bluuebunny/crossref_metadata_2025 huggingface dataset:
Cypress mortality (mal del cipres) in the Patagonian Andes: comparisons with similar forest diseases and declines in North America
Authors: Filip G. M. , Rosso P. H.
Published: March 2003

Widespread mortality of Cordilleran cypress (Austrocedrus chilensis) occurs in developed and pristine forests in south‐western Argentina and possibly south‐eastern Chile. Affected trees may die rapidly but mortality is commonly preceded by several decades of severely restricted radial stem growth. Roots are often affected by one or more types of decay. Cypress mortality, locally termed ‘mal del cipres’, is similar to a major forest disease in North America: Port‐Orford‐cedar (Chamaecyparis lawsoniana) root disease in Oregon and California and a major tree decline: Alaska yellow‐cedar (Chamaecyparis nootkatensis) decline in south‐east Alaska. This paper discusses several hypotheses concerning mal del cipres and compares current forest decline research in Patagonia with North America.
Dry mass production in seedlings of Norway spruce infected by the needle rust Chrysomyxa rhododendri
Authors: Plattner K. , Volgger W. , Oberhuber W. , Mayr S. , Bauer H.
Published: March 2003

The aim of this study was to assess the losses in productivity of Norway spruce (Picea abies) due to the attack by Chrysomyxa rhododendri, a rust that only penetrates new developing flushes. Three‐year‐old seedlings were artificially infected once or twice in two consecutive years and the dry mass was determined at the end of the growing season. Dry mass accumulation of all parts including roots was significantly reduced if more than about one‐third of the young foliage was infected. Shoot and root dry mass of once severely infected seedlings were 32 and 48% less than that of controls. This deficit could not be compensated during a following rust‐free year. When seedlings were infected in two consecutive years, dry mass accumulation was reduced by 58% compared with controls. Results indicate that rejuvenation of and afforestation with Norway spruce can seriously be impaired by Chrysomyxa at the alpine timberline where Rhododendron sp. (the telial host of the parasite) is widespread.
Xylem vessel diameter as a factor in resistance of Ulmus minor to Ophiostoma novo‐ulmi
Authors: SOLLA A. , GIL L.
Published: March 2003

An investigation has been carried out to study the relationship between the susceptibility of Ulmus minor to Ophiostoma novo‐ulmi and the diameter of its xylem vessels. Vessel diameters have been analysed in seven Spanish elms of known susceptibility, taking measurements from second and third year rings in 3‐year‐old branches. In the second year rings no relationship could be observed between the vessel diameters and the susceptibility of the trees. In the third year rings the mean diameter and the percentage of vessels larger than 100 μm were found to be significantly greater for the group of elms of high susceptibility. In the third year rings the vessel transectional area (VTA) and the theoretical hydraulic conductance (THC) were calculated. The decrease in VTA and THC became increasingly noticeable in the group of high susceptibility elms as vessels of larger diameter were excluded from the calculation. Xylem vessel diameters and the proportion of large vessels were correlated with the susceptibility of U. minor to Dutch elm disease. How these properties influence the dispersal of the fungus, the sap flow and the tree's ability to compartmentalize the disease is discussed.
Incomplete movement ofCryphonectria hypovirus 1within a vegetative compatibility type ofCryphonectria parasiticain natural cankers on grafted American chestnut trees
Authors: Hogan E. P. , Griffin G. J.
Published: March 2003

American chestnut trees, grafted in 1980 from large survivors, were inoculated in 1982 and 1983 with four white (European) hypovirulent strains ofCryphonectria parasitica, infected withC. hypovirus 1(CHV1); this hypovirus has been shown to be capable of moving rapidly within the mycelium of a vegetative compatibility (vc) type ofC. parasiticain blight cankers. Using a 49‐cell lattice plot, 17.8×17.8 cm, the spatial patterns and frequencies of white and pigmented isolates and white and pigmented vc types were investigated within superficial cankers on the grafts located outside the hypovirulent‐strain‐inoculated zone. Four of six cankers assayed contained white isolates, and three of the four had random spatial patterns of white isolates, based on join‐count statistics. Vc tests, using pigmented isolates and pigmented single‐spore colonies of white isolates, indicated that the majority of whiteandpigmented isolates recovered from each of two cankers assayed were in one vc type. White and pigmented lattice‐plot cells of the same vc type were frequently in contact with each other, indicating incomplete movement of CHV1withina vc type. Nine and 10 vc types were found in the two cankers; it is hypothesized that small, white vc type areas in each canker may be a source of CHV1 transmission to the major vc types. Based on join‐count statistics, the spatial pattern of the single, major vc type in one canker was non‐random (aggregated), whereas the other canker had a random major vc type pattern. White and pigmentedin vitrovariants (sectors) ofC. parasitica, that resemble white and pigmentedin vivovariants in spatial contact and vc compatibility, were intermediate hypovirulent and virulent on forest American chestnuts, and dsRNA positive and negative, respectively. Incomplete movement of CHV1 within a vc type could be a major cause of the prevalence of pigmented isolates in superficial cankers on chestnut trees.
Dissociative identity disorder and the nurse–patient relationship in the acute care setting: An action research study
Authors: McAllister Margaret , Higson David , McIntosh Wendy , O'Leary Sally , Hargreaves Lenaire , Murrell Lorraine , Mullen Von , Lovell Fran , Kearney Jeanette , Sammon Di , Woelders Shirley , Adams Toni , Davies‐Cotter Denis , Wilson Jenny , O'Brien Julie
Published: March 2003

