bluuebunny/crossref_metadata_2025 huggingface dataset:
PREVALENCE OF SIGNIFICANT CAROTID STENOSIS IN CHINESE PATIENTS WITH PERIPHERAL AND CORONARY ARTERY DISEASE
Authors: Cheng Stephen W. K. , Wu Lisa L. H. , Lau Hung , Ting Albert C. W. , Wong John
Published: March 2003

Background: The prevalence of extracranial carotid stenosis in the Chinese population is not known. This study aims to investigate and compare carotid disease in several groups of high‐risk patients.

Method: Routine screening carotid duplex scans were performed on high‐risk Chinese patients without cerebrovascular symptoms. These consisted of 249 patients with peripheral vascular disease, 207 patients with coronary artery disease, and 45 patients with abdominal aortic aneurysm. In addition, 220 patients with cerebrovascular symptoms and 58 patients with carotid bruits were scanned. A group of 108 healthy individuals was included as a control. The data of all 887 subjects were analysed.

Results: Carotid stenosis of 70% or greater was detected in 37.7% of patients in the cerebrovascular disease group and 24.5% of patients with peripheral arterial disease; it was higher than in patients with coronary artery disease (11.1%), asymptomatic carotid bruit (10.3%) and aortic aneurysms (8.9%; P < 0.001). No significant disease was found in the controls. Patients with cerebrovascular disease have more severe degrees of carotid stenosis and significantly more total occlusions. Smoking, age and male sex were the main risk factors for high‐grade (≥ 70%) carotid stenosis.

Conclusion: The prevalence of extracranial carotid stenosis in Chinese patients is not low. Patients with peripheral arterial disease have the highest risk of significant carotid stenosis: routine carotid duplex screening in these patients is recommended.
THE GENETIC BASIS OF BREAST CANCER AND ITS CLINICAL IMPLICATIONS
Authors: Bennett Ian C. , Gattas Michael , Teh Bin Tean
Published: March 2003

While it has long been recognized that a proportion of breast cancer cases are the result of an inherited familial predisposition, precise knowledge of the underlying genetic processes has been lacking. Recent advances in molecular biology, however, have shown that hereditary breast cancer may eventuate as a result of mutations on several specific gene loci including BRCA1, BRCA2, ATM gene, PTEN and p53. Several other less frequently occurring predisposition genes such as the androgen receptor gene (AR), the HNPCC genes and the oestrogen receptor gene may also be involved, but to a lesser extent. Overall, approximately 5–10% of all breast cancers are thought to involve one of these inherited predisposition genes, with BRCA1 and BRCA2 being responsible for as much as 90% of this group. Because of the complex nature of genetic testing, mutation analysis is not presently routinely available outside genetic counselling clinics. In this review the current knowledge and role of each predisposition gene is outlined and the management implications of genetic testing for members of breast cancer families for both affected and non‐affected members are discussed. The need to provide comprehensive counselling for women with an inherited predisposition to breast cancer has seen the evolution of the familial cancer clinic, involving a multidisciplinary specialist team approach. Familial cancer clinics will provide individuals with information about their risk of developing breast cancer and offer advice regarding further management strategies. It is important that surgeons, who have traditionally played a key role in breast cancer treatment, remain cognizant of these advances in genetic molecular biology, and in so doing continue to remain key participants in the conduct of breast cancer management.
SPLENIC VASCULAR LESIONS: UNUSUAL FEATURES AND A REVIEW OF THE LITERATURE
Authors: Lam K. Y. , Yip K. H. , Peh Wilfred C. G.
Published: March 2003

Hamartoma and peliosis are uncommon splenic lesions. Approximately 120 splenic hamartomas and 40 splenic peliosis have been reported in the English literature. In the present study, a unique case of multiple splenic hamartomas with peliosis was reported. The splenic lesions were incidental findings in a 36‐year‐old man with ruptured sarcomatoid renal cell carcinoma. They were diagnosed clinically as metastatic renal cell carcinoma. On pathological examination, peliosis was noted in the splenic hamartomas as well as in the splenic parenchyma. In addition, the clinicopathological features of five other splenic hamartomas (including one giant hamartoma) noted in our department were presented. A re‐evaluation of the features of the splenic hamartomas documented in the English literature was also done.
AUSTRALIAN DISASTER TRIAGE: A COLOUR MAZE IN THE TOWER OF BABEL
Authors: Nocera Antony , Garner Alan
Published: March 2003

Background: The objective of this study was to review the systems of disaster triage used by Australian State and Territory ambulance services and compare their triage taxonomy, methodology and documentation with the Australian Council on Health Care Standard’s (ACHCS) National Triage Scale, which is used in all Australian hospital emergency departments.

Methods: A postal survey of the State and Territory ambulance services during October 1996 was conducted. Details of the mass casualty incident (MCI) triage systems were then compared with the ACHCS National Triage Scale. Colours specified or used on a triage tag were checked for compliance with Standards Australia AS‐2700 1996 Colour Standards for General Purposes. Participants consisted of those State and Territory ambulance services which would be the initial emergency medical service responders in the event of an MCI in an Australian capital city, and the ACHCS. The main outcome measure was the homology between the respective triage taxonomies, methodologies and documentation systems.

