bluuebunny/crossref_metadata_2025 huggingface dataset:
Determinants of further survival in centenarians
Authors: Shimizu Kenichiro , Hirose Nobuyoshi , Arai Yasumichi , Gondo Yasuyuki , Wakida Yasushi
Published: March 2003

Background:

The purpose of the present paper was to study the impact of selected clinical and demographic variables on further survival in subjects over 100 years old.

Methods:

In 1992 the authors assessed activities of daily living, cognitive function, and nutritional status in 38 centenarians (seven men and 12 women living in the Tokyo metropolitan area as well as three men and 16 women living in Aichi prefecture; mean age: 100.9 ± 1.6 years). Survival data were recorded until 1996. Cox proportional hazard regression analysis was used to identify variables influencing likelihood of further survival in centenarians.

Results:

In 1996 21 subjects had died and 17 were still living. Of the 38 subjects, nine had illnesses at initial evaluation such as hypertension or other cardiovascular disease. Centenarians with a high cognitive level tended to have a high (independent) activities of daily living (ADL) score and/or a good nutritional condition. Cognitive levels were higher in men than in women. Cox proportional hazard regression analysis indicated that a high ADL score, a high level of cognitive function, or nutritional status tended to be advantageous for further survival in centenarians. Of the three parameters, after adjustment for clinical variables, only a high serum albumin concentration was a significant factor favoring survival in centenarians (hazard ratio: 0.44 for a 1‐SD increment in serum albumin concentration; 95% confidence interval: 0.23–0.85). The presence of illness, the age in 1992, or gender was not related to mortality risk in centenarians.

Conclusion:

Undernourishment jeopardizes survival even in late life.
Assessment of brain atrophy in elderly subjects with diabetes mellitus by computed tomography
Authors: Ushida Chika , Umegaki Hiroyuki , Hattori Ayako , Mogi Nanaka , Aoki Shigetaka , Iguchi Akihisa
Published: March 2003

Background:

Several studies have shown cognitive functional impairment in elderly subjects with diabetic mellitus (DM). However, there have been few studies on the image of the brain in DM subjects.

Methods:

To assess brain atrophy in elderly DM subjects their brain images were evaluated using computed tomography (CT). Thirty‐eight DM subjects and 17 non‐DM subjects (60–80 years of age) were included. The mean age for DM subjects and control subjects were 71.2 ± 5.5 years and 71.6 ± 5.7 years, respectively. For assessment of brain CT images, five indices (Evan’s ratio, inverse cella media index, width of the third ventricle, the width of the temporal horns on both sides, and the maximal width of the Sylvian fissure at insula on both sides) were used.

Results:

Evan’s ratio and the temporal horns on both sides in DM subjects were significantly larger than those in control subjects. Further analysis within DM subjects, who were divided into three groups according to their therapy (insulin, medication, and diet therapy), showed that insulin‐treated subjects had the widest temporal horns.

Conclusions:

The current study suggested that elderly DM subjects had brain atrophy compared with age‐matched non‐DM subjects. The insulin‐treated group had the highest amount of brain atrophy of the DM subjects.
Sleep problems as a risk factor for fall in community‐dwelling older persons
Authors: Kawamoto Ryuichi , Doi Takaaki
Published: March 2003

Background: Falls cause serious problems for the elderly. Sleep problems impair the control of postural balance and cause falls, and lack of sleep induces sleepiness, which in turn causes inattentiveness. The present study aims to clarify the relation between sleep disorders and falls among the community‐dwelling elderly and to determine whether or not sleep disorder is an independent risk factor for falls.

Methods: Of 2274 community‐dwelling persons aged 65 and older who participated in the first study in July 1998, 1771 (77.9%) who responded to the questions concerning sleep disorders were the subjects in the present study.

Results: There were 1521 persons (85.9%) who had not experienced any fall during
the past year, 194 (11.0%) who had one or two falls, 27 (1.5%) had
three to four falls and 29 (1.6%) had more than five falls. The relation
between the history of falls and the sleep problems indicates that the odds ratio
for the history of falls was significantly higher if the nocturnal sleep disorder
was more intense (P < 0.001) and the sleep hours during the day were longer
(P < 0.01). In order to determine the independent risk factors for falls,
the general linear model analysis was conducted using the significantly different
background. The nocturnal sleep problems (F = 4.05; P = 0.018), the
daytime sleep (F = 4.17; P = 0.016) and nocturnal sleep problems and
interaction between (*) daytime sleep (F = 2.54; P = 0.038) were significant
independent explanatory variables as the age (F = 14.4; P < 0.001),
difficulty in walking (F = 4.30; P = 0.038), history of stroke (F
= 64.1; P < 0.001) and arthralgia (F = 5.31; P = 0.021).

Conclusion: The data emphasize that the sleep disorder is closely related to falls.
Self‐reported functional ability predicts three‐year mobility and mortality in community‐dwelling older persons
Authors: Kawamoto Ryuichi , Doi Takaaki
Published: March 2003

Background:  A comprehensive evaluation of the functions of community‐dwelling older persons was conducted in 1988. Three years after the 1988 study commenced, the relationship between these background factors and changes during the subsequent 3 years were examined.