This paper presents the results of an action research study into the acute care experience of Dissociative Identity Disorder. The study, which was grounded in principles of critical social science, utilized focus group interviews and narrative construction. Nurses and patients are under‐represented in all clinical evaluation and their voices need to be heard if services are to be truly collaborative. Findings of the study extend intrapsychic theories of trauma to emphasize the interpersonal relationship between nurse and person who can work together to facilitate recovery from trauma, make connections both intra and interpersonally and build resilience.
Australian Indigenous mental health
Authors: Brown Ron
Published: March 2003

ABSTRACT:

Understanding the complexity of another culture’s health concerns is fraught with difficulty, yet ‘ways forward’ abound. Many researchers, including Indigenous people, have recorded cultural understandings of health, and made recommendations that have influenced the planning of Indigenous peoples’ mental health care. Indeed, there is anticipation with vision for the future. Australian Indigenous people have suffered many losses, which have resulted in much social unrest, and mental and spiritual sorrow. The difficulty of belonging and adjusting to two different cultural contexts has led to particular physical health and mental health concerns for some. Health for Indigenous people is viewed within a holistic and community lifestyle framework, which is related to both past and present issues, and it is not necessarily individualized or compartmentalized. A closer liaison between the health traditions of both cultures, working together with education, good will and understanding of each other’s health business, and working together within mainstream health services may assist with healing, reconciliation and improved Aboriginal holistic health.
Undergraduate nursing students’ views of mental health nursing in the forensic environment
Authors: Martin Trish , Happell Brenda
Published: March 2003

The literature clearly demonstrates that mental health nursing tends to be viewed negatively by undergraduate nursing students. While positive clinical experiences have been found to encourage more favourable attitudes towards mental health nursing, suitable placements are becoming scarce. An evaluation of clinical placements at the Victorian Institute of Forensic Mental Health (VIFMH) was undertaken to determine whether appropriate learning opportunities were offered, and identify the impact of the placement on students’ attitudes to mental health nursing. The results suggest that VIFMH provides valuable learning experiences to increase students’ understanding of mental health nursing and is effective in producing more positive attitudes towards this area of practice.
TYRANNY OF DISTANCE? THE HEALTH OF MID‐AGE WOMEN LIVING IN FIVE GEOGRAPHICAL AREAS OF AUSTRALIA
Authors: Brown Wendy J. , Young Anne F. , Byles Julie E.
Published: March 2003

Over 14 000 women aged 45–50 are participating in the Australian Longitudinal Study on Women’s Health, which is designed to track the health of Australian women for 20 years, and to understand lifestyle and healthcare factors that influence women’s health. The study deliberately overrepresents women from rural and remote areas. This analysis of baseline data from the study compares the responses of women living in urban areas (capital city, other metropolitan), large rural centres, small rural centres, other rural areas and remote areas (remote centres, other remote areas) of Australia. The data show that while women in this age group who live in rural and remote areas have similar levels of self‐rated health, they have significantly fewer visits to general practitioners and specialists (P < 0.001) and more visits to alternative healthcare providers than women living in urban areas. Rural and remote area women were also more likely to undergo gynaecological surgery than women living in urban areas (P < 0.001). Other results suggest that being overweight is more common among women from rural and remote areas, and that these women also report lower levels of stress than women from urban areas (P < 0.001). Further follow up will allow any divergence in health and healthcare equity to be explored as these women get older.
THE DEVELOPMENT OF THE ADVANCED ROLE OF RURAL NURSES IN NEW ZEALAND
Authors: Ross Jean
Published: March 2003

This paper offers an informative insight into the development of the advanced role of rural nursing practice in New Zealand. Provided is a futuristic vision of nurses’ contribution for the provision of primary rural health care. The concept of advanced nursing practice will be discussed within the context of the interdisciplinary healthcare team. It is argued that as nurses take on advanced practice, it is essential they receive appropriate clinical and theoretical skills to ensure they are in a position to provide competent and clinically safe, effective health care in an ethical, efficient manner. A description of a survey, undertaken by the author, studying rural nurses’ skills provides the recommendation for the development of an appropriate postgraduate course at Masters level, designed specifically for primary rural nurses for the advanced role. The provision of this advanced education together with preparation and support, can pave the way for the highly skilled and knowledgeable nurses of the future working in collaboration with the interdisciplinary rural healthcare team and rural community.
‘SWALLOWING THE MEDICINE’: DETERMINING THE PRESENT AND DESIRED MODES FOR DELIVERY OF CONTINUING MEDICAL EDUCATION TO RURAL DOCTORS
Authors: Hoyal Francis Michael Digby
Published: March 2003

