bluuebunny/crossref_metadata_2025 huggingface dataset:
Elevated homocysteine levels in euthymic bipolar disorder patients showing functional deterioration
Authors: Osher Yamima , Sela Ben‐Ami , Levine Joseph , Belmaker Robert H
Published: December 2004

Objective:  Previous studies have found elevated plasma homocysteine levels in schizophrenic patients. This study examined homocysteine levels in euthymic bipolar patients.

Methods:  Homocysteine levels in 41 euthymic outpatients with bipolar disorder (DSM IV) were compared with 305 comparison subjects from a large employee health screening program. Homocysteine levels were assessed using high‐pressure liquid chromatography by fluorescence detection following labeling of homocysteine with monobromobimane. Functional deterioration in patients was rated as ‘present’ or ‘absent’ by consensus of two treating clinicians.

Results:  Data were analyzed by two‐way (sex, patient versus control) ANCOVA, with age as the covariant. Significant effects were found for age (p < 0.001) and for sex (p < 0.001) and a significant two‐way interaction was found for group by sex (p < 0.001). One‐way (by group) ANCOVAs were then performed separately for each sex. For the male subjects, a main effect was found for group (p = 0.001) and for age (p < 0.001): young male bipolar patients have higher homocysteine levels than controls. Among the females, bipolar patients had homocysteine levels, which were lower than controls across all age groups (p < 0.05) with homocysteine levels increasing with age for both groups (p < 0.001). ANCOVA, which divided subjects into three groups – bipolar patients with and without functional deterioration versus comparison subjects – found a significant group by sex interaction (p < 0.05). Sheffe’post‐hoc comparisons revealed that among the male subjects, bipolar patients showing deterioration had homocysteine levels which were significantly higher than those of comparison subjects, while bipolar subjects without deterioration had homocysteine levels which were almost identical to the comparison subjects.

Conclusion:  Bipolar patients who show functional deterioration have plasma levels of homocysteine, which are significantly elevated as compared with controls.
Biochemical and psychiatric predictors of Li+ response and toxicity in Li+‐treated bipolar patients
Authors: Layden Brian T , Minadeo Nicole , Suhy Joyce , Abukhdeir Abde M , Metreger Tabitha , Foley Kathleen , Borge George , Crayton John W , Bryant Fred B , Freitas Duarte Mota de
Published: December 2004

Background:  It has not been determined whether biochemical or psychological variables predict clinical response and toxicity to Li+ treatment.

Methods:  From 30 Li+‐treated bipolar patients, we measured biochemical variables in red blood cells (RBCs) that encompassed the cell membrane abnormality and the Li+/Mg2+ competition mechanism. Psychiatric measures of depression, mania, and side effects of Li+ toxicity were correlated with these biochemical variables. Physician classification of Li+ response and toxicity for each patient were used for determining whether significant differences in biochemical variables and psychiatric measures existed between full and partial responders, and as well as toxic and non‐toxic Li+‐treated bipolar patients.

Results:  Serum [Li+] ([Li+]e), the ratio of intracellular RBC to serum Li+, [Li+]i/[Li+]e, and phosphatidylcholine shared moderate proportions of variance (10–15%) with several of the psychiatric measures. Physician assessment of full response was predicted by higher levels of [Li+]e and lower scores on the Hamilton Slowing subscale (95.6% accuracy), whereas higher lithium‐binding constants and higher Hamilton total scores perfectly predicted physician classification of partial response. Higher scores on Hamilton Slowing subscale and General Side Effects (GSE) scale were strongly predictive of physician classified Li+ toxicity (80% accuracy), whereas lower levels of [Li+]e and lower scores on the Hamilton Symptom Severity subscale perfectly predicted physician rated non‐toxicity in these patients.

Conclusions:  We found distinct [Li+]e levels that predict response and/or toxicity. Specifically, when [Li+]e was in the range of 0.93–1.42 mM, full response without toxicity was predicted; higher values predicted toxicity; lower values predicted partial response.
Occupational therapists report a low level of knowledge, skill and involvement in evidence‐based practice
Authors: McCluskey Annie
Published: December 2004

This study was conducted to collect information about Australian occupational therapists’ involvement in evidence‐based practice. The study aimed to document: (i) respondents’ level of knowledge and skills; (ii) their level of participation in continuing education; and (iii) perceived barriers to evidence‐based practice. A purposive sample of 85 occupational therapists was invited to complete a questionnaire prior to attending an introductory workshop on evidence‐based practice. Sixty‐seven questionnaires were returned and analysed (78.8% response rate). Half of the respondents rated their level of knowledge and skills required for evidence‐based practice as low (conducting database searches = 50.7%; critically appraising literature = 53.0%). The majority of respondents (79.1%) reported a low level of knowledge about electronic databases. Few respondents had attended education sessions on evidence‐based practice (15.0%). The six most commonly reported barriers to adopting evidence‐based practice were lack of time, a large caseload, limited searching skills, limited appraisal skills, difficulty accessing journals and a perceived lack of evidence to support occupational therapy intervention. The majority of occupational therapists in this sample were entering the first phase of continuing professional development in relation to evidence‐based practice.
Conducting a needs assessment to justify the provision of occupational therapy services in a rheumatology outpatient clinic
Authors: Cranitch Carol
Published: December 2004