Results: All eight State and Territory ambulance services used a numerical and colour coded system to indicate triage priority during an MCI. There were five different triage tag designs for triage documentation, six different triage taxonomies and five different triage methodologies with minimal homology between the different triage systems and the National Triage Scale used in hospitals. Only two ambulance triage systems specifically triaged emotional disturbance. Several triage tags and their patient attachments were made from perishable materials and are thus likely to fail under field conditions.

Conclusion: The multiplicity of triage systems used within Australia will result in avoidable confusion, thus hindering the medical response to an MCI, especially for incidents near State or Territory borders. There is little evidence to support the continued use of triage tags. Australia needs to develop a uniform system of patient triage as a national priority.
DONOR SITE MORBIDITY AFTER QUADRICEPS TENDON HARVEST FOR ROTATOR CUFF REPAIR
Authors: Comley ANDREW S. , Krishnan JEGAN
Published: March 2003

Background: The central quadriceps tendon provides a useful free tendon graft, although the morbidity of harvesting it is unknown in elderly patients.

Methods: The donor site morbidities of 10 patients after central quadriceps tendon (CQT) graft harvest were reviewed for rotator cuff repair. Patients were reviewed by questionnaire and clinical examination at a minimum of 5 months after surgery.

Results: A majority of patients reported significant donor site pain and reduction in knee reliability and function. Six of 10 patients had reduced quadriceps power attributable to the graft harvest.

Conclusion: The harvesting of the CQT graft is associated with significant morbidity, especially in an elderly population with limited functional reserve.
URETERIC REFLUX IN ADULTS AND CHILDREN TREATED EXCLUSIVELY BY ENDOSCOPIC TEFLON INJECTION: A 10‐YEAR EXPERIENCE
Authors: Hughes P. D.
Published: March 2003

Background: Since 1988 the author has used only endoscopic injection of Teflon (polytetrafluoroethylene) paste in the correction of ureteric reflux, in adults and children.

Methods: The present paper reports a series of 32 patients, 18 children and 14 adults, with 45 refluxing ureters so treated. Intra‐operative cystogram was carried out and a second Teflon paste injection was given under the same anaesthetic where persistent reflux was demonstrated after the initial Teflon injection, to reduce the number of anaesthetics given.

Results: In those patients who consented to a delayed cystogram after the first injection of Teflon, there was a cure rate of 83.3% in children and 70% in adults from that first injection.

Conclusion: Endoscopic retro‐ureteric injection of Teflon paste is done as a day case under general anaesthesia and causes the patient no pain postoperatively. It gives a high cure rate and is an option that should be offered to every patient where a decision has been made to correct ureteric reflux.
IN‐HOSPITAL MORTALITY AND ASSOCIATED COMPLICATIONS AFTER BOWEL SURGERY IN VICTORIAN PUBLIC HOSPITALS
Authors: Ansari M. Z. , Collopy B. T. , Hart W. G. , Carson N. J. , Chandraraj E. J.
Published: March 2003

Background: The purpose of the present paper was to determine the mortality rate and associated complications after large bowel resection and anastomosis in Victorian public hospitals.

Methods: A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was undertaken. The data were collected from all Victorian public hospitals performing hemicolectomy and anterior resection (resection of the rectum with anastomosis) from 1987/88 to 1995/96.

Results: A total of 11 036 patients underwent hemicolectomy or anterior resection in the time period studied, there being a 7% increase in the rate of operations performed over the 9 years. Two‐thirds of these operations were for carcinoma of the large bowel. The anastomotic leak rate of 4.5% fell slightly but the in‐hospital mortality rate of 6.5% did not change over the study period. The total morbidity recorded (mainly major complications) was 24.6%. The patients most at risk of death were the elderly with pre‐existing cardiac or respiratory disease undergoing an emergency operation.

Conclusions: Notwithstanding some inaccuracies of coding and reporting, the morbidity and mortality for surgery of the large intestine remains high, largely due to the comorbidities of the patients, although certain technical complications such as leakage of an anastomosis after anterior resection are still associated with a significantly increased risk of death. Consideration should be given to the routine use of high‐dependency nursing units for these high‐risk patients after major colorectal surgery, and support from physicians to reduce morbidity and mortality from associated medical conditions worsened by surgery.
CUT OR PASTE? THE USE OF GLYCERYL TRINITRATE PASTE IN THE TREATMENT OF ACUTE AND CHRONIC ANAL FISSURE
Authors: Ward David I. , Miller Brian J. , Schache David J. , Cohen Jon R. , Theile David E.
Published: March 2003

Background: Anal fissure unresponsive to conservative measures such as stool softeners frequently requires surgical intervention. The present study describes the use of glyceryl trinitrate (GTN) in the treatment of acute and chronic anal fissure.

Methods: Eighteen consecutive patients with anal fissure were treated with 0.5% GTN paste in soft white paraffin applied twice daily to the anus. These patients were followed at regular intervals to assess symptom control, rate of healing, adverse effects and recurrence rate.