A National Needs Assessment of the continuing professional educational needs of Australian rural medical practitioners was conducted on a model previously successfully used in Queensland. The objective was to describe and quantify the continuing education needs of rural medical practitioners in order that service providers might more expeditiously set educational curricula in continuing medical education (CME) provision. A major component of the study was to determine which modes of CME delivery rural doctors currently use and which they would prefer to use. Rural doctors were perceived to be slow to access new technologies and training may be required in order for the doctors to use them.
Farm‐related fatal injury of young and older adults in Australia, 1989–1992
Authors: Mitchell Rebecca J. , Franklin Richard C. , Driscoll Timothy R. , Fragar Lyn J.
Published: March 2003

This paper describes the types of, and circumstances surrounding, unintentional farm‐related fatal injuries involving young and older adults in Australia. Information was obtained from an inspection of coronial files for the period 1989–1992.

Around 14% of all farm‐related fatalities in Australia during 1989–1992 were of young adults aged 15–24 years and approximately one‐quarter were of older adults aged ≥ 55 years. Young adults were commonly fatally injured in motor vehicle incidents and in incidents involving firearms. Tractors were the most common agent involved in fatal incidents involving older adults.

Intervention measures to prevent fatalities of older adults in agriculture should focus on the safe use of tractors, while for young adults it appears prevention efforts should centre around safe use of firearms and operation of motor vehicles on the farm. Ways to overcome barriers to the use of injury prevention measures in rural Australia should be further explored.
DOES ONE SIZE REALLY FIT ALL? WHY THE MENTAL HEALTH OF RURAL AUSTRALIANS REQUIRES FURTHER RESEARCH
Authors: Fraser Caitlin , Judd Fiona , Jackson Henry , Murray Greg , Humphreys John , Hodgins Gene A.
Published: March 2003

ABSTRACT: In this paper the need for further investigation into the mental health of rural Australians will be discussed. It will be argued that while research to date has yielded valuable information, the volume and scope of existing studies has been inadequate to address the needs of the diverse and dynamic communities in non‐metropolitan Australia. The diversity that exists within rural Australia is examined and the potential effects of this diversity on mental health status are highlighted. Then a number of issues that are relevant to people living in non‐metropolitan areas that underscores the need for further study into rural mental health are identified. Finally, some specific areas that require further examination are outlined and some guiding principles for future mental health research are proposed.
MEN'S HEALTH PROMOTION BY GENERAL PRACTITIONERS IN A WORKPLACE SETTING
Authors: Aoun Samar , Johnson Lyn
Published: March 2003

ABSTRACT: A project to promote men's health through diabetes education and screening was undertaken throughout rural industries in 1999/2000 in the south‐west of Western Australia. Five hundred and twenty‐five men aged 40–65 years participated from 27 industries. Sixty‐four per cent of these men were identified at high‐risk of developing diabetes and were referred to their general practitioner (GP) for follow‐up. Seventy‐six per cent of those at‐risk visited their GP and hence the strategy adopted has been appropriate in engaging men in the preventive concept of seeking care, that is, getting them to attend their GP when they only have the risk factors but not the disease. However, men were left short of knowing how to achieve a change in their lifestyle behaviour and take appropriate action. Given the constraints of rural practice and the need to prioritise those with disease and gaps in service provision for both health services and GPs, there are two challenges: identifying those at‐risk and modifying their behaviour.
New South Wales rural general practice from a Yank's perspective
Authors: Benzie Daniel
Published: March 2003

The author, a family practice specialist from Minnesota in the United States, worked as a locum in rural New South Wales for 6 months. This provided him with the opportunity to reflect on the differences between the specialty of family practice in his home state of Minnesota and general practice in New South Wales; and to recognise that general practice in New South Wales is at a crossroads. This paper highlights the need for general practitioners (GPs) to work together and support each other, to provide quality care and to lobby both State and Commonwealth governments on the importance of broadly trained GP specialists in rural communities. To influence the future of their profession, GPs in New South Wales need to focus on quality of care and on educating themselves, their colleagues and the communities in which they work.
Starting out in rural New South Wales: the experiences of new graduate occupational therapists
Authors: Lee Sarah , Mackenzie Lynette
Published: March 2003

The current shortage of health personnel in rural Australia is compounded by the difficulty in recruiting and retaining new graduate health professionals in rural practice. This qualitative study aimed to explore the experiences of five new graduate occupational therapists who began their careers in rural New South Wales (NSW). Data were collected via semi‐structured, individual interviews. Results indicated that new graduates were attracted to their rural positions by multiple factors, especially their previous rural experience. Participants experienced low self‐confidence during their transition from student to therapist. Rewarding and challenging aspects of rural practice were identified. New graduates valued challenging aspects of rural practice as opportunities for skill development. Results suggest that increasing the number of occupational therapy graduates with rural experience may attract more graduates to rural practice. Furthermore, enhancing the support available to new graduates in rural positions may help retain graduates in rural practice.
Child Sexual Abuse I: Psychopathology
Authors: Nurcombe Barry
Published: March 2003

Objective: To review scientific literature concerning the prevalence, childhood outcome and adult outcome of child sexual abuse, and the hypothetical models that have been postulated to explain its psychopathology.