Investigating the best method of service delivery, or the ‘need’ for a particular service is gaining increasing support as demands intensify across the health‐care system, often with reduced financial resources. Following a restructuring within the Occupational Therapy department at the Austin and Repatriation Medical Centre, a limited amount of time (0.2 EFT Grade II) became available to provide additional services within the hospital. Occupational therapy services to patients of the rheumatology outpatient clinics had ceased since funding cuts approximately 7 years before, yet there had been numerous requests for service. As part of quality assurance activities, a needs assessment was conducted, interviewing clients attending these outpatient clinics. The Health Assessment Questionnaire, a Visual Analogue Scale for Pain, and a non‐standardised questionnaire were used to assess the need for occupational therapy by this patient group. Thirty‐five people were interviewed over a period of 2 weeks. The results supported increased occupational therapy involvement with this client population within the rheumatology outpatient clinic specifically in the areas of improving functional performance, pain management and hand therapy. The study also highlighted a need for promotion of the occupational therapy role both with clients and the medical staff.
Goal attainment scaling: Clinical implications for paediatric occupational therapy practice
Authors: McLaren Chrisdell , Rodger Sylvia
Published: December 2004

Children with disabilities pose unique challenges for occupational therapists when the value of therapy programmes and the child's individual progress are being evaluated. Children whose development is atypical may make progress through a course of intervention and/or maturation, yet standardised tests frequently used by occupational therapists are often not sensitive enough to detect these changes. In this current climate of economic rationalism and accountability, providing documentary evidence of occupational therapy programme benefits is essential. This paper addresses the utility of goal attainment scaling for objectively and systematically documenting the outcomes of occupational therapy intervention. Goal attainment scaling provides a direct, reliable and accurate method of assessing treatment‐induced client change. The process of goal attainment scaling is described and the literature on goal attainment scaling in paediatrics is reviewed. It is concluded that goal attainment scaling is a useful clinical process and measure of therapy programme outcomes for children with disabilities.
Predictors of occupational therapy students’ clinical performance: An exploratory study
Authors: Tan Kia‐Pei , Meredith Pam , McKenna Kryss
Published: December 2004

Determining factors that predict student clinical performance can enable the early identification of students at risk of clinical difficulties. This exploratory study examined the ability of grade point average, trait anxiety, the completion of an elective preclinical practical course, and age to predict the clinical performance of occupational therapy students. Forty‐nine occupational therapy students provided demographic and academic details, and completed parts of The Sixteen Personality Factor Questionnaire (Fifth Edition) before commencing their first major clinical placement. Clinical performance was measured in eight behavioural areas using a 53‐item evaluation tool. Grade point average was the most important and consistent positive predictor of student clinical performance. Some areas of performance were positively predicted by trait anxiety and age, and negatively predicted by completion of the preclinical course. The need for future research on other potential predictors is highlighted. Improved knowledge of predictors might inform the curricula of occupational therapy training programs, and allow the early identification of students at risk of clinical difficulties so that appropriate supports can be implemented to assist them to reach their full clinical potential.
Psychiatrist or Sex Worker? Emotional Awareness in Ethics Education
Authors: Parkinson John
Published: December 2004

Objective: When too many psychiatrists have been behaving like prostitutes, it is instructive to compare and contrast that ancient profession with our own. The present paper sets out to do that.

Methods: Codes of conduct are compared and clinical anecdotes discussed.

Results: Both professions give time and services in exchange for money. Guidelines for each highlight limits and boundaries. A danger is ‘falling in love’, a quasi-psychotic experience that facilitates some phases of development but which can be destructive when uncontained. Since the advent of cognitive behavioural therapy (CBT), transference and countertransference are concepts no longer widely used. However, many behaviourists know the importance of a therapeutic alliance and see the therapist as a figure who can invoke idealization and dependence. All psychiatric treatment has a developmental aspect because it seeks to replace primitive feelings and impulsivity with mature behaviour. Adolescence brings not only sexual development but emotional change from the dependent child to the adult capable of care and bonding. Sexual attraction is more mature the more the element of neediness is modified by care and concern.

Conclusions: Peer groups are commended for both professions. In psychiatric training, human development should be learnt not just as theoretical background but as lively reality in clinical work, alerting psychiatrists to monitor their own maturity in the doctor-patient setting. The value of personal therapy or analysis is discussed, together with possible adverse sideeffects.
Establishment and Evaluation of a Clinical Pathway for Young Suicide Attempters and Ideators
Authors: Hazell Philip
Published: December 2004

Objective: To develop, implement and evaluate a pathway to care for young people presenting with suicidal ideation or deliberate self-harm.

Methods: A working party consisting of key stakeholders was established to review existing practice, consider recommendations formulated in other centres, formulate a pathway, identify training needs for clinical staff, identify gaps in resources that would hinder the implementation of the pathway, and to evaluate effectiveness.