Results: Two patients were lost to follow‐up. Twelve of the remaining 16 were cured. Of these, symptomatic relief was obtained for most within 2 days, and for all within 1 week. No patient required cessation of treatment due to adverse effects. Treatment failed in four of 16 patients. Two of these patients subsequently underwent successful surgical procedures, and two patients (while not completely cured) had sufficient symptomatic relief to decide against surgery.

Conclusions: The use of GTN paste in the treatment of acute and chronic anal fissure may be a safe and effective modality that can be considered as first‐line treatment for this condition.
SUPRATRIGONAL CYSTECTOMY AND ILEOCYSTOPLASTY IN MANAGEMENT OF INTERSTITIAL CYSTITIS
Authors: Costello Anthony J. , Crowe Helen , Agarwal Dinesh
Published: March 2003

Background: Interstitial cystitis is a chronic non‐infectious inflammatory disease of the bladder of unknown aetiology which is characterized by irritative voiding symptoms and suprapubic pain related to bladder filling. Surgical treatment is indicated in severely symptomatic patients when medical therapies have failed, usually after a period of several years. The authors’ experience with a modified technique of ileocystoplasty following supratrigonal cystectomy performed in five patients with interstitial cystitis is presented here.

Methods: A modified technique of bladder augmentation using ileum following supratrigonal bladder resection is described.

Results: All patients experienced relief from their symptoms. No patient had residual bladder pain and urinary frequency settled down in all. Bladder capacity was increased significantly. Three patients voided spontaneously postoperatively and two required clean intermittent self‐catheterization.

Conclusions: Supratrigonal cystectomy and ileocystoplasty can be a satisfactory option in refractory cases of interstitial cystitis. A simplified technique of ileal bladder construction that provides satisfactory bladder capacity is presented. Most urologists are familiar with ileal surgery, having used the ileum as a conduit after cystectomy for urinary diversion.
A PROTOCOL OF EARLY SPIRAL COMPUTED TOMOGRAPHY FOR THE DETECTION OF STONES IN PATIENTS WITH RENAL COLIC HAS REDUCED THE TIME TO DIAGNOSIS AND OVERALL MANAGEMENT COSTS
Authors: Patel Manish , Han Stephen S. Y. , Vaux Kenneth , Saalfeld John , Alexander J. Harvey
Published: March 2003

Background: The recent use of spiral computed tomography (CT) without contrast for the diagnosis of acute flank pain has been shown to be highly sensitive and specific for the detection of urolithiasis. This method has not, however, been evaluated for its contribution to savings in management costs. The present study aims to evaluate the cost savings gained by instituting a protocol of early spiral CT to investigate these patients.

Methods: The records of 200 patients presenting to the Accident and Emergency Department (A&E) with acute flank pain during two periods were retrospectively reviewed. The first period was before the spiral CT protocol was instituted and the second was after. Cost analyses between the two periods were performed.

Results: After the spiral CT protocol, 72 versus 31 patients had a definitive diagnosis prior to discharge from hospital. The time taken to diagnosis was also significantly shorter after the protocol implementation (6.3 vs 16.8 h). This resulted in a shorter time spent in the A&E, and hence bed cost savings. Radiological costs were reduced by 22%, but the major cost saving was made by a reduction in time spent in A&E (44%).

Conclusions: The implementation of a protocol of early spiral CT for patients with suspected renal colic has led to earlier definitive diagnosis and shorter hospital stays. This is associated with a significant reduction in costs associated with managing this condition.
RISK FACTORS FOR PERI‐OPERATIVE STROKE COMPLICATING CAROTID ENDARTERECTOMY: SELECTIVE ANALYSIS OF A PROSPECTIVE AUDIT OF 1000 CONSECUTIVE OPERATIONS
Authors: Frawley J. E. , Hicks R. G.
Published: March 2003

Background: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri‐operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high‐dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all peri‐operative strokes.

Methods: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri‐operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis > 70%, and contralateral carotid occlusion as potential causes of peri‐operative stroke were defined. Results were statistically analysed using odds ratio and Fisher’s exact test.

Results: None of the potential risk factors was statistically significant for peri‐operative stroke. Female gender was associated with a significant risk of peri‐operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke.

Conclusions: Prospective audit is a useful tool for identifying causes of peri‐operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy.
Progress of surgical training in papua new guinea to the end of the 20th century
Authors: Watters David A. K. , Theile David E.
Published: March 2003

Background: Health care in Papua New Guinea (PNG) throughout the 20th century has been characterized by a significant shortage of medical practitioners and surgical expertise. A number of initiatives within the country and from outside have sought to address these deficiencies of numbers and quality. The present paper seeks to review the development of surgery and surgical training in PNG.

Methods: Review of the surgical literature, reports and records in the Division of Surgery at the University of Papua New Guinea (UPNG), and personal observations are used to look critically at the content and productivity of the various training initiatives.

Results: For the first half of the century, PNG relied on national medical assistants who were trained, supervised and directed by expatriate doctors. Medical training of PNG doctors began in 1951 and by 1999 more than 600 doctors had graduated. Expatriate specialist surgeons arrived in 1950 and were the only surgeons until the postgraduate Master of Medicine (surgical) programme produced its first graduates in 1978. This programme has now produced 37 surgeons who are reasonably well distributed throughout the country. Higher surgical diplomas were introduced in 1994 for more specialized training of some of the general surgeons. These training developments have been supported by AusAid as well as by Australian surgeons.