Method: Selective critical review of literature.

Results: Estimates of prevalence of sexual abuse suggest that a significant number of children of both sexes are affected. Research into the psychopathology of sexual abuse is hindered by methodological problems. However, sexual abuse has been associated with a number of psychiatric disorders and maladaptive lifestyles in childhood and adulthood. Several theoretical models of the psychopathology of child sexual abuse are examined and compared.

Conclusions: A transactional model is the most comprehensive and encompassing.
Cannabis Use and Psychosis: A Review of Clinical and Epidemiological Evidence
Authors: Hall Wayne , Degenhardt Louisa
Published: March 2003

Objective: This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a ‘cannabis psychosis’, i.e. a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms.

Method: Literature relevant to drug use and schizophrenia is reviewed.

Results: There is limited clinical evidence for the first hypothesis. If ‘cannabis psychoses’ exist, they seem to be rare, because they require very high doses of tetrahydrocannabinol, the prolonged use of highly potent forms of cannabis, or a preexisting (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia.

Conclusions: It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of ‘self-medication’, or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.
Understanding and Evaluating Qualitative Research
Authors: Fossey Ellie , Harvey Carol , Mcdermott Fiona , Davidson Larry
Published: March 2003

Qualitative research aims to address questions concerned with developing an understanding of the meaning and experience dimensions of humans’ lives and social worlds. Central to good qualitative research is whether the research participants’ subjective meanings, actions and social contexts, as understood by them, are illuminated. This paper aims to provide beginning researchers, and those unfamiliar with qualitative research, with an orientation to the principles that inform the evaluation of the design, conduct, findings and interpretation of qualitative research. It orients the reader to two philosophical perspectives, the interpretive and critical research paradigms, which underpin both the qualitative research methodologies most often used in mental health research, and how qualitative research is evaluated. Criteria for evaluating quality are interconnected with standards for ethics in qualitative research. They include principles for good practice in the conduct of qualitative research, and for trustworthiness in the interpretation of qualitative data. The paper reviews these criteria, and discusses how they may be used to evaluate qualitative research presented in research reports. These principles also offer some guidance about the conduct of sound qualitative research for the beginner qualitative researcher.
DECREASING LENGTHS OF STAY: THE COST TO THE COMMUNITY
Authors: Caplan Gideon , Board Neville , Paten Anne , Tazelaar‐Molinia Jodie , Crowe Philip , Yap Su‐Jen , Brown Ann
Published: March 2003

Background: Patients who are discharged earlier from hospital frequently require support from professional and unpaid carers at home after discharge. Hospitals save money per patient by discharging earlier, but it is not known whether the costs to community services and unpaid carers outweigh the savings to the hospital.

Methods: We prospectively studied the total costs, patient satisfaction, time off work and pain scores of 224 patients who underwent elective herniorrhaphy or laparoscopic cholecystectomy and who lived locally before and after re‐engineering the elective surgical service. The components of the re‐engineered surgical service were a peri‐operative unit, pre‐admission anaesthetic assessment based on self‐reported questionnaires, day of surgery admissions, enhanced patient education, clinical pathways, and post‐acute care.

Results: The patients treated through the re‐engineered surgical service had a significantly shorter length of stay (LOS) (mean LOS: 2.2 vs 3.2 days; P < 0.001) but neither they nor their carers required more time off work. Significant determinants of time off work were smoking, heavy lifting at work and a higher pain score at day 7. Patients treated through the re‐engineered surgical service recorded significantly higher satisfaction with their treatment. The cost saving to the hospital outweighed the cost of increased services provided in the community, so that the overall cost of providing treatment was over $200 less per patient through the re‐engineered service.

Conclusions: This study demonstrates that changes in care provision that result in shorter LOS and greater cost effectiveness may better meet patients’ needs than existing systems.
ON‐THE‐TABLE COLONIC LAVAGE
Authors: Hulme‐Moir M. , Parry B. R. , Hill G. L.
Published: March 2003

Single‐stage surgery is an acceptable option in the modern management of many acute colonic conditions. Anastomosing unprepared colon is a major concern. A technique is described that allows on‐the‐table colonic lavage to be performed without contamination of the abdominal cavity.
HIGH PRESSURES ARE GENERATED AT THE TIP OF LAPAROSCOPIC GRASPERS
Authors: Cartmill J. A. , Shakeshaft A. J. , Walsh W. R. , Martin C. J.
Published: March 2003

Background: Despite its importance the interface between tissue and instrument is poorly understood.