Results: No existing pathways were identified that could be applied to the local context. A pathway was developed by consensus and disseminated to relevant clinical areas. A training strategy involving clinical placements was implemented. Critical gateway points along the pathway were identified and monitored. Compliance with gateway points was satisfactory, with the exception of review by a mental health clinician in the emergency department. More than 75% of young people presenting on the pathway attended community follow up, which is higher than the rate of compliance with follow up reported in most other studies.

Conclusions: Establishing a clinical pathway permitted the delineation of roles and responsibilities. Although the pathway was developed for a local context, service planners may find it helpful to follow the steps in the pathway development process that have been outlined.
From the 1870s to the 1970s: the Changing Face of Public Psychiatry in South Australia
Authors: Bell Maureen
Published: December 2004

Objective: To give an overview of the development of psychiatric services in South Australia from the 1870s to the 1970s, to describe some of the milestones in their progress, and to demonstrate that many of the guiding principles of contemporary services can be found to have their roots in this period.

Conclusions: Psychiatric services in South Australia progressed in fits and starts, but not for want of commitment and concern by those responsible for the care of the mentally ill. While in broad outline the development of services followed the course taken in other states, it is clear that the individual efforts of staff of the hospitals and a number of members of the public played an important role in improving the conditions and treatment of those with a mental illness, and laying the foundations for the movement of psychiatric services from their early isolationist position into the general health arena.
‘Auspsyc’: an Email Discussion List for Psychiatrists and Trainees
Authors: Buchanan John
Published: December 2004

Objective: To describe ‘auspsyc’, an email discussion list for psychiatrists, psychiatry trainees and psychiatry medical officers in Australia and New Zealand.

Conclusions: auspsyc provides free, open and timely communication about matters of professional concern. A variety of issues have been covered by members since its inception. Guidelines have been developed to ensure that the email discussion list functions efficiently and that ‘netiquette’ is observed.
Can Psychiatry Reclaim its Soul? Psychiatry's Struggle Against a Dispirited Future
Authors: Halasz George
Published: December 2004

Objectives: To examine reasons why ‘religion’ and ‘psychiatry’, as systems of belief, have a fraught, mistrustful relationship based on conflict regarding the source of knowledge. The former insists that revelation, not rational empirical evidence, the latter's claim for superiority, is the ultimate source that illuminates the soul, not just the self. This tension is illustrated with the case of ‘facilitated communication’, a method that purportedly improves communication for children with pervasive developmental disorder. The controversy highlights an aspect of the differences between ‘scientific’ and ‘religious’ discourse and offers a further dimension to contemporary psychiatry's crisis: the three-way tension between the brain-less, mind-less and soul-less psychiatry.

Conclusion: The suggestion for a possible remedy is to revisit the source of discontent, the Aristotelian doctrine that challenged the ancient wisdom of the immortality of the soul.
Dr Radovan Karadzic: Psychiatrist, Poet, Soccer Coach and Genocidal Leader
Authors: Kaplan Robert M.
Published: December 2004

Objective: To consider the life of psychiatrist, Dr Radovan Karadzic, and the following questions: (i) whether there was anything in Karadzic's personal life to predict his subsequent career as genocidal leader; (ii) what kind of psychiatrist was Karadzic; and (iii) what comparisons can be made with other genocidal leaders?

Conclusions: Karadzic, who, in addition to practising psychiatry, was variously poet, troubadour, soccer coach, chicken farmer, businessman, ecologist and petty criminal, had an astonishing rise to power, becoming president of the Bosnian Serb Republic. As a result of atrocities committed during the Bosnian Civil War 1992-1995, Karadzic stands indicted as a suspected war criminal for crimes against humanity and genocide, the first doctor so indicted since the Nuremberg Doctors' Trial in 1946. Many aspects of Karadzic's personality remain deeply enigmatic. Nevertheless, his grandiose self-image, reckless and profligate nature, boundless opportunism and grotesque capacity for self-deception are his most enduring characteristics.
Clinical Practice Guidelines: A Tool to Measure Variance
Authors: Tobin Margaret , Wilson Andrew , Codyre David , Rosen Alan , Barton David
Published: December 2004

Objective: To outline plans of the RANZCP Quality Improvement Committee (QIC) for the implementation of the Clinical Practice Guidelines (CPG) into clinical practice in Australia and New Zealand, and provide views of the QIC on the role of CPG as a quality improvement tool.

Conclusions: Clinical Practice Guidelines are of limited utility unless there is clinician buy-in and they are used as a tool to measure variance as part of a continuous quality improvement cycle. The QIC actively encourages debate regarding the content and development process of the CPG as well as methods for their use in routine clinical practice.
Summary of Guideline for the Treatment of Panic Disorder and Agoraphobia
Authors: Andrews Gavin , Oakley-Browne Mark , Castle David , Judd Fiona , Baillie Andrew ,   RANZCP Clinical Practice Guideline Team for Panic Disorder
Published: December 2004

Objective: To provide a summary of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline for the treatment of panic disorder and agoraphobia

