bluuebunny/crossref_metadata_2025 huggingface dataset:
A Comparison in Hospitalization Rates Between a Community-Based Mobile Emergency Service and a Hospital-Based Emergency Service
Authors: Hugo Malcolm , Smout Matthew , Bannister John
Published: March 2003

Objectives: The aims of this study were to compare the rates of inpatient admission between a mobile community-based psychiatric emergency service and a hospital-based psychiatric emergency service, and to identify the clinical characteristics of consumers more likely to be admitted to hospital.

Methods: A retrospective, quasi-experimental design was used with a 3-month cohort of all face-to-face emergency service contacts presenting at the mobile and hospital-based sites. The Health of the Nation Outcome Scales and details of the outcome following initial assessment were completed for all contacts, and each group was compared for differences in clinical characteristics and outcome.

Results: Hospital-based emergency service contacts were found to be more than three times as likely to be admitted to a psychiatric inpatient unit when compared with those using a mobile community-based emergency service, regardless of their clinical characteristics. Those with severe mental health disorders such as schizophrenia and major affective disorder, and experiencing problems with aggression, non-accidental self-injury, hallucinations and delusions, problems with occupation, activities of daily living, and living conditions were more likely to be admitted to hospital. Nevertheless, after controlling for clinical characteristics, site of initial assessment accounted for a substantial proportion of the variance in decisions to admit to hospital.

Conclusions: Emergency psychiatric services which include a mobile component and provide a specialized multidisciplinary team approach appear to be most effective in providing services in the least restrictive environment and avoiding hospitalization.
Valid Assessment of the Clinical Features of Depression by Relatives Appears to Slip Under the RADAR
Authors: Parker Gordon , Parker Gordon , Gladstone Gemma , Mitchell Philip , Welham Kay , Malhi Gin , Loo Colleen
Published: March 2003

Objective: We report on the development of an observational measure designed for completion by relatives, the Recent Appearance of Depression Assessed by Relatives (RADAR), and consider its validity.

Method: One hundred and one patients with a current major depressive episode had a relative or close friend complete the RADAR, while psychiatrists and research assistants collected extensive data.

Results: Correlated against both patient self-report and psychiatrist-rated depression severity measures, RADAR scores evidenced poor validity overall. Recent Appearance of Depression Assessed by Relatives scores also failed to differentiate depressive subtypes, in that scores for patients with melancholic depression were not significantly higher than for those with non-melancholic depression.

Conclusions: Results are consistent with previous findings of poor agreement between clinicians and corroborative witnesses in assessing clinical depressive features, and argue against reliance on corroborative witness reports.
Costs of Schizophrenia and Other Psychoses in Urban Australia: Findings from the Low Prevalence (Psychotic) Disorders Study
Authors: Carr Vaughan J. , Neil Amanda L. , Halpin Sean A. , Holmes Scott , Lewin Terry J.
Published: March 2003

Objective: To estimate the costs associated with the treatment and care of persons with psychosis in Australia based on data from the Low Prevalence Disorders Study (LPDS), and to identify areas where there is potential for more efficient use of existing health care resources.

Method: The LPDS was a one-month census-based survey of people with psychotic disorders in contact with mental health services, which was conducted in four metropolitan regions in 1997–1998. Mental health and service utilization data from 980 interviews were used to estimate the economic costs associated with psychotic disorders. A prevalencebased, ‘bottom-up’ approach was adopted to calculate the government and societal costs associated with psychosis, including treatment and non-treatment related costs.

Results: Annual societal costs for the average patient with psychosis are of the order of $46 200, comprising $27 500 in lost productivity, $13 800 in inpatient mental health care costs and $4900 in other mental health and community services costs. Psychosis costs the Australian government at least $1.45 billion per annum, while societal costs are at least $2.25 billion per annum (including $1.44 billion for schizophrenia). We also report relationships between societal costs and demographic factors, diagnosis, disability and participation in employment.

Conclusions: Current expenditure on psychosis in Australia is probably inefficient. There may be substantial opportunity costs in not delivering effective treatments in sufficient volume to people with psychotic disorders, not intervening early, and not improving access to rehabilitation and supported accommodation.
Schema-Focused Cognitive Therapy for Bipolar Disorder: Reducing Vulnerability to Relapse Through Attitudinal Change
Authors: Ball Jillian , Mitchell Philip , Malhi Gin , Skillecorn Ashleigh , Smith Meg
Published: March 2003

Objective: Acceptance of, and adaptability to illness, are major determinants of adherence to treatment and functional recovery. This paper addresses the major psychosocial factors associated with bipolar disorder and the role of psychological interventions in symptom management and adaptability to the illness experience. A new model is presented highlighting the role of developmental experiences and temperament in determining reactions to bipolar disorder. The authors propose that by addressing reactions to the illness experiences and effects on self-concept through schema-focused cognitive therapy, functional recovery is more likely to occur among those patients functioning below expectation.