Conclusions: Surgical expertise has progressively improved throughout the 20th century with the most major advances being achieved in the last decade. Training programmes have provided an expanding core of expertise of considerable quality, but the numbers of doctors and surgeons remain well below requirements.
Grantsmanship: achieving success in research funding
Authors: Gotley D. C.
Published: March 2003

High‐quality research is seldom feasible without skilful grantsmanship. Like most skills it is learnt and then improved by practice. Fortunately, there is a consistent formula to constructing a research grant, provided certain guidelines are followed. The grant application need not be a significant barrier between a good idea and its realization in improvements to patient care. This paper outlines the essential principles in the construction of the successful research grant application.
Minimally invasive surgery for primary hyperparathyroidism: a systematic review
Authors: Reeve Thomas S. , Babidge Wendy J. , Parkyn Robert F. , Edis Anthony J. , Delbridge Leigh W. , Devitt Peter G. , Maddern GuY. J.
Published: March 2003

Background: The aim of the present paper was to systematically review the literature regarding the safety and efficacy of minimally invasive parathyroidectomy techniques in patients with primary hyperparathyroidism. Studies using unilateral or endoscopic exploration following imaging were compared with bilateral open neck exploration.

Methods: Studies on minimally invasive parathyroid surgery were identified using MEDLINE (1984 to August 1998), EMBASE (1974 to August 1998) and Current Contents (1993 to week 34, 1998). The search terms were ((endoscop* or (minimal* and invasive) or unilateral) and parathyroid). The Cochrane Library was searched from 1966 to issue 3 1998, using the search terms ‘parathyroidectomy or parathyroid resection’. Human studies of patients with primary hyperparathyroidism using unilateral or endoscopic exploration were included. Animal studies describing minimally invasive technique development were also included. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. Studies directly comparing the unilateral method with bilateral open neck exploration were used to analyse outcomes.

Results: Analysis of data using odds ratios and 95% confidence intervals (CI) indicated a tendency to favour the unilateral technique. These individual studies generally had large CI, however; therefore preference to the unilateral procedure cannot be espoused with certainty. There is also a selection bias due to the strict enrolment criteria for unilateral surgery.

Conclusions: The proposed role of minimally invasive parathyroid surgery is for patients with primary hyperparathyroidism who have unilateral parathyroid pathology. To assess the safety and efficacy of minimally invasive techniques it is suggested that their introduction be monitored as part of a trial in Australia, from which data should be accrued to a register.
PELVIC FRACTURE PATTERN PREDICTS PELVIC ARTERIAL HAEMORRHAGE
Authors: Hamill James , Holden Andrew , Paice Rhondda , Civil Ian
Published: March 2003

Background: The association between pelvic fracture pattern and the need for pelvic arterial embolization remains controversial. To address this issue, a study of the experience at Auckland Hospital was undertaken.

Methods: Review was undertaken of a trauma database, blood bank database, patient records and pelvic radiographs. Of the 364 pelvic fracture patients admitted over a 4‐year period, 76 were transfused with 6 or more units of blood in the first 24 h and these constitute the study population.

Results: Embolized patients were older (median age 42 vs 29.5 years; P < 0.05) and had a higher abbreviated injury score for the pelvic girdle (median 3 vs 2; P < 0.05) compared to non‐embolized patients. Revised trauma score (median 7.69 vs 7.55), injury severity score (median 29 vs 30.5), morbidity (55 vs 39%) and mortality (45 vs 32.1%) rates did not differ significantly between embolized and non‐embolized groups, respectively. The median blood transfusion requirement in the first 6 h from injury was 14 units in embolized and 8 units in non‐embolized patients (P = 0.005). Embolization was required in 12 of 27 (44.4%) patients with fracture patterns indicative of major pelvic ligament disruption, whereas seven of 38 (18.4%) patients without these fracture patterns required embolization (P < 0.05).

Conclusions: The need for pelvic embolization correlated with fracture patterns that indicated major ligament disruption, although the relationship was not sufficiently strong to warrant change to current indications for pelvic angiography.
PHOENIX DATE PALM INJURIES: A REVIEW OF INJURIES FROM THE PHOENIX DATE PALM TREATED AT THE STARSHIP CHILDREN’S HOSPITAL
Authors: Adams Christopher D. , Timms Fiona J. , Hanlon Michael
Published: March 2003

Background: The purpose of this study was to review patients treated for penetrating Phoenix date palm injuries. Documentation of the clinical behaviour of these injuries was sought as they have different clinical outcomes to other foreign body injuries.

Methods: Data was collected via a retrospective review of patient files and imaging studies of all patients with foreign body injury admitted to the Orthopaedic Service of Starship Children’s Hospital between 1992 and 1997.

Results: Of 250 patients admitted with foreign body injuries, 21 cases were identified as caused by the Phoenix date palm. The age range was 5 to 12 years. There was a median delay of 43 days between the time of injury and presentation to hospital. An average of 1.3 operations were performed on each patient. Ultrasound was used in 12 cases, foreign body was identified in 10 patients— a sensitivity of 83%. Intraoperative ultrasound was also found to be beneficial in three of these cases.