Methods: A thin film pressure transducer was deployed between the jaws of eight different laparoscopic instruments and a simulated tissue to study the forces generated at the tip of laparoscopic graspers and the effect of a change in angle of tissue tension at the interface between tissue and laparoscopic grasper.

Results: Pressure was concentrated at the tip of the instrument. Localized pressures increased on average from 210 kPa to 650 kPa as the angle of grasp was increased from 0 to 135°. There was a wide variation between instruments with some exhibiting increases in tip pressure of a factor of eight as the angle was increased.

Conclusion: High pressures are generated at the tip of laparoscopic graspers. Pressures increase as the angle of incidence of the grasper in relation to the tissue increases. The changes in pressure with change in angle are independent of load and handle pressure.
THE RETURN TO COREE: THE SURGICAL CONNECTION
Authors: Pheils Murray T.
Published: March 2003

Samuel Wilson purchased Coree in 1865. In 1874 he donated £30 000 to Melbourne University to build the Wilson Hall, used for ceremonial occasions including medical graduation. Samuel McCaughey purchased Coree in 1881. In 1919 he left large bequests used by Sydney University to found the first Chair of Surgery. This was held by Frances Percival Sandes from 1921 to 1928. David McCaughey died of general peritonitis at Coree in 1899, his son Samuel married Una McKellar who was Thomas Dunhill’s stepdaughter. Thomas Dunhill, pioneer thyroid surgeon, gave the hand of his stepgranddaughter, Unity McCaughey, to Murray Pheils in London in 1941. Roy McCaughey created the McCaughey Institute at Coree in 1945 in memory of his nephew Michael McCaughey who was killed in action in New Guinea. Pioneering work in ovum transfer and in vitro fertilization in sheep was carried out at Coree by Neil Moore from 1959 to 1971. Roy McCaughey left a bequest to the Royal Australasian College of Surgeons in 1972, this was used to endow the Sir Roy McCaughey Scholarship in 1995.
EFFECTS OF ADRENALINE OR ENDOTOXIN TOLERANCE STATES ON MESENTERIC BLOOD FLOW IN ENDOTOXAEMIA
Authors: Baykal A. , Iskit A. B. , Kaynaroglu V. , Guc M. O. , Sayek I. , Sanaç Y.
Published: March 2003

Background: Endotoxic shock is associated with release of catecholamines as well as decreased mesenteric vascular perfusion, which is thought to cause remote organ injury. Adrenaline tolerance was reported to decrease mortality in endotoxic shock and have cross‐tolerance with endotoxin tolerance. Our aim was to investigate the effect of these two tolerance conditions on the lipopolysaccharide (LPS)‐induced decrease in mesenteric blood flow (MBF).

Methods: Adrenaline tolerance was developed by injecting 0.03 mg/kg adrenaline to Swiss‐albino mice, gradually increasing the dose to 2 mg/kg over 5 days. Endotoxin tolerance was developed by injecting saline for 4 days and LPS 1 mg/kg at the fifth day. Control animals were injected with saline for 5 days. At 72 h after completion of injections, half of the animals in each group were challenged with saline and the other half with 20 mg/kg LPS, at 0 h. Mesenteric blood flow was measured at 4 and 24 h.

Results: Neither endotoxin nor adrenaline tolerance prevented an LPS‐induced decrease in MBF.

Conclusion: A low dose of LPS prior to a higher dose does not prevent an LPS‐induced decrease in MBF and may actually prime for a decrease. Also, catecholamines are not primary mediators of LPS‐induced decreases in MBF.
‘STAB AND SPLIT’: A ‘BLOODLESS’ AND ‘SCARLESS’ SKIN INCISION TECHNIQUE FOR MINOR SURGERY
Authors: Yamataka Atsuyuki , Pringle Kevin C.
Published: March 2003

The ‘stab and split’ skin incision technique was applied to children requiring minor surgery. A small stab incision was made on a skin crease and split open with mosquito forceps. After the surgical procedure was completed, the wound was closed in layers with a subcuticular suture to the skin. In all cases, splitting caused virtually no blood loss because subcutaneous veins were left intact, and the wounds healed well, especially in infants. ‘Stab and split’ is an effective alternative incision technique for minor surgery in younger children.
IS THE ‘TUNNEL OF DEATH’ A SUITABLE MODALITY FOR INVESTIGATING THE SEVERELY TRAUMATIZED CHILD?
Authors: Mackay Athol
Published: March 2003

Background: The child who has suffered severe physical trauma and is physiologically unstable can often present a diagnostic dilemma to the clinician in the emergency room.

Methods: In an attempt to clarify the situation there is often a decision made to perform computed tomographic scanning in such children.

Results: This is an extremely dangerous investigation in this situation given that the child has to have a GA as well as being unstable from the injuries.