Method: A systematic review of the current literature including an Index Medicus/MEDLINE search was conducted, focusing on risk factors, cognitive vulnerabilities and triggers associated with bipolar disorder. Psychological treatments available for the treatment of bipolar disorder are reviewed and details of a novel schema-focused cognitive model for this condition are presented. Traditional models of adaptation to chronic illness are outlined and incorporated into the proposed model. Schema-focused cognitive therapy is proposed as an approach to help patients reduce cognitive vulnerability to relapse in addition to adopting effective mood management strategies.

Results and Conclusions: There is a need for psychological treatments which reduce the risks associated with poor functionality in patients with bipolar disorder. Schema-focused cognitive therapy specifically targets the temperament, developmental experiences and cognitive vulnerabilities that determine adjustment to illness. This proposed treatment, combined with pharmacotherapy, may offer new psychotherapeutic options for the future.
A Survey of the Quality of Web Based Information on the Treatment of Schizophrenia and Attention Deficit Hyperactivity Disorder
Authors: Kisely Stephen , Ong Greg , Takyar Ashish
Published: March 2003

Objective: To systematically assess the quality, accountability and readability of Internet information on the treatment of schizophrenia and Attention Deficit Hyperactivity Disorder (ADHD), using a standardized pro forma.

Method: We analysed the 20 most highly ranked pages on the treatment of ADHD and schizophrenia, identified by five common Internet search engines.

Results: There was little overlap in the sites identified by different search engines. In the case of schizophrenia, one site was identified three times and another eight sites twice; while for ADHD four sites were identified twice. Accountability (Silberg score), presentation and readability, as assessed by the Flesch-Kincaid Grade Level score, were poor. Mean Silberg, presentation and Flesch-Kincaid Grade Level scores were 3.2 (range 0–9) out of 9, 1.9 (range 0–4) out of 4, and 11.5 (range 6.5–12.25), respectively. There was no statistical difference in scores between the two diagnoses. Depending on the recommendation, agreement with evidence-based practice for schizophrenia ranged from only 2 to 55% (mean = 2.8 (range 0–9) out of 12), while that for ADHD was from 14 to 54% (mean = 1.6 (range 0–6) out of 6). Only 50% of the sites advised readers to clarify information with an appropriate health professional. Interrater reliability in pro forma scores for schizophrenia and ADHD was high (r = 0.96 and 0.95, respectively, p < 0.0001). Sites in the top 10% of scores were significantly more likely to be owned by an organization or have an editorial board than those in the bottom 10%.

Conclusions: The Internet contains misleading information on both schizophrenia and ADHD. The methodology used in this paper could be adapted for other psychiatric conditions.
Clinical and Personality Correlates of a New Measure of Depression: A General Practice Study
Authors: Parker Gordon , Parker Gordon , Hilton Therese , Hadzi-Pavlovic Dusan , Irvine Penelope
Published: March 2003

Objective: There is a need for a brief, efficient depression screening measure for general practice settings, particularly for identifying those who are at high risk of depression. We therefore test the usefulness of a measure developed in a sample of medically ill hospitalized patients.

Method: More than 600 patients attending six Sydney general practices completed the Depression in the Medically Ill (DMI-10) measure, in conjunction with sociodemographic, depression history and personality profile measures. The impacts of sociodemographic, personality and lifetime depression variables on DMI-10 scores (and identified ‘cases’) were examined as a measure of its usefulness.

Results: Gender did not influence depression scores, while there were slight associations between DMI-10 scores and age, marital and occupational status. Higher scores were returned by those with more severe, lengthier and perceived stressful medical illnesses. Using a predetermined cut-off score, 36% rated as putative ‘cases’, a prevalence almost identical to our general hospital study. ‘Cases’ were distinctly more likely to have had previous depressive episodes, to have sought help for such episodes and to have received antidepressant medication. They also scored higher on measures of anxious (anxious worrying and irritability) and self-critical (‘depressive personality’) personality styles.

Conclusions: The DMI-10 appears useful as a brief and acceptable screen for depression in a general practice setting, both identifying those who are likely to be currently depressed and those with a background of previous depression.
Depression in People Living with HIV/AIDS Attending Primary Care and Outpatient Clinics
Authors: Komiti Angela , Judd Fiona , Grech Paul , Mijch Anne , Hoy Jennifer , Williams Ben , Street Alan , Lloyd John H.
Published: March 2003

Objective: Our aim was to gain an estimate of the rate of depressive disorder in patients with HIV/AIDS attending general practice and to investigate factors associated with depression. A further objective was to determine the ability of non-mental health medical practitioners to detect depressive symptoms in their patients with HIV/AIDS.

