bluuebunny/crossref_metadata_2025 huggingface dataset:
A REVIEW OF ‘TRADITIONAL’ ABORIGINAL HEALTH BELIEFS
Authors: Maher Patrick
Published: March 2003

Western health professionals often experience difficulties in service delivery to Aboriginal people because of the disparity between Aboriginal and Western health belief systems. This article reviews the literature which considers ‘traditional’ Aboriginal health beliefs and medical systems. The traditional Aboriginal model of illness causation emphasises social and spiritual dysfunction as a cause of illness. Supernatural intervention is regarded as the main cause of serious illness. There are gender divisions in Aboriginal society that impact on the delivery of Western healthcare. Management strategies such as preventative care, bush medicine, and the role of traditional healers are discussed. These belief systems are considered with particular reference to their interactions and implications with regard to the Western medical system. This information provides a framework to allow improved understanding by health professionals of the health‐related decisions made by Aboriginal people.
A POTTED HISTORY OF 19TH‐CENTURY REMOTE‐AREA NURSING IN AUSTRALIA AND, IN PARTICULAR, QUEENSLAND
Authors: Yuginovich Trudy
Published: March 2003

ABSTRACT

Knowledge of the history of remote‐area nursing in Australia is necessary if we are to truly understand the processes that have dictated the boundaries and reality of the scope of practice for today’s RANs (remote‐area nurses). This paper briefly explores and discusses the social context and history of remote‐area nursing in Australia and, in particular, Queensland during the 19th century.
INEQUITABLE DISTRIBUTION OF GENERAL PRACTITIONERS IN AUSTRALIA: ANALYSIS BY STATE AND TERRITORY USING CENSUS DATA
Authors: Wilkinson David
Published: March 2003

ABSTRACT

The objective of this study was to describe the distribution of general practitioners in each State and Territory, stratified by statistical division and adjusted for estimated community need. The location of general practitioners was obtained from the 1996 Census of Population and Housing. Community need was estimated from crude death rates supplied by the Australian Bureau of Statistics. On average there are 920 people per full‐time general practitioner in Australia. Three States are relatively oversupplied by up to 5% (Australian Capital Territory) and the rest are relatively undersupplied by up to 12% (Western Australia). Adjusted for estimated need, the Australian Capital Territory is oversupplied by 71% compared with all of Australia, while Western Australia is undersupplied by 15%. More marked differences occur within the States, with the statistical division containing each capital city in each State that is relatively overserved. The greatest oversupply is in Sydney, where 33% fewer people share a full‐time general practitioner than the whole of New South Wales (adjusted for need, oversupply in Sydney is 63%). Relative undersupply is greatest in Queensland, with 133% more people sharing each general practitioner in the north‐west statistical division compared with the whole State. The distribution of general practitioners between and within States and Territories is unequal and inequitable. In each State, capital cities tend to be relatively oversupplied compared with more rural areas. While these data do not inform the absolute level of service needed in a community, they do suggest that strategies to redress the inequitable distribution are required.
Mechanics of an Educational Exchange
Authors: Pearce Christopher , Korda Elizabeth
Published: March 2003

Rural general practitioners occasionally exchange practices internationally. The process of exchanging is a complicated one, which involves multiple bureaucarcies. Exchanging is not for the anxious or impatient. We exchanged with a family physician in Canada and had to arrange registration, provider numbers and immmigration for our Canadian colleague, as well as for ourselves in Canada. In addition, there are many personal details (cars, house, etc.) that must also be sorted out.
Patterns of Use of Complementary Health Services in the South‐West of Western Australia
Authors: Sherwood Patricia
Published: March 2003

The objective of this research was to identify patterns of complementary health service usage by rural Western Australians in the south‐west of the State. Complementary health providers identified by health users included homeopaths, chiropractors, naturopaths, acupuncturists, faith healers, herbalists, reiki or energy workers, counsellors, physiotherapists, osteopaths, podiatrists and reflexologists. More than half of the health provider usage in the region was with complementary therapists and the remainder with medical doctors. The main reason identified for using complementary therapists was their level of skills and the main reason identified for not using them was a lack of knowledge about what their services could provide.
BRIGHT STARS IN THE SKY?
Authors: Lipscombe Joan , Gregory Gordon
Published: March 2003