Conclusions: Phoenix date palm injuries often have a protracted course. The initial diagnosis and treatment of such injuries is often delayed. Fracturing and fragmentation of the barbs may occur and multiple surgical procedures may be required to remove all of the foreign material. The Phoenix date palm barbs may cause a severe tissue reaction with sterile granulomatous synovitis and bony pseudo‐tumour formation. A high level of suspicion on history taking and surgical exploration is needed. Total synovectomy for delayed joint or tendon sheath involvement may be required when fragmentation has occurred. Ultrasound has higher sensitivity for detection of thorn foreign bodies than magnetic resonance imaging.
LIVER TRANSPLANTATION IN PATIENTS WITH TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS
Authors: Chui A. K. K. , Rao A. R. N. , Waugh R. C. , Mayr M. , Verran D. J. , Koorey D. , McCaughan G. W. , Ong J. , Sheil A. G. R.
Published: March 2003

Background: In patients with intractable oesophageal variceal bleeding, transjugular intrahepatic portosystemic shunts (TIPSS) are being used increasingly as a bridge to orthotopic liver transplantation (OLTx). There is little information in the literature concerning variations in the operative techniques of OLTx required because of the presence of TIPSS.

Methods: A retrospective review of patients treated by TIPSS prior to OLTx was undertaken. The aims were to assess the effectiveness of TIPSS in bridging patients to OLTx and to examine whether TIPSS influence the operative management of OLTx.

Results: Over a 4‐year period eight adult patients underwent TIPSS insertion prior to OLTx in the Australian National Liver Transplant Unit (ANLTU). Transplantation was performed at a mean of 14.6 (0.3–53.8) months after TIPSS insertion. Prevention of major recurrent variceal haemorrhage prior to transplantation was achieved in six cases. In two patients the stents were predominantly intrahepatic and they did not interfere with OLTx. In five patients the stents extended into the portal vein, requiring removal during OLTx either by division of the stent with the recipient portal vein, followed by removal of the fractured stent wires from the portal veins (n= 3), or by ‘endarterectomy’ of the recipient portal vein, allowing removal of the intact stent (n= 2). In one case where the stent extended into the suprahepatic inferior vena cava, removal was achieved by traction without difficulty. All patients are alive at a mean of 24 (7–53) months post‐transplant and none has portal vein abnormalities. When compared to 178 adult patients who had no TIPSS and underwent primary OLTx during the same study period, there was no difference in the length of operating time or the usage of blood products during OLTx.

Conclusion: Transjugular intrahepatic portosystemic shunts offer a bridge to OLTx by providing effective control of variceal haemorrhage. In the present series TIPSS did not increase surgical morbidity or mortality, but emphasis is placed upon the need for optimal TIPSS placement within the liver to facilitate subsequent OLTx.
Study of Venous Blood Flow Changes During Laparoscopic Surgery Using a Thermodilution Technique
Authors: Marshall N. J. , Bessell J. R. , Maddern G. J.
Published: March 2003

Background: Many modalities exist to analyse those factors that contribute to venous stasis and deep venous thrombosis (DVT) during laparoscopic surgery. To the authors’ knowledge intraoperative measurement of femoral venous blood flow has not yet been performed nor has the influence of sequential compression devices been assessed using this parameter.

Methods: The thermodilution technique similar to that employed in cardiac output measurement was used to determine changes in blood flow in the right femoral vein during laparoscopic cholecystectomy. Deep venous thrombosis prophylaxis involved peri‐ operative use of sequential compression devices and subcutaneous heparin 5000 U.

Results: Pneumoperitoneum and the Trendelenburg position reduced femoral venous return in four of the six patients studied, but sequential compression devices failed to return blood flow to baseline in a predictable fashion.

Conclusions: Although the measurement of blood flow using thermodilution is regarded as a reliable technique, during general anaesthesia the results may be susceptible to haemodynamic variations related to the anaesthetic agents as well as to the laparoscopic procedure. In addition sequential compression devices (when used alone) may not provide adequate prophylaxis against DVT because they do not predictably increase femoral blood flow.
Biliary Symptom Scoring as a Method of Selecting Patients for Cholecystectomy
Authors: Gani J. S. , Oakes L. H.
Published: March 2003

Background: A group of patients referred to general surgeons for the treatment of gall bladder stones was studied to evaluate the role of a numerical symptom scoring system (biliary symptom score (BSS)) as a tool to improve the assessment of patients and reduce the incidence of post‐cholecystectomy symptoms.

Methods: Fifty‐seven patients with gallstones and abdominal symptoms referred to general surgeons were studied. All patients were interviewed by a surgeon in training independently from the treating surgeon and given a subjective and objective assessment of their symptoms (using the BSS); they were then categorized into biliary, non‐biliary and possible biliary groups. The results of the interviews remained unknown to the treating surgeon throughout the period of study. The symptom status of all patients was re‐ evaluated 6–12 months later; the patients’ outcome was compared with their initial objective score and the subjective assessment by the independent assessor and with the treating surgeon’s initial assessment.