Method: Participants comprised 322 persons living with HIV/AIDS ((PLWHA); 13 females, 309 males; mean age 41.4, SD = 8.9) who were recruited from four general practice clinics specializing in HIV medicine and from an infectious diseases clinic. Medical, psychiatric and sociodemographic data were obtained. In addition, participants completed the Inventory to Diagnose Depression (IDD), a self-report measure to detect depression.

Results: Twenty-two per cent of the sample met criteria for a current Major Depressive Episode (DSM-IV defined) on the IDD. Overall, there was moderate agreement between treating doctors’ diagnosis of depression and patients’ self-report of depressive symptoms. A multivariate model indicated that being in a current relationship was associated with lowered odds of depression (OR = 0.43; CI = 0.23–0.81). The factors strongly associated with increased odds of depression were a past history of illicit drug use (OR = 2.98; CI = 1.60–5.54) and a diagnosis of ‘stress’ by treating doctors (OR = 5.65; CI = 2.50–12.77). HIV-related medical variables such as immune function, use of antiretroviral medication and duration of HIV infection were not associated with depression.

Conclusions: There was a high rate of self-reported depression in this group of PLWHA which was also recognized by treating clinicians. Being in a relationship appeared to afford protection against depression while having a history of illicit drug use and current ‘stress’ were highly associated with depression. Interestingly, HIV-related medical variables including laboratory markers of HIV disease, duration of illness and antiretroviral medication regimen were not related to depression.
AUSTRALIA’S BREAST SURGERY WORKLOAD IS CHANGING: COMPARISON OF A METROPOLITAN AND A RURAL HOSPITAL
Authors: Spillane A. J. , Littlejohn D. , Wong S. , Robertson A. O. , Crowe P. J.
Published: March 2003

Background: Breast cancer is a common disease in our community and its incidence is increasing. As a result of the improvements in community awareness and introduction of screening, patients are being diagnosed with earlier breast cancer and with a higher incidence of pre‐invasive disease. Improvements in radiology, often coupled with minimally invasive diagnostic modalities, have lessened the requirement for open diagnostic biopsies and also reduced the number of operations for benign breast disease.

Methods: An audit of the surgical workload at Prince of Wales/Prince Henry Hospitals and Tamworth Base Hospital was conducted to document and compare the above changes in the metropolitan and rural settings. This study was conducted between 1987 and 1996 to assess the effect of screening and improved technology over a 10‐year period.

Results: The study found that a high percentage of malignant lesions are being diagnosed by fine‐needle aspiration biopsy (FNAB) with a corresponding reduction in open biopsy rate at the Prince of Wales Hospital. There is a smaller percentage of benign operations in both settings with a reduction of equal proportion. The reporting of the pathology specimens has markedly improved at both institutions. There has been a reduction in the number of patients having modified radical mastectomy and there has been a corresponding increase in breast conservation surgery especially at the Prince of Wales/Prince Henry Hospitals, although there was an unexpectedly high incidence of breast conservation surgery at Tamworth Base Hospital in 1987. In 1996 the rates of breast conservation surgery were the same in both hospitals.

Conclusions: There are minimal differences in the quality of surgical care being offered to patients at the Tamworth Base Hospital compared with the Prince of Wales Hospital and both institutions are within reach of the accepted best management practices available.
TESTICULAR AND PARATESTICULAR TUMOURS IN CHILDREN: 30 YEARS’ EXPERIENCE
Authors: Sugita Yoshifumi , Clarnette Thomas D. , Cooke‐Yarborough Clair , Chow Chung W. , Waters Keith , Hutson John M.
Published: March 2003

Background: Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life‐threatening diseases. The aim of this study is to review patients during a 30‐year period with these tumours and assess clinical aspects to improve management.

Methods: The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis.

Results: The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis‐sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease.

Conclusion: Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis‐sparing surgery should be considered for benign tumours.
IMMUNE CELL SUBPOPULATIONS IN REGENERATED SPLENIC TISSUE IN RATS
Authors: Smith Eric , De Young Neville J. , Drew Paul A.
Published: March 2003

Background: Asplenic patients have an increased risk of infections. Operations such as autotransplantation or splenic artery ligation have been suggested to ensure retention of functional splenic tissue after splenectomy, but their protective value is unclear. Immune responses, such as production of antibody, remain impaired in humans and animals even when such tissue is present, and phagocytosis is less efficient than by normal spleen tissue. In the present study the cellular composition of regenerated tissue is determined.

Methods: Splenic tissue was obtained from rats 6–9 months after splenic autotransplantation, splenic artery ligation or sham operation. The lymphocyte and macrophage subpopulations were labelled using a panel of monoclonal antibodies and analysed by flow cytometry.

Results: Both the total number of cells and the number of cells per gram of tissue were significantly reduced. There was a substantial reduction in the percentage of some of the cells examined (CD4+ and CD8+ T lymphocytes subsets), but not all (B lymphocytes, ED1+ and ED2+ macrophages, OX2+ and OX6+ cells).