Methods:  The study was a comprehensive evaluation of the daily functions of community‐dwelling elderly people, and encompassed age, gender, mode of living, marital status, financial status, family relationships, basic activities of daily living, visual and hearing impairment, a history of disease, self‐related feeling, social role, social support, habits and physical exercise and the relationship between independence and survival for 3 years after the basic study. The subjects were 2274 community‐dwelling elderly people who participated in the first survey in July 1998 and who were aged 65 years and over at that time. Unassisted questionnaire sheets were used for the first survey and changes since the first survey.

Results:  Thirty men and 60 women died during the 3 year period. Data were also gathered about the daily activity levels of 1709 persons (75.2%) with 1499 (87.7%) ranking J for independence and 210 persons (12.3%) ranking A to C for dependence. Age, gender, basic activities of daily living (BADL), history of falls, self‐related happiness, participation in community events and physical‐exercise habits were found to be explanatory variables for independence after three years; as were age, gender, and BADL for survival.

Conclusion:   The explanatory variables relating to independence and prognosis of life of the elderly obtained in this study will be important in future considerations of the issue of care‐taking and measures to enable it.
Megakaryoblastic transformation of chronic myelomonocytic leukemia presenting with severe bone pain
Authors: Sahara Makoto , Inoue Satoshi , Sunaga Shinji , Kitagawa Hiroshi , Ako Junya , Hoshino Shinjiro , Toba Kenji , Ouchi Yasuyoshi
Published: March 2003

A 77‐year‐old woman, who had suffered from osteoporosis with compression fractures of vertebrae, was admitted to our hospital because of increasing bone pain. She had anemia and monocytosis, and was diagnosed as chronic myelomonocytic leukemia (CMML). Although chemotherapy was initiated, she died from pneumonia. Autopsy revealed multiple tumors composed of megakaryoblastic cells in her bone marrow and extramedullary organs and, therefore, the pathological diagnosis was made as megakaryoblastic transformation of CMML. Severe bone pain was considered to be a symptom of megakaryoblastic transformation of CMML.
Ethnic difference in contribution of alleles of the interleukin‐1 receptor antagonist gene to predisposition to osteoporosis
Authors: Sugiyama Hiroaki , Ogawa Sumito , Emi Mitsuru , Shiraki Masataka , Hosoi Takayuki , Orimo Hajime , Ouchi Yasuyoshi , Inoue Satoshi
Published: March 2003

Background:  The interleukin‐1 receptor antagonist (IL‐1RA) plays an important role in bone metabolism, and molecular defects are implicated in the pathogenesis of osteoporosis. Studies performed in Caucasian populations have demonstrated an association between allelic variants of the IL‐1RA gene and bone mineral density (BMD).

Methods: In the study reported here, we examined whether variation of the IL‐1RA gene would correlate with osteoporosis among 287 Japanese postmenopausal women.

Results:  The allele frequencies and distribution in this ethnic group were remarkably different from those reported for Caucasians and phenotypes such as Z scores of lumbar spine (L2–4) and total body BMD, as well as various biochemical markers related to bone metabolism, were not significantly different among groups of IL‐1RA genotypes in the present study.

Conclusion:  Our results emphasize the importance of considering ethnic background in assessing the etiological significance of candidate genes in osteoporosis.
Yellow nail syndrome in an elderly man
Authors: Amiya Eisuke , Ako Junya , Kozaki Koichi , Iijima Katsuya , Nagase Takahide , Ouchi Yasuyoshi
Published: March 2003

A case of yellow nail syndrome is described. Yellow nail syndrome is an uncommon disorder, which is characterized by the triad of slow‐growing yellow nails, peripheral edema, and pleural effusions. An 80‐year‐old man was admitted to University of Tokyo Hospital for the evaluation of pretibial edema lasting over 35 years. Marked bilateral pretibial edema, discoloration of the nails, and onycholysis were noted on physical examination. Chest X‐ray showed pleural effusions. The biopsy of the skin revealed ectatic lymph vessels with peripheral interstitial edema. Thorough examination should be emphasized in treating patients with unexplained peripheral edema or pleural effusions.
Arterial pulse wave velocity in elderly patients with dementia
Authors: Komai Norio , Ohishi Mitsuru , Kaibe Masaharu , Jinno Toyohisa , Katsuya Tomohiro , Higaki Jitsuo , Rakugi Hiromi , Inoue Takashi , Ogihara Toshio
Published: March 2003

Background:  Cardiovascular events influence the quality of life and mortality of elderly patients. Arterial stiffness measured by aortic pulse wave velocity is a useful means of predicting the presence of cardiovascular diseases, even in subjects over 70 years old. This procedure is non‐invasive, but the usefulness and easiness of aortic pulse wave velocity for patients with dementia are still unclear. Therefore, to determine how useful and easy it is to measure aortic pulse wave velocity, we evaluated arterial stiffness in patients with or without dementia who required care and support for their daily life.

Methods:  Fifty‐nine subjects over 70‐years‐old who suffered from dementia were enrolled in this study. After we excluded arteriosclerosis obliterans (ankle‐brachial pressure index < 0.80; n = 10) by arterial pulse wave velocity, we classified these subjects into two groups: subjects with Alzheimer's disease (n = 25) and subjects with vascular dementia (n = 24) who were diagnosed by magnetic resource imaging and mini‐mental state examination.