Results: Fifty‐one patients were able to be analysed. Subjective independent assessment and BSS were closely correlated (φ = 0.89). Use of the BSS improved the accuracy of the independent assessor from 53% (subjective assessment) to 69%, but this was at the cost of recommending cholecystectomy in 30% of the patients with non‐biliary symptoms. The accuracy of experienced consultant general surgeons was 98% with a single case of post‐cholecystectomy syndrome (2%).

Conclusion: Numerical BSS improves diagnostic accuracy for a surgeon in training by reducing the number of patients classified with possible biliary symptoms, but it remains significantly less accurate than the subjective clinical assessment of an experienced consultant general surgeon.
Gallstones and Gall Bladder Carcinoma
Authors: Vitetta L. , Sali A. , Little P. , Mrazek L.
Published: March 2003

Background: The present study reviewed the occurrence of gall bladder carcinoma in patients who underwent a cholecystectomy for gallstone disease.

Methods: A retrospective study of demographical and clinical information for patients who underwent a cholecystectomy and operative cholangiogram for gallstones predominantly in three major hospitals located in the northern area of Melbourne was carried out.

Results: Gall bladder carcinomas were observed in 14 patients (3.2%; 95% confidence interval (CI): 1.8–5.3%) consisting of 11 women and three men of median age 78.5 years (interquartile range: 77–81) from a series of 439 patients with a male‐to‐female ratio of 1–2. The results of the present study show that primary carcinoma of the gall bladder in this descriptive retrospective cohort was always associated with single or multiple cholesterol gallstones that were impacting on the gall bladder wall. Cholesterol ‘solitaire’ gallstones were ovoid in shape with diameters > 3 cm along their longest axis, whereas multiple cholesterol gallstones varied in size and number from two or three large stones (1–2 cm), to numerous smaller stones (variable size to 0.5 cm). No patient with gall bladder carcinoma had either brown or black pigment gallstones.

Conclusion: It is postulated that gall bladder carcinoma may be intimately associated with large or numerous cholesterol gallstones that in the first instance may interfere with the mechanical functioning of the gall bladder. The size as well as the number of gallstones present in the gall bladder may contribute significantly to the promotion of a gallstone filling defect of the gall bladder that may cause chronic mechanical damage to the gall bladder mucosa. The present report supports the hypothesis that gall bladder carcinoma is an age‐dependent malignancy, present mostly in women, that may be intimately associated with long‐standing benign gallstone disease of the gall bladder.
Erythromycin enhances oesophageal motility in patients with gastro‐oesophageal reflux
Authors: Chrysos Emmanuel , Tzovaras George , Epanomeritakis Emmanuel , Tsiaoussis John , Vrachasotakis Nikolaos , Vassilakis John Sophocles , Xynos Evaghelos
Published: March 2003

Background: Intravenous (i.v.) erythromycin enhances gastric emptying and oesophageal motility in both healthy and disease situations, acting either as a motilin or acetylcholine agonist. The purpose of the present paper was to investigate any possible effect of i.v. erythromycin on oesophageal motility in patients with gastro‐oesophageal reflux (GOR).

Methods: In 15 patients with GOR (proven on 24‐h ambulatory oesophageal pH measurement), standard oesophageal manometry was performed after i.v. injection of placebo and 200 mg erythromycin, in a random blind fashion.

Results: Erythromycin significantly increased lower oesophageal sphincter (LOS) pressure from 17 ± 5 to 41 ± 10 mmHg (P < 0.001), without affecting the postdeglutition relaxation of LOS. Erythromycin also increased the amplitude (from 79 ± 34 to 97 ± 40 mmHg; P < 0.001), duration (from 3.4 ± 0.6 to 3.8 ± 0.6 s; P = 0.005), velocity (from 3.1 ± 0.8 to 3.5 ± 1.15 cm/s; P = 0.0047) and strength (from 149 ± 84 to 201 ± 103 mmHg·s; P < 0.001) of peristalsis at 5 cm proximal to the LOS. Similarly, the drug increased the amplitude of peristalsis at 10 and 15 cm proximal to the LOS (from 70 ± 39 to 77.4 ± 37 mmHg; P = 0.049 and from 36 ± 20 to 49 ± 36 mmHg; P = 0.004, respectively) and the duration of peristalsis at the same levels (from 3.1 ± 0.6 to 3.3 ± 0.5 s; P = 0.011, and from 2.7 ± 0.6 to 3 ± 0.5 s; P = 0.003, respectively).

Conclusion: Intravenously administered erythromycin improves impaired oesophageal motility in patients with GOR. This observation might be of clinical use.
Intravenous cannula: An instrument and a port in laparoscopic surgery
Authors: Yeung Gustus H. C. , Leung Siu L. , Tse Samson
Published: March 2003

Background: An intravenous cannula was used experimentally as a cheap and scarless alternative to an endoloop to provide retraction and lumen occlusion. It is also a miniport for introduction of ligatures and small catheters.

Methods: This possibility was explored during standard procedures such as laparoscopic cholecystectomy and laparoscopic appendectomy.

Results: This technique was successfully applied in 89% of laparoscopic cholecystectomies and 86% of laparoscopic appendectomies.