Conclusions: The reduction in the T lymphocyte subsets in regenerated splenic tissue compared with the normal spleen might explain the immunological dysfunction which persists after splenic autotransplantation. The reduction in the number of macrophages may be responsible for the alteration in phagocytic efficiency of regenerated splenic tissue.
ROUTINE AUTOTRANSPLANTATION OF AT LEAST ONE PARATHYROID GLAND DURING TOTAL THYROIDECTOMY MAY REDUCE PERMANENT HYPOPARATHYROIDISM TO ZERO
Authors: Zedenius J. , Wadstrom C. , Delbridge L.
Published: March 2003

Background: Permanent hypoparathyroidism, although a recognized complication of total thyroidectomy, is an outcome that all endocrine surgeons try to avoid.

Methods: To minimize the risk of postoperative hypoparathyroidism a strategy was developed of routine autotransplantation of at least one parathyroid gland into the ipsilateral sternomastoid muscle during every total thyroidectomy. One hundred consecutive patients undergoing total thyroidectomy were included in the study. Serum calcium and albumin levels were measured pre‐operatively, on the first 2 postoperative days, and after 2 weeks, or until return to normal serum calcium levels without calcium supplementation. If patients developed biochemical evidence or symptoms of hypocalcaemia postoperatively, a calcium replacement was administered according to defined protocol.

Results: In 74 cases one parathyroid gland was autotransplanted: 44 for inadvertent removal or anatomical reasons, 19 because of devascularization (assessed by a cut through the gland’s capsule and evaluation of the capillary bleeding pattern), and 11 by protocol. In 25 cases, two or more glands were autotransplanted. Fourteen patients developed symptoms of hypocalcaemia and received calcium supplementation, as did another 13 asymptomatic patients with only biochemical evidence of hypocalcaemia. At follow‐up 3 months postoperatively the incidence of permanent hypoparathyroidism was zero, with all patients being normocalcaemic without calcium supplementation.

Conclusions: This strategy, easily adopted by any experienced surgeon, has the potential to eliminate permanent hypoparathyroidism following total thyroidectomy.
TEACHING GALL BLADDER SURGERY: REMEMBRANCE OF THINGS PAST, OR DEFENSIVE CHOLECYSTECTOMY REVISITED
Authors: Costa Alan De
Published: March 2003

Among the remaining concerns for surgeons performing laparoscopic cholecystectomy are the incidence of bile duct injury and the rate of conversion to open operation. The open operation itself, now infrequently performed, and then only for complicated disease, poses a particular challenge to the surgeon in training. The lessons learned from the era of open cholecystectomy as summarized in the principles of defensive cholecystectomy, provide useful guidelines for the laparoscopic surgeon, particularly with regard to the objectives of dissection in Calot’s triangle. Attainment of these objectives during laparoscopic cholecystectomy may be easily recorded and are useful exercises for teaching and quality assurance. Flexibility with laparoscopic dissection can be taught to reflect the development of the laparoscopic technique and should allow most patients with gallstones to be treated laparoscopically. Alternative operations (cholecystostomy and subtotal cholecystectomy) may be appropriately performed laparoscopically in the occasional patient where safe cholecystectomy may not be possible by either technique. Whenever the opportunity arises, open cholecystectomy should be carefully taught to the trainee surgeon, emphasizing the principles of defensive cholecystectomy.
GRAFT DILATATION FOLLOWING ABDOMINAL AORTIC ANEURYSM RESECTION AND GRAFTING
Authors: Robinson D. A. , Lennox A. , Englund R. , Hanel K. C.
Published: March 2003

Background: It has been suggested that graft dilatation following repair of abdominal aortic aneurysm (AAA) is associated with complications such as anastomotic aneurysm and graft rupture. The purpose of the present study was to document the degree of dilatation observed in grafts after aneurysm repair and to correlate this with any graft‐related complications.

Methods: Between January 1987 and December 1992, 219 patients had elective repair of their AAA at St George Hospital. A follow‐up ultrasound scan was available for 154 of these patients. The following factors were examined: age, sex, size of aneurysm, type and size of graft, time of follow‐up scan, size of graft at follow‐up and any graft‐related complications.

Results: The mean graft dilatation observed in knitted grafts (42.6%; 95% CI: 39.1–46.1%) was significantly greater than that observed for woven grafts (25.5%; 95% CI: 19.0–32.1%; P < 0.0001). There were no graft‐related complications.

Conclusions: Graft dilatation is a predictable phenomenon following AAA repair. It is more pronounced in knitted than in woven grafts, but does not necessarily lead to graft‐related complications or failure.
DIAGNOSTIC AND THERAPEUTIC APPROACHES TO CAROTID BODY TUMOURS: REPORT OF THREE CASES AND REVIEW OF THE LITERATURE
Authors: Kaman Lileswar , Singh Rajinder , Aggarwal Rajeev , Kumar Rajinder , Katariya Arunanshu Behera and Rabindra Nath
Published: March 2003

Background: Carotid body tumour is a rare neoplasm of the carotid body. Three cases of carotid body tumour presenting as a painless progressive mass in the neck region are reported here. A review of the relevant literature regarding carotid body tumours is also presented.