Results:  The authors of the present paper could easily and precisely evaluate arterial stiffness of all patients. The mean pulse wave velocity of right and left brachial‐tibial arteries in subjects with Alzheimer's disease (1740 ± 385 cm/s) was significantly lower than those subjects with vascular dementia (2436 ± 586; P < 0.001).

Conclusion:  The data included in the present study indicate that subjects with Alzheimer's disease had decreased arterial stiffness and would show a lower risk of cardiovascular diseases compared to subjects with other diseases including vascular dementia.
Asymptomatic cerebral infarction on brain MR images and cognitive function in elderly diabetic patients
Authors: Araki Atsushi , Ito Hideki
Published: March 2003

Background:  The assessment of cognitive function is of great importance in the management of elderly patients with diabetes mellitus. The purpose of the present study was to examine the effects of glucose control and asymptomatic cerebral infarction on impaired cognitive function in elderly patients with diabetes mellitus.

Methods:  Two hundred and thirteen elderly diabetic patients (59 men, 154 women) with a mean age of 75 years; and 40 non‐diabetic subjects participated in this study and underwent both brain magnetic resonance imaging (MRI) and several domains of cognitive function tests. Based on the brain MRI findings and neurological deficits, the subjects were divided into four groups: (i) the symptomatic cerebral infarction (CI) group; (ii) the asymptomatic CI group; (iii) the diabetic control group without any CI; and (iv) the non‐diabetic control group. Cognitive function was assessed using the mini‐mental state examination (MMSE), and the subtests of Wechsler Adult Intelligence Scale – Revised (WAIS‐R) (the digit symbol test, the backward digit span test, the similarities test, and the picture arrangement test). Attention/complex psychomotor skill and visual memory were assessed with the digit symbol substitution test, the Stroop test, and the Benton visual retention test.

Results:  Attention/complex psychomotor skill and visual memory were more impaired in the diabetic control group without any CI than in the non‐diabetic control group. The asymptomatic and symptomatic CI groups were significantly inferior to the non‐diabetic and diabetic controls in the digit symbol substitution test and Stroop test. The degree of cognitive impairment significantly correlated to the presence and number of small‐sized cerebral infarction, but to a less degree, large‐sized infarction. Multivariate analysis revealed that age, HbA1c, and cerebral infarction on MR images were independently associated with the impairment of complex psychomotor skill in patients with diabetes mellitus.

Conclusions:  The presence of asymptomatic cerebral infarction on brain MR images as well as hyperglycemia could explain the impairment of attention/complex psychomotor skill and visual memory in elderly patients with diabetes mellitus.
Does type of surgeon matter in rectal cancer surgery? Evidence, guideline consensus and surgeons’ views
Authors: Solomon Michael J. , Thomas Robert J. , Gattellari Melina , Ward Jeanette E.
Published: March 2003

One of the most obvious but controversial trends in contemporary surgical practice is that of subspecialization. There is a lack of definitive evidence that subspecialization improves cancer outcomes largely because previous research is compromised by confounding variables of referral practice, lack of standardized definitions of surgical skills and selection bias. Randomized controlled trials of generalized versus subspecialist surgical care are unlikely ever to be performed. The present study of surgeons’ views about the role of subspecialization in the care of colorectal cancer patients demonstrates partisan reactions among surgeons themselves (89% response rate). Results of national audits will contribute to wider debate about surgical subspecialization in colorectal cancer.
Frequency and predictors of axillary lymph node metastases in invasive breast cancer
Authors: Chua Boon , Ung Owen , Taylor Richard , Boyages John
Published: March 2003

Background:  The objectives of the present study were to evaluate the incidence and predictors of axillary lymph node metastases (ALNM) in patients with breast cancer, and to identify if axillary surgery could be safely omitted in selected patients.

Methods:  Between January 1996 and May 2000, 492 patients underwent 501 axillary lymph node dissections (ALND). The incidence of ALNM was correlated with clinical and pathological characteristics by univariate and multivariate analyses.

Results:  Axillary lymph node metastases were found in 41% (207/501) of cases. Univariate analysis showed that palpability of primary and axillary lymph node (ALN), pathological tumour size, grade, lymphovascular invasion (LVI) and multifocality or multicentricity were significant predictors of ALNM. By multivariate analysis, palpability of ALN, pathological tumour size, LVI and multifocality or multicentricity remained as independent predictors. Among the 431 cases without palpable ALN, no ALNM were found if the tumour was ≤ 5 mm, non‐multifocal or multicentric, and without LVI, or the tumour was a tubular or mucinous car­cinoma ≤ 15 mm (n = 21). The frequency of ALNM in the absence of the other risk factors was 11% (7/64) if the tumour size was > 5–10 mm, and 17% (19/113) if the tumour was > 10–20 mm. However, the incidence of ALNM was 72% for the 32 clinically node‐negative cases with multifocal or multicentric tumour ≥ 10 mm and LVI. Those patients with palpable ALN (n = 66) had a greater than 50% risk of ALNM.