Conclusions: Evidence-based treatments for panic disorder and agoraphobia are now clear. These conditions are chronic and disabling in nature, are complicated by delayed treatment and the presence of other psychiatric conditions, and the presence of severe agoraphobia is a negative prognostic indicator. Choice of therapy will depend on the skill of the therapist in applying psychological treatments as well as the preferences of the patient, but there is a role for both psychological and evidence-based pharmacological approaches. The present article is a summary version of the comprehensive Clinical Practice Guideline (Australian and New Zealand Journal of Psychiatry, 2003) which was developed in accordance with National Health and Medical Research Council (NHMRC) criteria. It provides a two-page desk-top summary for use in clinical practice. Economic evaluation of the available evidence-based treatments showed that at 1 year the cost of cognitive behaviour therapy (CBT) is less than the cost of the average drug therapy (CBT becomes cheaper than paroxetine at 8 months, than clomipramine at 11 months and cheaper than imipramine at 13 months). During the second and subsequent years the superiority of CBT increases whether or not the drugs are continued. Evidence levels for specific treatments are provided in the comprehensive guideline and placed in the context of overall principles of thorough assessment and quality clinical management.
Summary of Guideline for the Treatment of Depression
Authors: Ellis Pete M. , Hickie Ian B. , Smith Don A. R.
Published: December 2004

Depression is common, serious and treatable. The Australian and New Zealand Clinical Practice Guideline for the Treatment of Depression by Specialist Services provides evidence-based treatment guidance across the spectrum of depressive disorders and delineates where specialist treatment and primary care management is indicated. The present summary version covers the key contents of the guideline. It includes assessment, treatment and general management issues by category type and severity of depressive disorder. Algorithms of first-line and subsequent treatment choices are provided for: (i) mild depression without complications; (ii) moderately severe depression (including with comorbid anxiety) and dysthymia; (iii) uncomplicated, melancholic or atypical depression; (iv) moderately severe depression with comorbid substance abuse; (v) moderate to severe depression with physical disorders; (vi) severe depression with melancholia; (vii) recurrent depression or failure to respond to a preferred first-line treatment; and (viii) psychotic depression, and severe depression with risk of suicide. Continuing and maintenance treatments for recurrent depression are discussed. Emerging evidence of the equal value of cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT) to pharmacological treatments for some depression is discussed, and the need to ensure that they are provided by suitably trained practitioners. Indications for hospitalization and electroconvulsive therapy (ECT) are also provided.
Paediatric radiotherapy in Australia and New Zealand: An anachronism in 2003?
Authors: Ahern Verity , Berry Martin
Published: December 2004

This report reviews the activities of the Paediatric Special Interest Group of the Royal Australian and New Zealand College of Radiologists in terms of its involvement with the Australian and New Zealand Children's Cancer Study Group and its research and educational activities. Examples of when and how radiotherapy is currently used in the management of paediatric malignancies are provided. Some thoughts for the future of both paediatric radiotherapy and our subspecialty are also presented.
A 5‐year audit of 778 neonatal renal scans (Part 1): Perplexing pyelectasis and suggested protocol for investigation
Authors: Acton Christine , Pahuja Monica , Opie Gillian , Woodward Alan
Published: December 2004

In this 5‐year review of 778 neonatal renal scans seen in an Obstetric Hospital, most infants were referred because of antenatal ultrasound findings, 92% with fetal pyelectasis. The results were classified according to the ultrasound findings. The majority of neonates (76%) had a normal postnatal scan. A number had vesicoureteric reflux (VUR) found on a micturating cystourethrogram. Persistant mild to moderate pyelectasis or hydronephrosis (15%) proved to be a normal variant in many infants, but had a similar appearance to those with an early obstructive cause (1%). Pyelectasis has proved to be a poor predictor of VUR. A protocol outlining paediatric management for neonates with persisting pyelectasis is included. There were 59 infants (8%) with a miscellaneous group of renal anomalies, many with a characteristic antenatal ultrasound appearance suggesting the diagnosis. These infants have been separately reported and illustrated (Part 2). Overall, 13% of infants were found to have significant findings of obstruction, VUR or miscellaneous anomalies affecting management.
A 5‐year audit of 778 neonatal renal scans (Part 2). Miscellaneous anomalies in 59 infants: A pictorial presentation
Authors: Acton Christine , Pahuja Monica , Opie Gillian , Woodward Alan
Published: December 2004

In this 5‐year review of 778 neonatal renal scans seen in an obstetric hospital, Mercy Hospital for Women, Melbourne, most infants were referred because of antenatal ultrasound findings. Ninety‐two percent of these had fetal pyelectasis. The results were classified on the ultrasound findings. The majority of neonates (76%) had a normal postnatal scan. A number had vesicoureteric reflux found on micturating cystourethrogram. Persisting mild/moderate pyelectasis or hydronephrosis (15%) proved to be a normal variant in many infants, but had a similar appearance to those with an early obstructive cause (1%). There were 59 infants (8%) with a miscellaneous group of renal anomalies, many with a characteristic antenatal ultrasound appearance suggesting the diagnosis. Review of these 59 infants illustrates the anomalies seen and reports the associated investigations and subsequent outcome in most cases.
Acute contrast reaction management by radiologists: A local audit study
Authors: Bartlett Murray J , Bynevelt Michael
Published: December 2004