Methods: Angiographic features were diagnostic of carotid body tumour and complete surgical excision was done.

Results: There was no mortality and minimum morbidity. There were no malignant tumours. All three patients belong to the high‐altitude area of Himachal Pradesh.

Conclusions: A high degree of clinical suspicion of upper posterior triangle neck masses and an accurate diagnostic work‐up are needed for operative planning.
INTERMITTENT PUMP VERSUS COMPRESSION BANDAGES IN THE TREATMENT OF VENOUS LEG ULCERS
Authors: Rowland Jeffrey
Published: March 2003

Background: The purpose of the present paper was to compare healing rate and leg swelling with an intermittent compression pump versus compression bandages in the treatment of venous leg ulcers, and to also compare patient compliance and satisfaction with the two techniques.

Methods: A randomized cross‐over study of patients attending an outpatient wound clinic (n = 16) was undertaken. A regular monthly follow‐up with measurement of ulcer size and leg volume was carried out, as well as completion of a questionnaire.

Results: Assessment was possible in 11 of the 16 patients. There was no significant difference between treatment types with regards to ulcer healing rates or control of leg oedema. The survey revealed that patients found the pump easier and more comfortable to use, with a trend towards increased compliance.

Conclusions: Although the present study was too small for generalizable conclusions, compression pumps and bandages are comparable in efficacy for the healing of venous leg ulcers. The compression pump is reported as being easier and more comfortable to use than bandages.
SENTINEL NODE BIOPSY IN BREAST CANCER: RECOMMENDATIONS FOR SURGEONS, PATHOLOGISTS, NUCLEAR PHYSICIANS AND RADIOLOGISTS IN AUSTRALIA AND NEW ZEALAND
Authors: Kollias James , Gill P. Grantley , Chatterton Barry , Raymond Wendy , Collins Peter J.
Published: March 2003

Background: Assessment of axillary lymph node status is necessary for patients with invasive breast cancer. Sentinel node biopsy is a new minimally invasive technique that may provide accurate assessment of regional lymph node status while limiting the morbidity associated with axillary clearance.

Methods: A workshop conducted in Adelaide in November 1998 aimed to assess current sentinel node mapping and biopsy techniques, and make recommendations regarding its application in the surgical management of early breast cancer in Australia and New Zealand.

Results: At the conclusion of the workshop, a consensus was reached regarding indications, exclusions, sentinel node mapping/biopsy technique, nuclear medicine requirements, pathology and safety of sentinel node biopsy in breast cancer. It was agreed that a feasibility study according to an agreed prospective protocol was necessary to validate the technique by breast surgeons. Surgeons that satisfied validation criteria for the feasibility study could then consider a prospective randomized study comparing sentinel node biopsy with standard axillary dissection.

Conclusions: Sentinel node biopsy in breast cancer involves close cooperation between members of a multidisciplinary team including surgeons, nuclear physicians, pathologists and radiologists. Although the technique has the potential to reduce morbidity associated with axillary surgery, surgical performance in this area will need to be closely monitored to ensure that the technique does not fall into disrepute by adversely affecting breast cancer prognosis.
LAPAROSCOPIC ANTI‐REFLUX SURGERY IN NEW ZEALAND: A TREND TOWARDS PARTIAL FUNDOPLICATION
Authors: Windsor John A. , Yellapu Srini
Published: March 2003

Background: The advent of laparoscopic anti‐reflux surgery has generated considerable debate regarding the best technique. The present study was undertaken to determine the trends and current technique in laparoscopic anti‐reflux surgery in New Zealand.

Methods: A confidential nationwide postal survey was sent to all general surgeons in New Zealand; it was repeated after a month, and followed up with a telephone prompt, if necessary.

Results: Of the 146 questionnaires sent out, 126 were returned (response rate: 86%), and 104 were excluded (no anti‐reflux surgery performed (n = 96); surgeon retired (n = 5); paediatric surgeon (n = 3)). The number of operations performed by the 22 (16%) adult general surgeons who had performed laparoscopic anti‐reflux surgery increased 4.6 times from 1991 to 1997 (474 open and 1218 laparoscopic operations). The median number of cases per surgeon was 30 (range: 5–300). In 1997 there were 208 (60%) total fundoplications (TF) and 135 (40%) partial fundoplications (PF) performed. Variations in the technique of TF included the Nissen–DeMeester (10 surgeons), the Nissen–Rosetti (nine surgeons), division of short gastric vessels (10 surgeons), and routine cruroplasty (14 surgeons). A PF had never been perfomed by six surgeons, was preferred by six surgeons, and four other surgeons were performing it more often. Variations in the technique of PF included posterior (12 surgeons) and anterior (four surgeons) forms.