Conclusion: Ultrasound is easier, less expensive, can be performed in the emergency room and can be performed by relatively inexperienced operators with good diagnostic accuracy.
AN AUSTRALIAN MASS CASUALTY INCIDENT TRIAGE SYSTEM FOR THE FUTURE BASED UPON TRIAGE MISTAKES OF THE PAST: THE HOMEBUSH TRIAGE STANDARD
Authors: Nocera Antony , Garner Alan
Published: March 2003

Background: The purpose of this study was to create a system of mass casualty incident triage that provides a common language platform for both ambulance and hospital personnel based upon standard daily operating procedures for both groups.

Methods: An annotated literature review was conducted.

Results: The Homebush Triage Standard taxonomy consists of five categories: immediate, urgent, not urgent, dying and dead, which are given the phonetic alphabet designations of Alpha, Bravo, Charlie, Delta and Echo, respectively, to facilitate radio voice communications. Colours are assigned to each category: red (Homebush Red), yellow (Homebush Gold), green (Homebush Green), white and black comply with Standards Australia AS‐2700 1996 Colour Standard for General Purposes, to ensure triage materials have consistent production standards. Numbers are reserved to either quantify or stratify individuals within a particular triage category. The Homebush Triage Standard methodology is based on START (Simple Triage Assessment and Rapid Transport) and SAVE (Secondary Assessment of Victim Endpoint) and documents triage priority using geographic triage with triage flags, instead of triage tags.

Conclusion: The Homebush Triage Standard provides a basis for both seamless patient reassessment at all points along the casualty evacuation chain and the audit of the medical response to mass casualty incidents. It allows hospital and ambulance staff to keep working using familiar routines and removes fundamental barriers to good communication during a time of crisis.
MANAGEMENT OF BILIARY TRACT COMPLICATIONS FOLLOWING LIVER TRANSPLANTATION
Authors: Jeffrey Gary P. , Brind Alison M. , Ormonde Donald G. , Frazer Christopher K. , Ferguson John , Bell Roger , Kierath Anthony , Reed William D. , House Anthony K.
Published: March 2003

Background: A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2‐year period.

Methods: A review was made of patient data collected prospectively, and confirmed by retrospective casenote review.

Results: A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end‐to‐end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T‐tubes had complications: three leaks at T‐tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T‐tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor–recipient bile duct mismatch; severe cellular rejection; and prolonged postoperative hypotension. Acute rejection, steroid‐resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re‐transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30–180 days) compared with 33.5 days (range: 22–70 days) for patients without. Of patients with end‐to‐end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery.

Conclusion: A total of 50% of patients with end‐to‐end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.
SKIN WRINKLING FOR THE ASSESSMENT OF SYMPATHETIC FUNCTION IN THE LIMBS
Authors: Vasudevan T. M. , Rij A. M. Van , Nukada H. , Taylor P. K.
Published: March 2003

Background: Wrinkling of the skin of the palm and sole is considered to be dependent on the presence of intact sympathetic nervous activity. Loss of sympathetic integrity could be simply and usefully assessed by the absence of wrinkling. To test this hypothesis, the skin wrinkle test was compared with the starch–iodine sweat test and sympathetic skin response (SSR) in patients with abnormal sympathetic function.

Methods: The three tests were carried out in 34 patients (68 limbs) undergoing temporary or permanent disruption of the sympathetic chain to upper or lower limbs. Included in this group were six diabetics undergoing chemical or surgical sympathectomy, lumbar epidural infusions following vascular surgery, and patients for whom sympathectomy was being considered. Sensitivity and specificity analysis and predictive values of the wrinkling response and the starch‐iodine test were related to the SSR as the standard.

Results: The wrinkle test showed a sensitivity of 97% and specificity of 95%, and bore good correlation to the SSR. The starch–iodine test showed sensitivity of 55% and specificity of 93%. A hypothesis for the mechanism of wrinkling based on the observations of the present study is proposed.

Conclusion: The wrinkle test is a reliable test of sympathetic function, is inexpensive and is easy to perform at the bedside. The sweat gland myo‐epithelial cells and absence of sebum could play an important role in the wrinkling response. It can be used to select patients who will benefit from sympathectomy, and can adequately evaluate sympathetic blockade.
Cost of Endovascular Versus Open Surgical Repair of Abdominal Aortic Aneurysms
Authors: Birch Simone E. , Stary David R. , Scott Alan R.
Published: March 2003

Background: Endovascular repair of abdominal aortic aneurysms (AAA) is a new minimally invasive method of aneurysm exclusion that has been adopted with increasing enthusiasm, and with acceptable clinical results. It is important, however, to assess new health‐care technologies in terms of their economic as well as their clinical impact. The aim of the present study was to compare the total treatment costs for endovascular (EVR) and open surgical repair (OSR) for AAA.

Methods: A retrospective review of patient hospital and outpatient records for 62 patients undergoing either EVR (n = 31) or OSR (n = 31) was carried out between June 1996 and October 1999. Resource utilization was determined by a combination of patient clinical and financial accounting data. Costs were determined for preoperative assessment, inpatient hospital stay, cost of readmissions and follow up, and predicted lifetime follow‐up costs.