Consultant radiologists and trainees must possess knowledge of optimal acute management of anaphylactic/anaphylactoid contrast reactions because patient survival depends upon prompt initial management. The aim of the present study is to assess the knowledge of first‐line management of these reactions among radiologists. Within one working day, and without prior knowledge, radiology consultants and trainees within four teaching hospitals in a major Australian capital city were asked to complete a confidential questionnaire regarding acute resuscitation management. Scenarios were presented of an adult who developed life‐threatening symptoms of anaphylaxis immediately after intravenous contrast administration, ventricular fibrillation and profound bradycardia. Questions were asked with regards to adrenaline, corticosteroid, antihistamines, intravenous volume expansion, cardio‐pulmonary rescuscitation and knowledge of the emergency telephone number. Sites were assessed for presence of an anaphylaxis management chart and also when each participant last completed a resuscitation course. Forty‐two participants were recruited. Overall, 53% of questions were answered correctly. Only 43% knew the adrenaline dose and if an incorrect dose was administered it was more likely to be an overdose. Notable inadequacies were also discovered with corticosteroid, atropine, antihistamine doses and intravenous fluid use. Only 26% had completed a resuscitation course in the past 2 years. Forty‐five percent knew the emergency telephone number and 55% of rooms using intravenous contrast contained an immediately visible chart for contrast reaction management. Radiologist and trainee knowledge of immediate life‐threatening contrast reaction management is deficient. Severe contrast reactions are uncommon with today's use of non‐ionic contrast, but they still occur. Experience in the management of anaphylaxis can only come from regular, compulsory training.
Cranial CT interpretation by senior emergency department staff
Authors: Arendts Glenn , Manovel Alvaro , Chai Alan
Published: December 2004

The aims of the present study were to determine the rate of misinterpretation of non‐contrast cranial CT scans by emergency specialists and trainees compared with specialist radiologists, and the proportion of misinterpretations that is consequential. A 12‐month prospective blinded cohort study was performed. One‐hundred and ninety of 1282 scans (14.8%) were misinterpreted, and 78 of these (41.1%) were of potential or actual consequence. We conclude that the performance of senior emergency department staff in non‐contrast cranial CT interpretation is no better than moderately good, and a large proportion of misinterpretations are of potential or actual clinical consequence.
MRI and preoperative embolization of a nasal cavity haemangioma in a child
Authors: Andronikou Savvas , Mandelstam Simone , Fasulakis Stephen
Published: December 2004

Haemangiomas are common benign tumours of the head and neck region in children. The nasal cavity, however, is an extremely rare site for such lesions in childhood. We present the typical MRI features of a nasal cavity haemangioma in a 12‐year‐old girl. Biopsy was avoided because of the MRI diagnosis and preoperative embolization of the mass was performed.
Mammographic features of breast cancer in young symptomatic women
Authors: Zadelis Sophia , Houssami Nehmat
Published: December 2004

The present study provides a descriptive analysis of the mammographic appearance of breast cancer in women aged 30−39 years presenting with symptoms, based on 65 cancers confirmed with histology. We correlate the findings with clinical presentation and histological findings. We describe, categorize and illustrate the different lesions seen on mammography. Our study shows that microcalcification, with or without associated masses, is a dominant feature of breast cancer visualized on mammography in women in this age group.
Views of Australian and New Zealand radiation oncologists and registrars about evidence‐based medicine and their access to Internet based sources of evidence
Authors: Veness Michael , Rikard‐Bell Glenys , Ward Jeanette
Published: December 2004

In order to determine the views of Australian and New Zealand (ANZ) radiation oncologists and registrars about evidence‐based medicine (EBM) and their access to, and use of, Internet‐based EBM resources such as MEDLINE and the Cochrane Library, a self‐administered postal survey was sent out in December 2000. A total of 191 of 243 practicing ANZ radiation radiation oncoloists (138) and registrars (53) responded (78.6% response rate). The main outcome measures were: (i) views about EBM and its promotion; (ii) previous EBM training; (iii) extent of Internet access and level of MEDLINE use and access to online medical journals; (iv) awareness of the Cochrane Library and other EBM resources; and (v) self‐assessment of common EBM technical terms. The results of the survey found that most (82.7%) indicated a positive view of themselves towards the current promotion of EBM. However, significantly fewer perceived their colleagues were as positive (χ2 = 35.2, d.f. = 1, P < 0.001). Most (84.8%) considered research findings ‘useful’ in day‐to‐day management of patients. The majority (70.2%) of respondents never had attended an EBM course; however, most indicated interest in such training. The majority (73.8%) reported having accessed MEDLINE or another bibliographic database in the previous month. Seventy‐seven respondents (40.3%) reported that, in the past month, a literature search/article had influenced their practice. Only a minority (28.3%) used the Cochrane Library. Self‐assessment of most of the 12 EBM terms was generally high. For radiation oncologists, past attendance at an EBM course was significantly associated with a better overall self‐assessment of these 12 terms (χ2 = 10.59, d.f. = 1, P = 0.001). These findings reveal strong support for EBM among ANZ radiation oncologists and registrars with most regularly accessing the Internet for evidence. However, lack of awareness of some relevant EBM related resources, particularly the Cochrane Library, remains a challenge. Our findings invite a concerted effort by those promoting EBM to ensure clinicians have both the skills and knowledge to practice EBM.
Subperiosteal aneurysmal bone cyst with associated bone marrow oedema: An unusual appearance
Authors: Slavotinek John P , Wicks Andrew , Spriggins Anthony J
Published: December 2004