Conclusion: There is significant variation in the technique of laparoscopic anti‐reflux surgery in New Zealand. A TF is preferred by 16 surgeons, but there appears to be a trend towards PF among the more experienced surgeons.
TEACHING ON THE RUN: TEACHING SKILLS FOR SURGICAL TRAINEES
Authors: Crowe Philip , Harris Peter , Ham John
Published: March 2003

Background: Increasing recognition of the need for training in teaching skills for clinical teachers has coincided with data that registrars and residents conduct much ‘on the job’ teaching as part of their routine work. While attention has been devoted to training consultants, support for the teaching role of the junior staff has been relatively neglected. The aim of the present report is to describe the teaching experiences of surgical registrars and the impact of a registrar teaching workshop.

Method: A half‐day programme combining presentation and discussion of surgical teaching with practical skills sessions was designed for surgical registrars at Prince of Wales Hospital. The programme included observation and feedback of brief teaching simulations at the bedside of volunteer patients to newly commenced clinical students, and small group sessions on clinic and operating theatre teaching. A pre‐workshop questionnaire sought information about the registrars’ own teaching, and a survey 3 months after the workshop determined if any changes to teaching practice had occurred.

Results: The registrars were generally moderately to very confident with their teaching ability but more than 75% felt that they were more confident after the workshop. Only three of 39 registrars had received any instruction aimed at improving their teaching skills, yet 34/39 had taught either on the ward, in the clinics or in the operating room. Follow‐up after 3 months revealed that most registrars were enjoying their teaching tasks more, and half had increased their teaching since the workshop and began discussing teaching with their surgical colleagues.

Conclusions: The present project demonstrates that relatively brief interventions focused on skill development may enhance the confidence and enjoyment of junior clinical teachers and increase the frequency of ‘teaching on the run’.
PERCUTANEOUS ENDOSCOPIC LASER DISCECTOMY
Authors: Boult Maggi , Fraser Robert D. , Jones Nigel , Osti Orso , Dohrmann Peter , Donnelly Peter , Liddell John , Maddern Guy J.
Published: March 2003

Background: The aim of the present paper was to systematically review the literature on percutaneous endoscopic laser discectomy (PELD) with respect to the safety and efficacy of the procedure. Where possible the procedure was compared with open discectomy.

Methods: Studies on PELD were identified using MEDLINE (1984 to December 1999), EMBASE (1974 to December 1999) and Current Contents (1993 to Week 1, 2000). A number of search terms were used: PELD; PLDD (percutaneous laser disc decompression); and laser and (spine or lumbar) and (disc* or disk*). The Cochrane Library was searched from 1966 to issue 4, 1999, using the search terms ‘discectomy’ or ‘discotomy’. Live human studies of patients with lumbar disc prolapses for whom surgery was appropriate were included. Cadaver studies were also included. A surgeon and reviewer independently assessed the retrieved articles for their inclusion in the review.

Results: Only 12 papers were identified that related to PELD. The level of evidence for safety and efficacy was low; there were no controlled, blinded or randomized studies. The highest level of evidence came from time series studies. No quantitative analysis could be undertaken for the present review.

Conclusions: Given the extremely low level of evidence available for this procedure it was recommended that the procedure be regarded as experimental until results are available from a controlled clinical trial, ideally with random allocation to an intervention and control group.
USE OF AN AMBULANCE‐BASED HELICOPTER RETRIEVAL SERVICE
Authors: Wills Vanessa L. , Eno Louise , Walker Christopher , Gani Jonathon S.
Published: March 2003

Background: John Hunter Hospital is the major trauma centre for a region covering more than 25 000 square kilometres. The helicopter primary retrieval service for trauma is paramedic staffed and protocol driven. The aim of the present study was to assess the overtriage rate created by such protocols, and to assess the benefit to patient outcomes that may be attributable to the service.

Methods: The John Hunter Hospital trauma database was used to identify all cases arriving by helicopter in 1996, as well as their demographic details, injury severity score, details of the accident and outcome. An expert panel reviewed the medical records for the 184 primary retrievals. Using a consensus model, estimates of time delay or saving were calculated and likelihood of benefit, no benefit or harm was assessed.

Results: A total of 3087 trauma patients were assessed at John Hunter Hospital in 1996, of which 8% arrived by helicopter. Of the primary retrievals, 67.6% had an injury severity score of 9 or less, with only 17.9% having a score of 16 or greater. Twelve patients were discharged from Emergency and 36% were discharged within 48 h. The overall mortality was 5.0%. Twenty‐five per cent of patients were retrieved within 35 km of John Hunter Hospital with minimal attributable benefit. Overall 1.7% of patients were felt to have been potentially harmed, 17.3% to have benefited and 81.0% to have had no attributable benefit related to the helicopter use.