Conclusions: In many instances a standard port for laparoscopic instruments was unnecessary, despite the fact that the authors did not intentionally work towards port number reduction for laparoscopic procedures.
Island flap perineoplasty for coverage of perineal skin defects after repair of cloacal deformity
Authors: Draganic Brian , Solomon Michael J.
Published: March 2003

Background: Traumatic cloacal defect is an injury sustained during childbirth in which the anovaginal septum is completely disrupted and the anus and vagina open as a common channel. Such injuries result in complete faecal incontinence and are difficult to repair both in terms of improving function and obtaining skin closure.

Methods: Four cases of traumatic cloacal defect with a delayed presentation are illustrated here. All were treated with an overlapping anterior sphincter repair in combination with island flap perineoplasty to achieve skin closure. Anorectal function before and after surgery and the success of achieving primary wound healing were evaluated.

Results: In all four cases profound incontinence was found preoperatively; all patients returned to normal or near normal continence following overlapping anterior sphincter repair. Island flap perineoplasty was successful in achieving primary healing in all cases and no flaps were lost to necrosis.

Conclusions: Island flap perineoplasty is an effective method of achieving skin closure after anterior sphincter repair of traumatic cloacal defects.
Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures
Authors: Kua Keith B. , Kocher Hemant M. , Kelkar Ashish , Patel Ameet G.
Published: March 2003

Introduction: Recent studies have highlighted the role of increased internal anal sphincter pressure and decreased anodermal blood flow in the pathogenesis of chronic anal fissures. The duration of the effect of topical 0.2% glyceryl trinitrate (GTN) ointment on anodermal blood flow in fissure and normal areas was investigated in patients with chronic anal fissures.

Methods: Six patients with chronic anal fissures in the posterior midline participated in the study. Blood flow measurements were performed on the anoderm using laser Doppler flowmetry before and immediately after the topical application of 0.2% GTN ointment and subsequent readings were taken at 5, 15, 30, 45 and 60 min in all four quadrants.

Results: The mean anodermal blood flow in the fissure region is significantly lower than the mean blood flow of the rest of the anoderm before 0.2% GTN ointment is applied (228.7 ± 61.8 flux units vs 439.3 ± 25.5 flux units, respectively; P < 0.05). Immediately after the application of local 0.2% GTN ointment there is a significant increase in anodermal blood flow over the anal fissure region (457.8 ± 56.5 flux units; P < 0.05) compared to the rest of the anoderm (457.4 ± 30.8 flux units). This increase is most marked at 5 min post‐GTN ointment application in the fissure area (474.6 ± 41.1 flux units) and the blood flow in the fissure region is consistently above the rest of the anoderm for most of the 60 min.

Conclusion: There is clearly reduced blood flow to the chronic anal fissure region compared to the rest of the anoderm. Topical application of glyceryl trinitrate ointment seems to significantly improve the blood flow to the fissured area in the first hour. This may therefore help in the healing of chronic anal fissures.
Endocrine tumours of the pancreas: Review and recent advances
Authors: Mullan Michelle H. , Gauger Paul G. , Thompson Norman W.
Published: March 2003

Pancreatic endocrine tumours (PET) are rare but nonetheless important to recognize and treat in a timely fashion. Significant morbidity occurs due to excess secretion of hormones, with all of the PET having some degree of malignant potential. Surgeons must plan directed operative strategies to deal with these tumours and be prepared to undertake aggressive palliative debulking resections if indicated. Somatostatin receptor scintigraphy and endoscopic ultrasound have been particularly helpful in both localizing and staging patients with PET. Other important advances in management include the use of long‐acting somatostatin analogues to inhibit hormonal secretion and tumour growth. The possibility of multiple endocrine neoplasia type 1 (MEN‐1) should be considered in any patient with a PET. The present article will review the various classes of PET, describe MEN‐1 in relation to PET and examine advances in imaging and localization. The role of surgery for PET is also discussed in the present review.
Occupational therapy students’ paradigms: A passage from beholder to practitioner
Authors: Björklund Anita
Published: March 2003

The present study explores the development of occupational therapist paradigms among occupational therapy students at the Occupational Therapy Educational Program at the University College of Health Sciences, Jönköping, Sweden. The study is an explorative, comparative study of nearly qualified (last year) and newly enrolled (first week) occupational therapy students’ world views and field of action views regarding occupational therapy. The students answered essay questions on paradigmatic matters, and their answers were analysed qualitatively. A study structure comprising three themes with appurtenant categories allowed comparisons between the two groups of students. A major finding was that the nearly qualified occupational therapy students’ notions (in contrast to those of the newly enrolled students) gave expression to a more holistic health perspective in which there were numerous examples of interrelations between themes belonging to different paradigm components. According to Törnebohm interrelations between different paradigm components are characteristic of paradigms.
Experiences and perceived roles of occupational therapists working with children with special learning needs during transition to school: A pilot study
Authors: Prigg Alison
Published: March 2003