A case of a subperiosteal aneurysmal bone cyst with adjacent bone marrow oedema is presented. Aneurysmal bone cysts have been well documented in the published literature; however, relatively few have been observed in a subperiosteal location, and associated bone marrow oedema in the absence of a demonstrable pathological fracture is a rare finding. Aneursymal bone cyst should be considered in the differential diagnosis of subperiosteal bone lesions and may be associated with bone marrow oedema.
Challenges in maxillofacial reconstruction on secondary cleft deformities
Authors: Chow Tak‐Kun , Yu Ngok‐Fung , Tang Nin‐Cheung , Yan Sik‐Wing
Published: December 2004

Cleft surgery demands much on the meticulous surgical skills and aesthetic sense in relation to craniofacial growth and functions. With the understanding of genetic interplay and peer review on the surgical outcome, cleft surgeons have made great strides in treatment concept during the past decades. It is inevitable that secondary cleft deformities may rely on the cumulative effects of functional and morphological abnormalities from the stage of primary repair. Problems could range from uncorrected defects, complicated healing from initial repair, to some exaggerated developmental facial disharmonies as the patients attain adolescent or adult age. For this reason, the Cleft Palate Team is posed an immense challenge in treating the residual cleft deformities. Some of the challenges include large oronasal fistula, severe maxillary or midfacial retrusion, and pursuit of aesthetics on lip nose complex correction. These problems demand sophisticated surgical skills and sound understanding of craniofacial bio‐physiology. The sequential treatment strategy of secondary cleft reconstruction as practiced in the United Christian Hospital is considered as the foundation in the management of those challenging maxillofacial complexities. The purpose of the present paper is to share our sequential protocol practiced in the United Christian Hospital as a foundation to accomplish those maxillofacial complexities. Treated clinical cases demonstrate the innovative application of distraction osteogenesis on severe cleft skeletal correction, the use of tongue flap for repair of large oronasal defect, and corrective radical rhinoplasty with fascial graft augmentation. The last section of the present report is concentrated on the practical application of Nasal Symmetry Index for assessing result of cleft rhinoplasty.
Retrospective study of the utility of nuclear scintigraphic‐labelled red cell scanning for lower gastrointestinal bleeding
Authors: Levy Richard , Barto Walid , Gani Jon
Published: December 2004

Background:  The aim of the present study was to evaluate the utility of nuclear scintigraphic‐labelled red cell scanning in the management of bleeding in patients with acute lower gastrointestinal haemorrhage (GIH) who require surgery.

Methods:  A prospective database was used to source data on all patients with lower GIH who underwent technetium‐99m (99mTc)‐labelled red cell scanning over a 10‐year period. A subgroup was identified from cross‐reference with the medical records identifying only those patients who continued to bleed and subsequently required laparotomy for further detailed retrospective study. One key question was asked: did the labelled red cell scan influence the type of operation performed by the operating surgeon?

Results:  The study identified 249 patients who underwent 287 labelled red cell scans for GIH. Forty patients (16%) underwent laparotomy for ongoing bleeding; 28/40 (70%) of the red cell scans were positive for bleeding. Six patients (15%) died postoperatively, none because of continued bleeding. The 99mTc‐labelled red cell scan was deemed to have been unhelpful in 22 (55%) cases. Twelve of the 22 scans were negative and 10 of the 22 scans were positive but were ignored by the surgeon. The 99mTc‐labelled red cell scan influenced the choice of operation in 18 out of 40 patients (45% of the operated group but only 7.2% of the total scanned group). Of these, 15 patients underwent colonic resection and three patients underwent small bowel resection.

Conclusion:  The present study demonstrates that labelled red cell scanning has only a small role to play in managing lower GIH. The 99mTc‐labelled red cell scanning should be used much more selectively. Its use should be limited to patients who continue to bleed after conservative management; it may allow these patients to be effectively treated by segmental bowel resection. Its most critical role, however, is probably to prevent suspected small bowel bleeding from being missed at operation.
Vascular disease risk factor management 4 years after carotid endarterectomy: are opportunities missed?
Authors: Middleton Sandy , Harris John , Lusby Robert , Ward Jeanette
Published: December 2004

Background:  Because a large percentage of patients surviving carotid endarterectomy (CEA) subsequently die from a vascular cause, the aim of the present paper was to determine risk factor management for a cohort of patients 4 years after their CEA.

Methods:  Surviving patients who had a CEA within the region administered by the Central Sydney Area Health Service in 1995 were asked to complete a self‐administered questionnaire to determine vascular risk factors.