Conclusions: Although the majority of retrievals are for minor injuries, the service provides benefit for the region. There is potential for harm, however, where base hospitals are overflown in situations where patients have airway compromise, and where patient transfer is delayed due to helicopter activation. Primary helicopter tasking to trauma cases within 35 km of the major trauma centre is seldom beneficial.
Grasper Trauma During Laparoscopic Cholecystectomy
Authors: Marucci Damian D. , Shakeshaft Anthony J. , Cartmill John A. , Cox Michael R. , Adams Stuart G. , Martin Christopher J.
Published: March 2003

Background: The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested.

Methods: The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was ‘sample’ and which was ‘control’ and to assess for histological markers of crushed tissue injury. The data were analysed by chi‐squared or Fisher’s exact tests.

Results: The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi‐squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi‐squared test, P = 0.0002 and P < 0.0001, respectively).

Conclusions: Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.
Of Blood, Inflammation and Gunshot Wounds: The History of the Control of Sepsis
Authors: Thurston Alan J.
Published: March 2003

Galen (AD 129–199) propounded the notion that all wounds healed by second intention and the concept of laudable pus became unshakeable for almost 15 centuries. But William of Saliceto (AD ca 1210–1280) held quite firmly that pus formation was bad for both wound and patient and proclaimed that wounds should heal by first intention. The first rational theory of the nature of infection was by Fracastoro (1478–1553), a physician of Verona who regarded infection as being due to the passage of minute bodies from one person to another. But it was not until the work of Pasteur (1822–1895) that bacteriology took a significant leap forward. The association between bacteria and infection was slow to be accepted. The work of Semmelweis (1818–1865) is notable for his association between bacterial infection and puerperal fever. Lister (1827–1912) began the modern movement to control infection with his pioneering work in antiseptic surgery. Other contributions came from von Bergman (1836–1907; steam sterilization of instruments) and Halstead (1852–1922; rubber gloves for surgeons). The aseptic system has changed very little since then except for the innovations of Sir John Charnley (1911–1982; the laminar flow enclosure). The development of safe antibacterial drugs has been confined to the 20th century. This was led by Domagk (1895–1964; sulfonamides) and was followed by Sir Alexander Fleming (1881–1955), Sir Howard Walter Florey (1898–1968) and Sir Ernest Boris Chain (1906–1979; penicillin) and Selman Waksman (1888–1973; actinomycin).
Trauma training in Australia and New Zealand: Results of a survey of advanced surgical trainees
Authors: Thomson B. N. J. , Civil I. D. , Danne P. D. , Deane S. A. , Mcgrath P. J.
Published: March 2003

Background: The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training.

Methods: A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons.

Results: Two hundred and seventy‐two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations.

Conclusions: Regional rotations may need to be developed to even out trainees’ experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.
Functioning adrenal tumours in children and adolescents: An institutional experience
Authors: Mishra Anjali , Agarwal Gaurav , Misra Anand Kumar , Agarwal Amit , Mishra Saroj K.
Published: March 2003

Background: The purpose of the present paper was to carry out an audit of clinicopathological profile and treatment outcome in 13 children with functioning adrenal tumours.

Methods: The medical records of 13 children with functioning adrenal tumours who were managed between June 1990 and January 1999 were reviewed. Demographic data, clinical features, biochemical and localization studies, operative details and follow‐up records were studied. Children with neuroblastoma were excluded.

Results: The mean age was 7.4 ± 5.3 years. Seven patients had Cushing’s syndrome (CS), two patients had virilizing tumours, three patients had phaeochromocytoma (PCC) and one patient had Conn’s syndrome. All patients (except one child with CS) were treated surgically. Two children with adrenocortical carcinoma (ACCa) died during the perioperative period. Histopathological diagnosis was adrenal cortical adenoma (ACAd) in four patients, ACCa in five patients and PCC in three patients. Two ACCa patients died of metastases at 12 and 14 months, respectively, while the third is alive and well at 30 months. Children with ACAd are alive and well at 91, 56, 32 and 27 months postoperatively. Children with PCC are free of disease (normal urinary metanephrines) at 63, 18 and 8 months after surgery but require antihypertensive drugs in low doses.

Conclusion: The outcome of surgery is good in cases of ACAd and PCC. Although outcome is poor in ACCa, surgery remains the mainstay of treatment and offers good palliation.
Breast reconstruction after mastectomy: A survey of general surgeons in Singapore
Authors: Lim Jeremy , Low Sze Chuan , Hoe Michael
Published: March 2003

Background: Breast cancer is the leading malignancy among women in Singapore. In the West as many as 30% of eligible patients undergo some form of reconstruction, but in Singapore breast reconstruction is not often performed.

