T_MLD and T_HLT groups), sedation was induced with thiopental 5 mg·kg−1 i.v. and further 2.5 mg·kg−1 i.v. rescue boluses were given if the sedation level was inadequate. In patients over 3 years of age (P_MLD and P_HLT groups), sedation was induced with propofol 1–1.5 mg·kg−1 i.v. and maintained with 0.1–0.15 mg·kg−1·min−1 continuous i.v. infusion, which was increased if the sedation level was inadequate. We recorded complications, if any, caused by sedation (hypoxia, vomiting, bradycardia, other major arrhythmias, convulsions, MRI artifact movements with increasing sedation, prolonged recovery).

Results:  No sedation complications occurred. The mean dose of thiopental required to warrant patient immobility was 0.227 ± 0.053 mg·kg−1·min−1 of procedure in T_MLD patients and 0.119 ± 0.061 mg·kg−1·min−1 of procedure in T_HLT patients (difference not significant). The mean dose of propofol required for immobility was 0.119 ± 0.054 mg·kg−1·min−1 of procedure in T_MLD patients and 0.115 ± 0.043 mg·kg−1·min−1 of procedure in T_HLT patients (difference not significant).

Conclusions:  Our protocol for sedation in the MRI setting proved safe and effective in children with MLD, who do not require different doses of sedatives compared with healthy children.
Intravenous paracetamol for postoperative analgesia in a 4‐day‐old term neonate
Authors: AGRAWAL SHRUTI , FITZSIMONS JOHN J , HORN VENETIA , PETROS ANDY
Published: June 2006

There are only a few clinical reports on the use of intravenous (i.v.) paracetamol in term neonates. This case report illustrates that when routes for administration of analgesics are restricted to i.v. only and when opioids are not indicated then i.v. paracetamol may be used. In our 4‐day‐old term infant, despite i.v. paracetamol for 48 h, the trough level during therapy was almost undetectable indicating rapid clearance. Although i.v. paracetamol is not licensed in this age group, it can prove very helpful when the only route of administration is intravenous.
Can Bispectral Index aid laryngeal mask placement in children?
Authors: LIM SOO IM , CHAMBERS NEIL A. , SOMERVILLE NICOLA S.
Published: June 2006

Background:  Laryngeal mask airway (LMA) placement requires an adequate depth of anesthesia to prevent patient movement and adverse airway responses. Patient movement, coughing, stridor or laryngospasm at LMA placement may result in transient hypoxia, injury to the patient and prolong time spent in the anesthetic room. The Bispectral Index Score (BIS) is a relatively new tool that has not yet established its place in routine clinical pediatric anesthesia practice. One potential use may be to predict an adequate depth of anesthesia for successful intraoperative interventions such as LMA placement in children.

Methods:  A total of 116 children aged between 1 and 16 years due to have an LMA placed under general anesthesia were enrolled into this prospective, blinded observational study. Complication or success of LMA placement was then analyzed in relation to the BIS value at the time of placement. Other clinical variables were also considered.

Results:  The difference in BIS values in children with complicated compared with successful LMA placement was small and BIS therefore appears not to be a reliable predictor for either. Inexperience of the anesthetist and a history of recent upper respiratory tract infection (URTI) may be better indicators for complications.

Conclusions:  Bispectral Index Score appears, from this study, not to be a useful tool to help predict complications of LMA placement or to help reduce airway complications during LMA placement. Other markers may be more useful predictors of adverse airway events.
Diminished Blalock‐Taussig shunt flow detected by cerebral oximetry
Authors: ROSSI MICHAEL , TIROTTA CHRISTOPHER F. , LAGUERUELA RICHARD G. , MADRIL DANIELLE
Published: June 2006

Near‐infrared spectroscopy is a noninvasive optical technique used to monitor brain tissue oxygenation. Measurement of cerebral oxygenation is a more sensitive monitor of oxygen delivery to the brain than other available monitors. Prolonged cerebral desaturation is correlated with poor neurological outcomes. We report a case where the cerebral oximeter alerted us to diminished blood flow in a preexisting Blalock‐Taussig (subclavian artery to pulmonary artery) shunt.
Short course preoperative radiotherapy is the single most important risk factor for perineal wound complications after abdominoperineal excision of the rectum
Authors: Chadwick M. A. , Vieten D. , Pettitt E. , Dixon A. R. , Roe A. M.
Published: June 2006

Aim  To determine factors associated with perineal wound complications following abdominoperineal excision of the rectum (APER) for rectal adenocarcinoma and their effects on time to healing.

Patients and methods  We studied all cases of APER performed in our unit by four consultants over 7 years. Seven out of nine factors considered important in wound healing were analysed using logistic regression and a multivariate model was built to examine interactions. Wound persistence was calculated using the Kaplan–Meier method.

Results  Data were available for 94 of 96 patients [male:female, 3:2, median age 72.5 (IQR: 64–78)]. Thirty‐nine (41%) patients had 25 Gray, 3‐portal, fractionated 5‐day short course preoperative radiotherapy (SCPRT). Dukes stages were A (34%), B (26%), C (40%). Perineal wound complications occurred in 44 (47%), 16% of these requiring return to theatre. Local recurrences occurred in 13 (15%). There was no evidence to suggest that either patient gender, age, smoking status, preoperative albumin or haemoglobin level, or T stage were associated with the development of wound complications. The odds of wound complications for a patient who had SCPRT was over 10 times that for a patient who did not have preoperative radiotherapy (odds ratio 10.15, 95% CI: 3.80–27.05, n = 94). Seventy‐four per cent of SCPRT and 96% of non‐SCPRT wounds had healed by 1 year. Estimated failed wound healing rates at 30 and 90 days were 64% (95% CI: 46–78) and 48% (95% CI: 30–64) in SCPRT patients compared with 23% (95% CI: 12–35) and 9% (95% CI: 3–20) in non‐SCPRT patients (log rank test P < 0.0001).

Conclusion  Patients who have an APER are over 10 times more likely to have a perineal wound complication if they have SCPRT than not. Two‐thirds of these will not have healed by 1 month, half by 3 months and over a quarter will still remain unhealed at 1 year. This has important implications for patient management decisions. Large prospective studies are needed to evaluate the effects of a selective policy for radiotherapy administered to patients requiring APER.