Results:  Of the 181 patients eligible to participate, 162 returned questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that they had been diagnosed with high blood pressure either before or after their CEA, only 79.2% recalled that their latest blood pressure reading was ‘about right for my age’. Nearly one in five (16.7%) who had had their cholesterol level checked in the last 12 months (n = 120) indicated that the reading was ‘too high’. Only 76.5% reported taking medications to ‘thin the blood’. Almost one‐fifth of patients (17.3%) were current smokers. Only 35.2% of patients participated in a level of physical activity sufficient to confer a health benefit. Further, 30.2% of patients were overweight and 14.8% were obese. The majority of patients (98.1%) reported having a regular general practitioner (GP). Of these, 98.7% had visited their GP at least once within the previous 6 months.

Conclusions:  Vascular risk factor management following CEA is suboptimal, inviting the implementation and evaluation of strategies to improve outcomes.
How should gynaecomastia be managed?
Authors: Daniels Ian R. , Layer Graham T.
Published: December 2004

Background:  The purpose of the present paper was to review the management of men referred to a breast clinic with presumed gynaecomastia.

Methods:  A retrospective analysis was carried out of 175 men over the age of 16 years who presented with breast enlargement and/or ‘lumps’, during a 7‐year period to a single‐surgeon. All patients had complete biochemical assessment (liver function tests, γ‐glutamyl transferase, prolactin, α‐fetoprotein, β‐human chorionic gonadotropin), and mammography and/or ultrasound with fine‐needle biopsy if indicated.

Results:  One hundred and seventy‐five men, median age 44 years (range: 18−89 years), were assessed. Thirty‐nine had bilateral true gynaecomastia and 88 had unilateral gynaecomastia (53% left). Carcinoma of the breast was diagnosed in eight, pseudo‐­gynaecomastia in 18, 13 had physiological pubertal changes only and nine had other diagnoses. Adverse drug reactions were possibly implicated in the aetiology of 47 patients, alcohol in seven patients, cannabis in one patient, testicular malignancy in four patients and hepatocellular carcinoma in one patient. Five patients were found to have hyperprolactinaemia. Twenty‐four per cent of patients were reassured without intervention; 18% failed to attend follow up. Sixteen per cent were treated with danazol, 15% underwent surgery and 28 were referred for management of their cause. Danazol was effective in 81%, and three patients required surgery when danazol was ineffective. One further patient developed testicular cancer 9 months after presentation.

Conclusion:  Men presenting to a breast clinic require clinical assessment to exclude diagnoses other than gynaecomastia. True gynaecomastia can be managed with exclusion of causative factors by non‐invasive investigation and examination. Many patients can be reassured as to the idiopathic nature of the condition and many will fail to attend follow up. Danazol is successful in some patients and surgery should be reserved for resistant cases.
Recognition and management of biliary complications after laparoscopic cholecystectomy
Authors: Thomson Benjamin N. J. , Cullinan Mark J. , Banting Simon W. , Collier Neil A. ,   on behalf of the Universities of Melbourne Hepatobiliary Group
Published: December 2004

Introduction:  Injuries to the extrahepatic biliary tree at laparoscopic cholecystectomy cause major morbidity and are a major source of litigation. Injuries are often diagnosed late, leading to further complications and decreasing the chance of a successful repair.

Methods:  A prospective study was carried out of all patients with extrahepatic biliary injuries from cholecystectomy who were referred to the surgeons of the Universities of Melbourne Hepatobiliary Group between 1997 and 1999.

Results:  Twenty‐seven patients sustained biliary injuries to the extrahepatic biliary tree. Twenty patients (74%) had unrecognized injuries at the time of cholecystectomy. The median time to referral was 9 days. Only two of 11 operative cholangiograms were interpreted as showing a biliary injury.

Conclusion:  Biliary injuries are still occurring at laparoscopic cholecystectomy. Guidelines about the management of a suspected biliary injury are discussed. Clinical, radiological and pathological assessment should enable prompt diagnosis and management should be instituted early, preferably with the involvement of a hepatobiliary specialist.
Improving the evidence‐base in surgery: evaluating surgical effectiveness
Authors: Young Jane M. , Solomon Michael J.
Published: December 2004

This second of two articles about clinical epidemiology reviews the generation and synthesis of evidence for the effectiveness of surgical procedures. While well‐designed randomized controlled trials of surgical procedures are considered the ‘gold standard’ of evaluation design, they may achieve high internal validity at the expense of external validity (generalizability). Improving the ­evidence‐base in surgery likely will require a comprehensive approach to surgical outcomes assessment, involving both improvements in the quality and quantity of randomized controlled trials as well as recognition of the complementary role of alternate study designs.
Granulomatous appendicitis progressing to Crohn's disease with bleeding complication
Authors: Ho Pei , Law Wai Lun , Choy Carolyn , Chan Gavin Shueng‐Wai , Chu Kin Wah
Published: December 2004

Granulomatous appendicitis can be idiopathic or due to a number of specific causes. Idiopathic granulomatous appendicitis is regarded as a separate disease entity and usually has a benign course. We report on a case of granulomatous appendicitis, which progressed to fulminant Crohn's colitis shortly after appendicectomy. During the treatment with intravenous steroid, torrential gastro­intestinal bleeding developed and emergency subtotal colectomy had to be performed. The clinical and histological features of the case are presented and the literature on granulomatous appendicitis reviewed.
Spinal cord injuries in Australian footballers
Authors:   Spinecare Foundation and The Australian Spinal Cord Injury Units
Published: December 2004

Background:  Acute spinal cord injury is a serious concern in football, particularly the rugby codes. This Australia‐wide study covers the years 1986−1996 and data are compared with those from a previous identical study for 1960−1985.