Conclusions: Routine ALND could be omitted in clinically node‐negative patients with either a ≤ 5‐mm, LVI‐negative tumour, or a ≤ 15‐mm tubular or mucinous carcinoma. Axillary lymph node dissection is still useful for determining pathological nodal status in all other cases, and in most cases with palpable ALN, as a therapeutic manoeuvre.
Surface landmarks of the facial nerve trunk: a prospective measurement study
Authors: Wong David S. Y.
Published: March 2003

Background:   Facial nerve identification and preservation is the key to safe parotidectomy in most clinical situations. Traditional approaches to the main trunk have depended solely on internal landmarks but localization may further be enhanced if data are avail­able on its position with reference to neighbouring external features.

Methods:   Prospective measurements were taken on a series of parotidectomy patients intraoperatively. Using that spot on the main trunk 10 mm proximal to its bifurcation as the reference point, the depth from the skin and its cranio‐caudal distance from the summit of the tragus were measured.

Results:   Thirty‐three patients were included, whose body mass index showed that they had average body build. The reference point nerve was 23.6 mm (SD = 5.1 mm) from the skin surface, and 18.8 mm (SD = 6.0 mm) caudal to the tragus.

Conclusion:   Measurements relating to the siting of the facial nerve trunk were obtained live at operation. This information should be helpful in the initial mobilization of the parotid gland from its posterior relations and in facilitating the classical internal landmarks in the 3‐D localization of the main trunk, thereby allowing quicker and safer parotidectomy.
Investigating chronic, bright red, rectal bleeding
Authors: Mehanna Daniel , Platell Cameron
Published: March 2003

Background: Chronic, bright red, rectal bleeding is a common symptom in our community and the aetiology is frequently benign anal disease. The aim of the present study was to determine the efficacy of performing a flexible sigmoidoscopy on patients with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who, on rigid sigmoidoscopy, are found to have an identifiable anal cause (e.g. haemorrhoids, fissure) for their bleeding.

Methods: A prospective study was conducted on patients presenting with chronic, bright red, rectal bleeding. Patients were considered at low risk for colorectal neoplasia if they fulfilled the following criteria: (i) less than 55 years of age; (ii) no past or family history of colorectal neoplasia or inflammatory bowel disease; (iii) no symptoms of altered bowel habit or abdominal pain; and (iv) a source of bleeding identified (e.g. haemorrhoids, fissure) on rigid sigmoidoscopy. All patients underwent a flexible sigmoidoscopy.

Results: Eighty‐two patients were entered into the trial, mean age 39 ± 9 years (range: 22–55 years), and the ratio of men:women was 1.8:1. The anal cause of bleeding was haemorrhoids in 96%, and anal fissure in 4%. At flexible sigmoidoscopy, five patients were found to have adenomatous polyps. Rigid sigmoidoscopy missed diminutive neoplastic lesions in 6% of patients.

Conclusions: Flexible sigmoidoscopy results in a low yield of colorectal neoplasia in patients presenting with chronic, bright red, rectal bleeding who are at low risk for colorectal neoplasia and who have an identifiable anal cause for their bleeding.
Faecal incontinence after lateral internal sphincterotomy is often associated with coexisting occult sphincter defects: A study using endoanal ultrasonography
Authors: Tjandra Joe J. , Han Wen R. , Ooi Boon S. , Nagesh Ananth , Thorne Marcus
Published: March 2003

Background: Troublesome faecal incontinence following a lateral internal sphincterotomy (LIS) is often attributed to faulty surgical techniques: division of excessive amount of internal sphincter or inadvertent injury to the external sphincter. The aim of the present paper was to assess the anatomic and physiological factors that may contribute to faecal incontinence following a technically satisfactory lateral internal sphincterotomy by a group of colorectal specialists.

Methods: Fourteen patients (nine women, five men; median age: 38 years; range: 23–52 years) who developed troublesome postoperative faecal incontinence were evaluated by clinical assessment, endoanal ultrasonography and anorectal physiological studies (manometry, pudendal nerve terminal motor latency) by two independent observers. The Cleveland Clinic continence score (0–20; 0, perfect continence; 20, complete incontinence) was used to quantify the severity of faecal incontinence. Fourteen continent subjects after a LIS (nine female patients, five male patients; median age: 36 years; range: 20–44 years) were also evaluated as ‘continent’ controls (continence score ≤ 4).

Results: In the incontinent group, the median postoperative Cleveland Clinic continence score was 9 (range: 6–13) compared with a preoperative score of 1 (range: 0–3). On assessment by endoanal ultrasonography the site of the internal sphincterotomy was clearly identified. There were additional coexisting defects, on endoanal ultrasonography, of the external anal sphincter in seven female patients, of the internal sphincter in two female and two male patients; and a defect of both the external and internal sphincters in a male patient who had had a prior fistulotomy. The pudendal nerve terminal motor latency (PNTML) was prolonged in two female patients on the side contralateral to the lateral internal sphincterotomy. In two of five male patients there was no evidence of any occult sphincter injuries. In the continent controls a defect of the distal portion of the external sphincter was noted in one female patient. None of the patients had a prolonged PNTML. The maximum voluntary contraction was significantly lower in the female subjects than in the female continent controls (92 mmHg vs 140 mmHg; P < 0.05), while the resting anal canal pressures and length of the high pressure zone were similar between the study subjects and the continent controls.