Methods: A postal survey of general surgeons in Singapore (response rate of 46%) was conducted to ascertain the factors influencing their decision to refer for reconstruction and the possible concerns they had about reconstruction.

Results: Age, anticipated psychosocial morbidity and the need for adjuvant therapy were the most important factors identified. The survey also found that almost 30% of respondents were unsure of whether reconstruction would mask recurrence. Despite this, almost 80% of respondents felt that reconstruction was worth the effort, but 55% (compared to less than 20% in the West) felt that patients did not want reconstruction despite being advised of its availability.

Conclusion: Lack of information and the perception that patients would not want reconstruction may be important reasons for the low emphasis placed on the role of breast reconstruction in post‐mastectomy patients.
Anal incontinence surgery: A small personal experience
Authors: Isbister William H.
Published: March 2003

Background: The true incidence of faecal incontinence in Saudi Arabia is unknown and probably relatively few patients seek treatment at the present time. In order to assess the types of treatment available and their outcomes, a retrospective audit of patients presenting at King Faisal Specialist Hospital during an 8‐year period has been undertaken.

Methods: Charts were examined in order to identify the cause of the incontinence, the severity and duration of the problem, the clinically determined resting and squeeze pressures, the anatomical muscular defect, the surgery performed, the surgical morbidity, the results of surgery and the length of follow up.

Results: Thirty patients (average age 36.9 years) were surgically treated for anal incontinence. Thirteen were females. Previous fistula surgery was the commonest cause for incontinence. Nine patients had generalized sphincter weakness. The average duration of symptoms was 71.6 months. Eighteen patients had overlapping sphincter repairs, of whom eight had wounds that became infected and 13 (72%) patients were ‘better’. Two of five patients were ‘better’ following dynamic graciloplasty. Stomata were constructed in 12 patients and six were closed. Surgery reduced mean incontinence scores (Wexner) from 10.4 to 5.0.

Conclusion: Overlapping sphincter repair can be safely performed for localized sphincter defects in Saudi Arabia with a high probability of improving continence. In contrast, dynamic graciloplasty is not a suitable operation for patients in this region, where cultural and social habits preclude satisfactory function of the stimulated neosphincter.
Costs of accessing surgical specialists by rural and remote residents
Authors: Rankin Sarah L. , Hughes‐Anderson Wayne , House Anthony K. , Heath Dugal I. , Aitken Robert J. , House Jill
Published: March 2003

Introduction: Access to surgical specialist services by rural and remote residents in Australia is limited. Little information is available on the cost to rural residents of accessing specialist treatment. The aim of the present study was to define the personal costs incurred by country patients in Western Australia when accessing specialist surgical services in a rural or metropolitan setting.

Methods: A random sample of 50 patients who attended a visiting rural surgical service between December 1998 and February 1999 inclusive was recruited. In a structured telephone interview patients were asked 40 non‐clinical questions relating to their recent specialist consultation. The cost of accessing these services was determined from time lost from work, distance and travel expenses. The same formula was then applied to estimate the cost of attending a base metropolitan hospital. The need for an accompanying person was determined from a subset of 16 patients who had transferred to metropolitan specialist consultation in the previous 12 months. Average waiting list times for consultations and common surgical procedures for the visiting service were compared with those for a metropolitan‐based service.

Results: An estimated saving of AU$1077 was made per specialist consultation when accessing a local rather than a metropolitan service. Savings were observed in travel time, distance travelled, lost income, provision of an escort and waiting time.

Conclusion: The present study shows that the personal costs and difficulties incurred by rural and remote residents when accessing specialist treatment can be reduced if a visiting specialist service is available.
The journey through an undergraduate occupational therapy course: Does it change students’ attitudes, perceptions and career plans?
Authors: McKenna Kryss , Scholtes Adri‐Anne , Fleming Jenny , Gilbert Jillian
Published: March 2003

Students’ attitudes towards people with a disability, their perceptions of the characteristics of a successful occupational therapist, and their future career plans were surveyed on entry to and exit from the Bachelor of Occupational Therapy course at the University of Queensland in Brisbane, Australia. Factors impacting on students’ career plans were also examined. Questionnaires were administered to 84 students on the first day of the course in 1994 and to 59 students on the last day of the course in 1997. Descriptive statistics were used to summarise and compare the data. While generally positive on entry to the course, students’ attitudes were even more positive on completion. Entry and exit perceptions of the characteristics considered important to being a successful occupational therapist were closely aligned with the values and ideals of the profession. At both survey points, students indicated a reluctance to pursue work in non‐metropolitan areas and in psychosocial, research and academic fields. Clinical placements and particular clinicians were identified as having the greatest impact on students’ career plans. These findings provide support for the notions that student self‐selection into occupational therapy may assist in bringing aware students to the course and that clinical experiences during the course serve as potent influences on future career plans. Tailored use of the processes of socialisation within occupational therapy courses may assist in attracting therapists to particular geographical and clinical areas.