Results: The two groups were well matched, with no significant difference with respect to age, gender, maximum aneurysm diameter or comorbid factors. Endovascular treatment resulted in a shorter intensive care unit (ICU) and hospital stay (mean: 0.07 vs 2.9 days, P < 0.001; mean: 6.0 vs 13.4 days, P < 0.001; respectively) and fewer postoperative complications (P = 0.003). The cost of hospitalization was less for EVR ($7614 vs $15 092, P < 0.001), but this was offset by the more costly vascular prosthesis ($10 284 vs $686). Costs were higher for the EVR group for preoperative assessment ($2328 vs $1540, P < 0.001) and follow up ($1284 vs $70, P < 0.001). Lifelong follow up could be expected to cost an additional $4120 per patient after EVR. Total lifetime treatment costs including costs associated with readmission for procedure‐related complications were higher for EVR ($26 909 vs $17 650).

Conclusion: Treatment costs for endovascular repair are higher than conventional surgical repair due to the cost of the vascular prosthesis and the greater requirement for radiological imaging studies.
Intramuscular haemangiomas: Hookwire localization prioir to surgical excision: Report of four cases
Authors: Quinn Paul S. , Sieunarine Kishore , Lawrence‐Brown Michael , Tan Patrick
Published: March 2003

Background: Haemangiomas of skeletal muscle are a rare entity, although they are still noted to be one of the most common deep tissue tumours of the lower limb. All such lesions are benign with no recorded evidence of metastasis; but they are associated with a 17–20% local recurrence rate which is thought to be related to inadequate primary surgical excision rather than histological subtype.

Methods: The present case series briefly discusses the pathophysiology, clinical manifestations, diagnostics, differential diagnosis and treatment modalities of intramuscular haemangiomas. The article then focuses on the recent introduction of ultrasound‐guided hookwire localization, which has enabled a great increase in complete surgical excision, resulting in much lower rates of local recurrence and a more pleasing functional and cosmetic result because unnecessary dissection is avoided.

Results: Preoperative ultrasound‐guided hookwire localization of deep and often non‐palpable intramuscular haemangiomas was very helpful in enabling a more complete surgical excision to be carried out.

Conclusion: Hookwire localization using ultrasound guidance is an invaluable tool in directing the surgeon intraoperatively when excising deep intramuscular haemangiomas.
Feasibility of day‐care open cholecystectomy: Evaluation in an inpatient model
Authors: Thomas Shaji , Singh Jagpreet , Bishnoi Prem Kumar , Kumar Ajay
Published: March 2003

Background: Open cholecystectomy is still a fairly frequently performed operation worldwide, and is used where laparoscopic surgery has failed or is contraindicated, and where some surgeons do not operate laparoscopically for technical reasons. In developing countries laparoscopic cholecystectomy is costly and is available only in a few centres. The present study was conducted to assess the feasibility of day‐care open cholecystectomy using an inpatient model.

Methods: Thirty patients were subjected to open cholecystectomy. Intraoperative nasogastric decompression and local wound infiltration with 0.25% bupivacaine was carried out. Postoperatively patients were encouraged to be ambulant, pass urine and start oral fluids. Intravenous fluids and parenteral medication were stopped at 8 p.m. when patients were assessed for feasibility for discharge. All patients were reassessed the next morning for any adverse effects that could have occurred had the patients been discharged on the evening of surgery.

Results: Prospectively, 73.3% of patients were considered to be dischargeable on the evening of surgery; but on reassessment the next morning, retrospectively, 93.3% of patients were actually dischargeable on the evening of surgery. A total of 76.6% of patients was actually discharged within 24 h of surgery. No patient required readmission. On follow up there were no complications that could be attributable to early discharge. A total of 83.3% of patients approved of day‐care open cholecystectomy.

Conclusions: Day‐care open cholecystectomy is safe and feasible. In developing countries, where the use of laparoscopic surgery is limited due to resource constraints, day‐care open cholecystectomy can lead to substantial savings in health‐care resources.
External laryngeal nerve in thyroid surgery: Recognition and surgical implications
Authors: Aina E. N. , Hisham A. N.
Published: March 2003

Background: Injury to the external laryngeal branch of the superior laryngeal nerve during thyroid surgery is not uncommon. Most surgeons tend to avoid rather than expose and identify the external laryngeal nerve (ELN). The aim of the present study was to analyse the frequency and types of ELN crossing the avascular space in relationship to the structures to the upper pole of the thyroid and related thyroid pathology.

Methods: One hundred and fifty‐one consecutive patients who had thyroid surgery from February 1998 to February 1999 and who met the required preoperative criteria were included into this prospective study. The frequency and type of ELN was documented as it crossed the potential avascular space.