Methods:  A retrospective review of 80 players with a documented acute spinal cord injury admitted to the six spinal cord injury units in Australia. Personal interview was carried out in 85% of the participants to determine the injury circumstances and the level of compensation. The severity of the neurological deficit and the functional recovery were determined (Frankel grade).

Results:  The annual incidence of injuries for all codes combined did not change over the study period, but there was some decrease in rugby union and an increase in rugby league. In particular there was a significant decline in the incidence of adult rugby union injuries (P = 0.048). Scrum injuries in union have decreased subsequent to law changes in 1985, particularly in schoolboys, although ruck and maul injuries are increasing; 39% of scrum injuries occurred in players not in their regular position. Tackles were the most common cause of injury in league, with two‐on‐one tackles accounting for nearly half of these. Schoolboy injuries tended to mirror those in adults, but with a lower incidence. Over half of the players remain wheelchair‐dependent, and 10% returned to near‐normality. Six players (7.5%) died as a result of their injuries.

Conclusions:  The rugby codes must be made safer by appropriate preventative strategies and law changes. In particular, attention is necessary for tackle injuries in rugby league and players out of regular position in scrummage. Compensation for injured players is grossly inadequate. There is an urgent need to establish a national registry to analyse these injuries prospectively.
Off‐pump technique in coronary artery bypass grafting in elderly patients
Authors: Yuan Lin Chih‐ , Hong Gou‐Jieng , Lee Kou‐Chen , Loh Shih‐Hurng , Tsai Chien‐Sung
Published: December 2004

Background:  The use of cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG) is associated with substantial morbidity and mortality, especially in the elderly. The purpose of this study was to evaluate the feasibility of beating heart coronary artery revascularization in patients aged at least 80 years.

Methods:  A retrospective chart review was carried out for 17 patients aged over 80 years who underwent isolated off‐pump CABG at the Tri‐Service General Hospital, Taiwan, during the period July 1999 to December 2000. The demographic characteristics, operative data, postoperative results and short‐term outcomes of patients were compared with those of 12 patients who underwent conventional CABG using CPB during the same time period.

Results:  The off‐pump group consisted of 13 men and four women with a mean age of 82.2 ± 0.9 years and an ejection fraction of 53.4 ± 4.1%. The on‐pump group consisted of eight men and four women with a mean age of 83.5 ± 0.5 and an ejection fraction of 42.0 ± 4.8%. The mean number of anastomoses performed per patient was 3.1 ± 0.3 in the off‐pump group and 3.0 ± 0.14 in the on‐pump group. There was no occurrence of stroke, myocardial infarction, re‐entry for bleeding or renal failure among patients in the off‐pump group. Intubation time (10.6 vs 48.4 h), intensive care unit stay (2.9 vs 4.2 days) and postoperative stay (12.7 vs 18.1 days) were significantly shorter in the off‐pump group than in the on‐pump group. No patient died in the off‐pump group, whereas one patient died in the on‐pump group.

Conclusions:  The results of this study suggest that the off‐pump technique is a safe and efficacious method for myocardial revascularization in elderly patients and that the short‐term outcome obtained with this technique are promising. Our data suggest that the off‐pump technique is preferable in these patients.
Sentinel lymph node dissection in papillary thyroid carcinoma
Authors: Chow Tam‐Lin , Lim Boon‐Hua , Kwok Samuel Po‐Yin
Published: December 2004

Background:  Occult lymph node (LN) metastasis is common in papillary thyroid carcinoma. Sentinel lymph node (SLN) biopsy has been proven to be successful and accurate to predict the nodal status in melanoma and breast cancer. We investigate the use of SLN in papillary thyroid carcinoma.

Methods:  Patients of previously untreated papillary thyroid carcinoma, diagnosed preoperatively by fine‐needle cytology without any palpable cervical LN are prospectively studied. Blue dye injection was utilized for the SLN biopsy followed by central compartment lymphadenectomy. The histopathological results of the SLN and lymphadenectomy specimens were compared.

Results:  Fifteen consecutive patients underwent surgery including SLN biopsy for papillary thyroid carcinoma. Occult nodal metastases were identified in 10 patients (67%). The other five cases had no nodal metastasis. SLN were found in 10 cases. One, two and three SLN were present in three, three and four patients, respectively. SLN were located in the central compartment in eight cases. The SLN were found in the lateral compartment in one case. In the remaining one case, the SLN were found in both the central and lateral compartments. Of the group with found SLN, false negative occurred in one case. The overall accuracy of the SLN in predicting the nodal status was 90%. The sensitivity, specificity, positive predictive value and negative predictive value were 88%, 100%, 100% and 67%, respectively. No complications were directly related to SLN biopsy.

Conclusion:  Occult nodal spread is frequently encountered in papillary thyroid carcinoma. SLN biopsy is safe and feasible in papillary thyroid cancer, however further studies are necessary to improve the diagnostic accuracy prior to routine clinical use.