Occupational therapists provide support to children with special learning needs and their families during the child’s transition from early childhood to mainstream school. Little has been documented regarding the role and experiences of occupational therapists working with children, families and teachers during transition in an Australian context. Six paediatric occupational therapists from one geographical area in New South Wales were interviewed and asked to relay their role and experiences when providing a service to children with special learning needs during their transition to school. Participants described their role to include: preparing the child for school; working with school personnel; and providing parental support. Although participants described both positive and negative experiences, among the negative experiences were: limited time to provide a service; recommendations to school personnel not being followed; school personnel not being supportive; feeling uncomfortable in the classroom; and limited involvement in planning. Participants described a role which is consistent with current school‐based occupational therapy practice; however, in the participants’ experience, there was a gap between the ideal service and what participants were able to provide. This included limited collaboration with teachers.
Retention: An unresolved workforce issue affecting rural occupational therapy services
Authors: Mills Anna , Millsteed Jeannine
Published: March 2003

Failure to retain health professionals in rural areas contributes to the poor health status of these communities through an inability to deliver reliable and consistent services. Considerable attention has been focused on factors affecting recruitment of health professionals. Far less is known about factors affecting the retention of occupational therapists. This was the focus of this study. Ethnographic interviews were used to explore the experiences of 10 occupational therapists who had left rural practice. Six themes emerged from the participants’ experiences, from when they first considered rural practice to reflections following their departure from it. These themes were initial appeal, facing the challenge, rural practice issues, the social sphere, reasons for leaving and the value of rural experience. These factors gave rise to a proposed Model of Retention Equilibrium, which suggests that retention can be improved by addressing the imbalance between incentives to leave and incentives to stay. The model provides a useful framework for occupational therapists contemplating rural practice, as well as for health services managers responsible for service delivery in rural areas.
Fellowship in Forensic Psychiatry
Authors: Jager Alan D
Published: March 2003

The training for Fellowship of the Royal Australian and New Zealand College of Psychiatrists (FRANZCP) provides a very sound base for not only passing the Section I FRANZCP examinations, but also for working in other environments. This paper describes how I planned and completed a Fellowship in Forensic Psychiatry in Calgary, Alberta, Canada, during the 5th year of training for the FRANZCP.
The Implementation of The Brennan Report: Centralised Selection of First Year Trainees for Ranzcp-Accredited Training in NSW
Authors: Burke David , Newman Louise
Published: March 2003

In January 1998 the Commonwealth Department of Health and Family Services published the findings and recommendations of a national study of the procedures for the selection of trainees in Australian medical colleges [ 1 ]. The report had been sponsored by the Medical Training Review Panel and conducted by Dr Peter J Brennan and Company.
Why would a Psychiatrist Work in a Bank?
Authors: Whiteford Harvey
Published: March 2003

This is the most common question I have been asked since the announcement of my appointment to the World Bank. This paper provides a brief history of the development of the Bank, its role in social development, population health and health service delivery, and the reasons behind its recent interest in mental health.
Assessment in Child and Adolescent Psychiatry: Interstate Difference
Authors: Luk Ernest S. L. , Robinson Philip , Birleson Peter , Cooper Howard
Published: March 2003

Assessment in child and adolescent psychiatry is the key to good practice. After reviewing practice in the UK and USA, the Victorian Framework for Child and Adolescent Mental Health Service Delivery stated a general assessment and presentation of feedback to the family may generally be completed within three hours by a welltrained specialist clinician. For many years, the Victorian Postgraduate Child Psychiatry Training Program has employed a four session assessment model in its Developmental Psychiatry Course. In a recent survey, the four session assessment model was found to be the norm of practice in Metropolitan Victoria.
Suicide: Warning Signs and Blame
Authors: Pridmore Saxby
Published: March 2003

Last year I claimed that newspaper reports of suicide indicate that in at least some instances, suicide is not predicted by those close to the subject [ 1 , 2 ]. This could be because the survivors are either not trained or not alert. But I believe that in certain cases, even those both fully trained and alert are unable to pick-up signs—because there aren't any. This leads to the proposal that some suicide is not preventable and that in these cases, the attribution of blame is wrong. I labour this point because we live in a ‘culture of complaint’ and I sense a strong drive to find someone responsible whenever a suicide occurs. I doubt that I lack compassion or that I am paranoid—but I do not deny the possibility.
Child Psychiatry in Laos
Authors: Einfeld Stewart
Published: March 2003

I had two goals in mind in undertaking a recent visit to Laos. The first was to see if there was any contribution we could make to the development of mental health services, particularly for children and adolescents, and the second was to gain a trans-cultural perspective on my own research work in developmental psychiatry.
Closure of a Long-Stay Ward: Five Years Onwards
Authors: Perera Mahendra H. , Parkinson John , Perera Dhara
Published: March 2003

Closure of psychiatric hospitals has engendered much debate. There is a growing body of literature resulting from such closures. Lamb [ 1 ] in a lecture has pointed out the need for deinstitutionalisation to be clinically driven rather than by pre-conceived ideology. Bachrach [ 2 ] discussed the need to espouse a bio-psycho-social and humanistic approach coupled with the provision of adequate resources. In a limited survey conducted among community homes and long-stay hospitals in London, it was found that the most disabled were still living in hospitals and received the poorest quality care. Whilst there were no overall differences amongst the community facilities, they noted the importance of staff training and morale in order to improve quality of care [ 3 ].