Conclusion: Troublesome faecal incontinence after a satisfactorily performed lateral internal sphincterotomy is often associated with coexisting occult sphincter defects.
Resecting large numbers of hepatic colorectal metastases
Authors: Moroz Paul , Salama Paul R. , Gray Bruce N.
Published: March 2003

Background: Despite the widespread use of surgical resection as a treatment for hepatic colorectal metastases, the value of resecting more than three metastases remains controversial. It was the objective of this study to determine if resection of larger numbers of metastases affects patient survival.

Method: The survival of 123 consecutive patients who underwent curative hepatic resection for colorectal metastases between 1989 and 1999 by a single surgeon was analysed retrospectively. Kaplan–Meier survival statistics and Cox regression were used to determine the factors that affected survival, and logistic regression was used to determine the factors that affected the risk of recurrence of hepatic disease.

Results: The median survival rate for the whole group of patients was 38
months, with 1, 3 and 5 year survival rates of 88%, 53% and 31%
respectively. The survival rate of patients undergoing resection of four to seven
metastases (n = 22; 5 year survival = 39%) was not significantly different
to that of patients undergoing resection of one to three metastases (n = 91;
5 year survival = 30%), P = 0.9. Age, sex, primary cancer site, hepatic
disease distribution, resection margins and adjuvant hepatic arterial chemotherapy
(HAC) did not affect survival. Local invasion of the hepatic metastases (relative
risk (RR) = 2.9; P = 0.001) and hepatic disease recurrence (RR = 2.1; P
= 0.007) were the only factors that independently affected survival. Local invasion
of the hepatic metastasis was the only factor associated with an increased risk of
hepatic recurrence (RR = 2.8; P = 0.03). Adjuvant HAC did not affect the risk
of hepatic recurrence (RR = 1.5, P = 0.4).

Conclusion: Although there are no randomized trials that quantify any survival benefit from resection of liver metastases, the comparison of our results with well documented historical evidence indicates that surgical resection of up to seven colorectal liver metastases can result in a significant survival benefit.
Combined endoscopic laser and radiotherapy palliation of advanced rectal cancer
Authors: Chapuis P. H. , Yuile P. , Dent O. F. , Sinclair G. , Low L. , Aggarwal G.
Published: March 2003

Background: In the palliative treatment of patients with advanced, inoperable rectal cancer, combined endoscopic laser and radiotherapy have been claimed to be more effective than laser therapy alone. The number of laser treatments, laser energy used, relapse rate, treatment of relapse, morbidity and survival in consecutive patients who were treated either by laser therapy alone or laser plus radiotherapy was compared.

Methods: Prospective data were analysed with regard to number of treatments, laser energy used, relapse rate, morbidity and survival for 56 consecutive patients.

Results: The crude relapse rate was significantly higher in the laser only group than in the laser plus radiotherapy group (58 and 15%, respectively; P = 0.002). There was no difference between the groups in the median total number of laser treatments or the mean total laser energy used. In patients experiencing a relapse, there was no difference in the median number of relapses, the number of laser treatments post‐relapse or the total energy used post‐relapse. Survival did not differ between the groups and there were no treatment‐related deaths.

Conclusions: These findings demonstrate a clear reduction in relapse after using combined laser and radiotherapy to palliate patients with advanced rectal cancer with no appreciable additional morbidity and have encouraged continuing use of this treatment.
Tumour implantation following laparoscopy using different insufflation gases
Authors: Gupta Anurag , Watson David I. , Ellis Tanya , Jamieson Glyn G.
Published: March 2003

Background: Because of the possibility of intraperitoneal seeding and port‐site
recurrences following laparoscopic surgery, the role of laparoscopy in cancer surgery
remains controversial. Previous experimental studies have suggested that chemical,
metabolic and immunological changes following carbon dioxide (CO2) insufflation
may be responsible for this phenomenon. Earlier experimental studies done by the
University of Adelaide Department of Surgery have also shown that helium insufflation
is associated with none of the adverse changes brought about by CO2 insufflation. Helium insufflation is also associated with lower rates of intra‐abdominal tumour spread. The aim of this study was to determine whether these identified benefits apply to inert gases in general.

Methods: Twenty‐four Dark Agouti rats were randomized to undergo laparoscopy
with 40 min insufflation using one of the following four gases (six rats in each
group); CO2, helium, argon and nitrogen. A tumour cell suspension was injected into the abdominal cavity at the beginning of laparoscopy. The rats were killed 7 days after surgery, and the peritoneal cavity and port sites were examined for the presence of tumour.

Results: Rats undergoing helium insufflation, had the least number of port‐site
recurrences and the least amount of intraperitoneal tumour spread. Argon and nitrogen
pneumoperitoneum were associated with a large number of port‐site recurrences and
widespread tumour seeding. The effect of CO2 insufflation was intermediate.