Results: A total of 202 ELN (92.7%) nerves were identified during thyroid surgery. The frequency of the ELN documented crossing the avascular space were: type 1 nerve, 35 (17.3%); type 2a, 113 (56%); and type 2b, 54 (26.7%). Sixteen (7.3%) ELN were not seen despite an extensive search; seven (3.2%) were cases of secondary thyroid surgery and six (2.8%) were cases of malignant related pathology. In 78 cases the goitres weighed more than 100 g and the frequencies of ELN distribution seen were: type 1, six (7.7%); type 2a, 32 (41%); and type 2b, 40 (51.3%). There was a considerably higher frequency of type 2b ELN (51.3%) in large goitres of more than 100 g.

Conclusions: The various technical problems in preserving the ELN need to be considered. Recognition of the potential avascular space aids the exposure and preservation of ELN. As such every attempt should be made to ensure safe dissection in order to reduce morbidity related to thyroid surgery.
Attitudes to evidence‐based practice in urology: Results of a survey
Authors: Stapleton Alan M. F. , Cuncins‐Hearn Astrid , Pinnock Carole
Published: March 2003

Background: The advantages of promoting evidence‐based care through implementation of clinical guidelines are well established. Clinical practice guidelines have been developed for lower urinary tract symptoms (LUTS) and prostate cancer screening. Aspects of the delivery of care by urologists or specialist registrars relevant to the guidelines were assessed.

Methods: A questionnaire was distributed at the 1999 meeting of the Urological Society of Australasia, which was attended by 187 Australasian and 33 foreign delegates. Questions addressed access to resources for evidence‐based medicine; perceived need; preferred sources of information; and then presented four clinical scenarios. These were: (i) treatment recommendations in early stage prostate cancer; (ii) the same scenario if the respondent was the patient; (iii) treatment recommendations after radical prostatectomy when there was a positive resection margin; and (iv) clinical investigations for mild to moderate LUTS.

Results: Of 220 possible responses, 132 were received, a response rate of 60%. Urologists overwhelmingly (100%) endorsed the need for access to evidence‐based reviews, although 28% claimed such access was non‐existent to poor. Clinical guidelines were the preferred source of evidence‐based information. For early stage prostate cancer in a 55‐year‐old man, radical prostatectomy was recommended by 93.2% of respondents, but this dropped to 83% when the respondent was the patient (P < 0.05), and a wider range of treatments was recommended. Pelvic radiotherapy and hormone therapy were equally recommended for biochemical progression following radical prostatectomy where there was a positive surgical margin. Investigations for LUTS included serum prostate‐specific antigen (PSA) testing (78.0%) and voided flow studies (77.3%).

Conclusions: Urologists express a need for evidence‐based practice resources, in particular clinical guidelines. Nevertheless their clinical approach is not necessarily consistent with existing guidelines, particularly for LUTS. An alteration in the recommendation when the respondent is the patient of interest and endorses the recommendation that patients with prostate cancer should be involved in treatment decisions.
A meaningful occupation: The just right challenge
Authors: Christie Ann
Published: March 2003

This article illustrates the academic, clinical and personal perspective of an occupational therapy clinician working in Child Mental Health in New Zealand. It reflects her enthusiasm, beliefs and values, and the ‘just right challenge’ in her work that stimulate her inner drive to succeed. It incorporates the conference theme of ‘common threads’, the dynamic, interwoven relationships between persons and environment, and a belief in sharing knowledge with others. The influences of life experiences, mentors and colleagues on self‐directed learning are outlined, together with the impact this has on professional and clinical development. In particular, the development of training packages for students on clinical placement, supervision, social interaction and roles of occupational performance in children with emotional, psychosocial and behavioural disturbances are highlighted. Included are descriptive vignettes outlining casework with children and their families, and the conscious use of self as an effective tool in the evaluation and intervention process.
Handgrip strength testing: A review of the literature
Authors: Innes Ev
Published: March 2003

Testing grip strength is a popular assessment used by occupational therapists in a range of clinical settings. It is fast, easy to perform, reliable and produces a result which is simple to record. Results of grip strength testing have been used to determine a baseline measure of performance against which change can be compared, as well as comparison of results to normative data. This article reviews the literature associated with the measurement of grip strength. It addresses the purposes of grip strength measurement; the instruments used and their reliability and accuracy; the testing position and protocol suggested for use and aspects of these which may influence results; the use of normative data and factors which influence grip strength, including age, gender and occupation; and various methods to determine level or sincerity of effort. Recommendations are made regarding these issues to enable clinicians to conduct grip strength assessments and interpret the results with confidence.
The process of evidence‐based practice in occupational therapy: Informing clinical decisions
Authors: Bennett Sally , Bennett John W.
Published: March 2003

As we move into the 21st century, there are increasing demands placed on occupational therapists to ensure their practice is based on sound evidence. Evidence‐based practice is an approach to clinical decision making that has gained considerable interest and influence during the last decade. This article describes and explains the process of evidence‐based practice and its application to clinical occupational therapy practice. Directions for resources that may assist therapists’ self‐directed learning are also provided. As health care becomes more evidence‐based, awareness of the principles, skills, and resources for evidence‐based practice is of relevance to all occupational therapists.