Conclusion: The choice of insufflation gas influences the incidence of port‐site metastases and the degree of intraperitoneal tumour spread following laparoscopic cancer surgery. The reduced port‐site recurrences and intraperitoneal spread that followed helium pneumoperitoneum is likely to be a unique property of this gas rather than a property of inert gases in general.
Total thyroidectomy is now the preferred option for the surgical management of Graves’ disease
Authors: Barakate Michael S. , Agarwal Gaurav , Reeve Tom S. , Barraclough Bruce , Robinson Bruce , Delbridge Leigh W.
Published: March 2003

Purpose:  Subtotal thyroidectomy has been advocated as the standard treatment for Graves’ disease because of the possibility of avoiding thyroxine therapy as well as the assumed lower risk of complications compared to total thyroidectomy. However, the long‐term results of subtotal thyroidectomy are not as good as they were previously believed to be, as evidenced by the increasing incidence of hypothyroidism. If the risk of complications from total thyroidectomy is no higher, then that procedure offers significant advantages in the surgical management of Graves’ disease. The aim of this study therefore was to compare the complication rate of the two procedures in patients with Graves’ disease.

Methods:  This was a retrospective case control study in a tertiary referral hospital. Information was obtained from an endocrine surgery database over the study period from January 1957 to December 2000. During that period 1246 patients with Graves’ disease underwent subtotal thyroidectomy and 119 patients underwent total thyroidectomy.

Results:  Prior to 1987 total thyroidectomy was rarely if ever performed whereas in the last 12 months total thyroidectomy comprised 95% of all procedures. There was no significant difference in the rate of permanent complications between the two procedures although temporary hypocalcaemia was significantly more common following total thyroidectomy. Permanent hypoparathyroidism resulted in one patient each who underwent total thyroidectomy (0.8%) and subtotal thyroidectomy (0.1%). Permanent recurrent laryngeal nerve palsy occurred in one patient who underwent total thyroidectomy (0.8%) and 5 patients undergoing subtotal thyroidectomy (0.4%).

Conclusion:  Given that subtotal thyroidectomy provides an unpredictable outcome and that the risk of permanent complications is no greater than with total thyroidectomy, there appears little logical reason to continue to recommend subtotal thyroidectomy for the surgical management of Graves’ disease. We believe that Graves’ disease should join the increasing list of thyroid conditions for which total thyroidectomy is the preferred option.
Issues of consent and privacy affecting the functioning of ASERNIP−S
Authors: Boult Maggi , Babidge Wendy , Roder David , Maddern Guy
Published: March 2003

The Australian Safety and Efficacy Register for New Interventional Procedures − Surgical (ASERNIP−S) undertakes horizon scanning, systematic reviews and audits. By disseminating information derived from these processes, ASERNIP−S aims to improve the quality of health care. In the present article, we discuss some of the legal and ethical issues surrounding the collection of identified data for the purposes of audit. The individual's right to privacy is considered as well as the benefits of improving the quality of surgical health care.
Persistent twitching of the Latissimus Dorsi muscle after a posterolateral thoracotomy
Authors: Hao Long , Clarke C. Peter
Published: March 2003

We report a case of persistent twitching of the latissimus dorsi muscle following a posterolateral thoracotomy, which continued despite several attempts at control including denervation, and was ultimately cured by total resection of the muscle.
Effect of thyroid hormones on stress ulcer formation
Authors: Koyuncu Ayhan , Aydintuǧ Semih , Koçak Saval , Aydin Cengiz , Demirer Seher , Topçu Ömer , Kuterdem Ercüment
Published: March 2003

Background:  Stress ulcers are gastric mucosal lesions that may cause life‐threatening upper gastrointestinal bleeding. Although it is known that hyperthyroid status prevents stress ulcer formation, the effect of thyroid hormones given just as the stress is beginning has not been studied. The aim of this study was to assess the effect of thyroid hormone supplementation on gastric stress ulcers at the beginning of the restraint stress.

Methods:  Thyroid hormones were administered to rats 2 days before or at the beginning of the restraint stress. The linear length of the gastric mucosal lesions, mucosal pH and thyroid hormone levels were measured and histopathological examinations were carried out.

Results:  It was found that both triiodothyronin and thyroxin reduce the length and depth of the stress ulcers (P < 0.001).

Conclusion:  Although the mechanisms by which the thyroid hormones act on stress ulcers are uncertain, current experimental studies suggest that thyroid hormones reduce the formation of stress ulcers in rats when given before or at the beginning of the stress.
The surgeon for the future and implications for training
Authors: Davidson Patricia M.
Published: March 2003

Clinical and technical skill may not be sufficient to fulfil society's expectations of surgeons. Other skills, which have been well defined in the published literature, include those of the professional, communicator, collaborator, manager, scholar and health advocate. It is the purpose of this review to explore the current understanding of these different domains and make comment about ways to improve training that will ensure that the surgeon of the future has the opportunity to develop broader expertize.
Minimally invasive thyroidectomy
Authors: Takami Hiroshi , Ikeda Yoshifumi
Published: March 2003

Background: Conventional thyroidectomies by a direct approach through the neck require long incisions in the neck that can result in prominent scars, hypesthesia, and paresthesia. Minimally invasive procedures have recently been adopted for the surgical treatment of thyroid disease as a means of preventing such problems.

Methods: In the present paper, the anterior chest approach and axillary approach to endoscopic thyroidectomy are described.

Results: Twenty‐two patients were treated by the anterior chest approach to endoscopic thyroidectomy and 28 patients by the axillary approach. The only complication was one case of postoperative emphysema. The patients were satisfied with the cosmetic results of the procedures and with the minimal degree of postoperative hypesthesia, paresthesia and discomfort.

Conclusion: Endoscopic thyroidectomy may become the procedure of choice for the surgical treatment of carefully selected patients with thyroid disease.
Biliary tract injury in laparoscopic cholecystectomy: Results of a single unit
Authors: Miroshnik Michael , Saafan Ahmed , Koh Simon , Farlow John , Neophyton John , Lizzio Joe , Yee Frank , Ethell Tony , Bean Andrew , Fenton‐Lee Douglas
Published: March 2003

Background:  Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them.

Methods:  A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures.

Results:  There were 899 women (74%) and 317 men (26%), with an age range of 13−92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by chol­angio‐enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting.

Conclusions:  Single‐centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting.
Gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma in New Zealand: Demographics, pathology and survival
Authors: Koea Jonathan , Phillips Anthony , Lawes Carlene , Rodgers Michael , Windsor John , McCall John
Published: March 2003

Introduction:  The aim of present paper was to document the incidence of gall bladder cancer, cancer of the extrahepatic bile ducts and ampullary carcinoma in New Zealand.

Methods:  Data were collected from the New Zealand Cancer Registry from 1980 to 1997 and combined with national census statistics to give crude and age standardized incidence rates.

Results:  Over the 18‐year study period, 226 carcinomas of the ampulla of Vater, 608 gall bladder cancers, and 486 extrahepatic cholangiocarcinomas were registered. The age standardized incidence rates for gall bladder carcinoma in all New Zealanders were 0.41/100 000 in men and 0.74/100 000 in women. The age standardized incidence rates for gall bladder cancer in Maori were 1.49/100 000 in Maori men and 1.59/100 000 in Maori women. The corresponding age standardized incidence rates for extrahepatic bile duct cancers were 0.67/100 000 in men and 0.45/100 000 in women. There were insufficient cases to calculate an age standardized incidence in Maori or Pacific Islanders. For carcinoma of the ampulla, the age standardized rates were 0.34/100 000 in men and 0.25/100 000 in women. There were insufficient cases to calculate an age standardized incidence rate for Maori or Pacific Islanders. When histology was defined adenocarcinoma was the most common form of cancer occurring in 66% of gall bladder cancers, 91% of extrahepatic bile duct cancers and 70% of ampullary cancers. Most tumours were advanced at presentation with regional or distant metastases present in 72% of gall bladder cancers, 63% of extrahepatic bile duct cancers and 69% of ampullary tumours at diagnosis. Survival was poor with median survivals of 86 days, 151 days and 440 days recorded for gall bladder cancer, extrahepatic bile duct cancer and ampullary cancer, respectively.

Conclusions:  The demographic profile, pathology and survival of patients with gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma are similar in New Zealand to that of other Western countries. However New Zealand Maori have a relatively high incidence of gall bladder cancer, and the incidence is equal in both Maori men and women, while cancers of the extra­hepatic bile duct and ampulla of Vater are rare in Maori. In comparison, cancers of the gall bladder, extrahepatic bile ducts and ampulla are rare in Pacific Islanders.
Application of image‐guided biopsy for impalpable breast lesions in Chinese women
Authors: Tsang Flora H. F. , Lo Jovanni J. , Wong Joyce L. N. , Lee Francis C. W. , Chow Louis W. C.
Published: March 2003

Background:  Screening for breast cancer has resulted in an increasing number of mammographically detected lesions that require further management. The Advanced Breast Biopsy Instrumentation system is a recently added biopsy technique for the management of such lesions. The present paper will review the authors’ experience in the use of this procedure in Chinese patients whose breast volume was smaller than that of Caucasians.

Methods:  Ninety‐three patients were listed for the procedure and 78 (84%) underwent the procedure successfully. Ninety‐two lesions were biopsied. Advanced Breast Biopsy Instrumentation (ABBI) was performed for clustered microcalcifications or abnormal mass/density. Minimally Invasive Breast Biopsy (MIBB), a suction‐assisted core biopsy device, was employed for more scattered lesions. For small volume breasts, it may be required to bring the hand through the aperture to get the targeted lesions onto the digital image or, in the case of ABBI, to excise just beyond the deep margin of the lesion rather than the recommended depth.

Results:  The ABBI was performed for 43 (46.7%) lesions and MIBB for 49 (53.3%) lesions. Nine (9.8%) were diagnosed to have ductal carcinoma in situ, two (2.2%) had ductal carcinoma in situ with microinvasion and eight (8.7%) had invasive ductal carcinoma. All the malignant lesions required further management. In addition, 19 (20.7%) were found to have atypical hyperplasia. Patients’ satisfaction and cosmetic outcome are good.

Conclusion:  The ABBI and MIBB procedures can be applied satisfactorily for biopsy of mammographic lesions with good ­cosmetic outcome in Chinese patients.
MECHANISTICALLY BASED MODELS FOR THE PREDICTION OF FATIGUE DAMAGE IN A BETA TITANIUM ALLOY
Authors: Soboyejo  , Rabeeh  , Li  , Soboyejo  , Rokhlin
Published: March 2003

This paper presents the results of recent studies of the micromechanisms of room temperature fatigue damage elucidated in a metastable beta Ti–15V–3Cr–3Al–3Sn alloy. The fatigue damage mechanisms observed include: grain boundary sliding, crack initiation/propagation, and crack coalescence prior to the onset of catastrophic failure. Mechanistically based models are presented for the prediction of fatigue damage (plasticity and cracking). The models are based on fracture mechanics idealizations of the complex damage modes observed during fatigue experiments, in which acoustic emission signals were collected from deformed sections. Following appropriate noise filtration and careful analysis of the detected acoustic emission signals, the number of counts due to cracking is shown to represent a scalar measure of damage. A modified power law expression (modified Paris law) is also proposed to describe the relationship between the cracking count rate and the effective stress intensity factor. Estimates of the fatigue lives are obtained by integrating between appropriate limits, after the separation of variables in the modified Paris law expression. The measured and predicted fatigue lives were generally in good agreement.
ANALYSIS OF FAILURE MECHANISMS IN THE INTERCONNECT LINES OF MICROELECTRONIC CIRCUITS
Authors: Bower  , Craft
Published: March 2003

Interconnect lines are thin wires inside microelectronic circuits. The material in an interconnect line is subjected to severe mechanical and electrical loading, which causes voids to nucleate and propagate in the line: microelectronic circuits often fail because an interconnect is severed by a crack. Many of the mechanisms of failure are believed to be associated with diffusion of material through the line; driven by variations in elastic strain energy and stress in the solid, by the flow of electric current, and by variations in the free energy of the solid itself. With a view to modelling interconnect failures, we have developed a finite element method that may be used to compute the effects of diffusion and deformation in an electrically conducting, deformable solid. Our analysis accounts for large changes in the shape of the solid due to surface diffusion, grain boundary diffusion, and elastic or inelastic deformation within the grains. The methods of analysis is reviewed in this paper, and selected examples are used to illustrate the capabilities of the method. We compute the rate of growth of a void in an interconnect by coupled grain boundary diffusion and creep; we investigate void migration and evolution by electromigration‐induced surface diffusion; we study the influence of electromigration and stress on hillock formation in unpassivated interconnects, and compute the distribution of stress and plastic strain induced by electromigration in a passivated, polycrystalline interconnect line.
LIFE PREDICTION OF CROSS‐PLY METAL MATRIX COMPOSITES UNDERGOING THERMOMECHANICAL FATIGUE
Authors: Neu
Published: March 2003

A life prediction model that was originally developed for the axial loading of unidirectional metal matrix composites (MMCs) undergoing combined thermal and mechanical loading is extended to the axial loading of cross‐ply MMCs by adding an internally initiated matrix fatigue damage term. This new term accounts for the growth of cracks that initiate at the location where fibre–matrix separation occurs in the transversely‐oriented plies. A comparison of the model predictions to experimental data on SCS‐6/Timetal 21S shows that the model reasonably accounts for the dependence of applied stress, temperature and environment, as well as cyclic frequency. The dominant damage accumulation process for cross‐ply MMCs with weak fibre–matrix bonds is described by this internally initiated matrix fatigue damage process for most stress–temperature cycle combinations. However, the fibre‐dominated damage accumulation process operates under in‐phase TMF when both stress and temperature are high. Environment‐enhanced matrix fatigue is the dominant damage accumulation process under isothermal fatigue when stress is low and temperature is high.
ARTIFICIAL RETARDATION OF FATIGUE CRACK GROWTH BY THE INFILTRATION OF CRACKS BY FOREIGN MATERIALS
Authors: Shin  , Huang  , Li
Published: March 2003

The effects of inducing artificial crack closure into fatigue cracks in AISI 304 stainless steel by infiltrating foreign materials have been investigated. The foreign materials used include pure epoxy resin and resin mixed with 0.3 μm and 4 μm TiO2 , 4 μm Fe, as well as 18 μm AISI 316L stainless steel. In all the cases studied, different degrees of crack growth retardation have been achieved. When the particle size was small enough or when the prop‐opening load for infiltration was large enough, crack arrest occurred. Crack retardation and arrest were mainly caused by the infiltrated material rather than the propping load. A rigid‐wedge model was found to have limited value in predicting the possible outcome of an infiltration. On the other hand, the degree of crack closure immediately on resumption of a test after infiltration could tell whether the treatment was going to be successful or not.
INFLUENCE OF PARTICLE SIZE AND VOLUME FRACTION ON DAMAGE AND FRACTURE IN Al–Al3 Ti COMPOSITES AND MICROMECHANICAL MODELLING USING THE GTN MODEL
Authors: He  , Steglich  , Heerens  , Wang  , Brocks  , Dahms
Published: March 2003

Six different Al–Al3 Ti composites were prepared via the powder metallurgy route. The size and volume fraction of Al3 Ti particles was varied for a systematic investigation of fracture behaviour. The dominant failure mechanism in the composites is particle fracture and void growth starting from the broken particles. In comparison with the pure Al–matrix, an incorporation of Al3 Ti particles reduces the crack initiation toughness and reduces the slope of the crack growth resistance curve. The inter‐particle distance was found to be the main microstructural parameter controlling the slope of the crack growth resistance curve. The modified Gurson–Tvergaard–Needleman model (GTN model) was applied to one of the composites. The behaviour of tensile specimens could be successfully modelled, whereas the experimentally observed crack propagation in precracked single edge bend specimens [SE(B)] could not be simulated with the GTN model.