ABSTRACT

Actions to improve the health of people in rural and remote areas are supported by people’s ability as individuals and as a community to take part actively in the design, management and evaluation of their own health services. To do this successfully, people need information about their health, resources to support their actions and political support or legitimacy. This article focuses on the third requirement. At the beginning of 2000, there seems to be strong political interest in improving the status of rural communities and rural services overall, including rural health and health services. The constellation of events that contribute to this encouraging state of affairs includes the Regional Australia Summit that was held in October 1999, the existence of a strategic framework for rural health that was agreed on by all health jurisdictions (Healthy Horizons), improved clarity about the relative state of health and health service utilisation in rural and remote areas, and the Prime Minister’s recent commitment to improve rural services. The next major national opportunity to convert these positive signs into action comes with the Federal Budget in May 2000, the content of which will be closely watched by people concerned about improving health in country areas.
BRIEF THERAPY FOR CHILDREN’S MENTAL HEALTH PROBLEMS: OUTCOMES IN A RURAL SETTING
Authors: Allison Stephen , Roeger Leigh , Dadds Vikki , Martin Graham
Published: March 2003

In rural areas where specialist services are not readily accessible, there are practical advantages to providing short courses of therapy for children’s mental health problems. Fifty‐five parents from a rural area in South Australia completed questionnaires before and 3 months after receiving brief, family‐orientated therapy from a child and adolescent mental health service. Clinically, these families were assessed as being suitable for brief therapy because the children had moderately severe emotional and behavioural problems and the families were not severely dysfunctional. The screening process sought to exclude more serious and complex presentations so those families were not included in the current study. Questionnaires measuring the severity of children’s mental health problems (Child Behavior Checklist) and the degree of family dysfunction (Family Assessment Device general functioning subscale) suggested that, on average, the sample met these entry criteria. The follow‐up evaluation after brief therapy found significant overall improvement in the Child Behavior Checklist scores, however some children continued to show substantial difficulties. Parents’ satisfaction with therapy was related to these scores after treatment. The results suggest that brief therapy was appropriate for most of the families and that routine follow‐up could help determine those who might benefit from further assistance.
ISSUES INFLUENCING THE PROVISION OF PALLIATIVE CARE SERVICES TO REMOTE ABORIGINAL COMMUNITIES IN THE NORTHERN TERRITORY
Authors: McGrath Catharine L.
Published: March 2003

Palliative care is a service available to many Australians subject to location and varying criteria. This paper seeks to identify some of the issues that hamper the provision of this sophisticated service to Aborigines living in remote parts of the Northern Territory. The paucity of literary sources of information demonstrates the need for research to be carried out in this field.
Why nurses are attracted to rural and remote practice
Authors: Hegney Desley , McCarthy Alexandra , Rogers‐Clark Cath , Gorman Don
Published: March 2003

Abstract:  This is the second paper of a larger study that examined the factors influencing the decisions of rural and remote area nurses, formerly employed by Queensland Health, to leave or to remain in this area of nursing. The study was a cross‐sectional survey that gathered data from nurses who had resigned from permanent positions in Queensland Health during the period February 1999 to May 2000. This paper reports only those factors that influenced their decision to remain in rural and remote area practice, which can be categorised into personal, professional and rural influences. The results of this study are congruent with previous national and international research findings into these issues for nurses in rural and remote areas. The paper makes recommendations to attract nurses to the rural and remote work force.
Lacrimal gland abscess: Two case reports
Authors: McNab Alan A
Published: March 2003

Background: Bacterial dacryoadenitis is rare and suppuration leading to abscess formation within the lacrimal gland has been very rarely reported in the antibiotic era.

Methods: The medical records and investigation results, including computed tomography (CT), of two patients with lacrimal gland abscess were reviewed.

Results: Two cases of lacrimal gland abscess, one a 28‐year‐old male and the other a 64‐year‐old female, are described. Both demonstrated a characteristic low‐density area within an enlarged lacrimal gland on CT. The first case had been treated with antibiotics and the abscess, when drained, was sterile. The second case settled spontaneously. Neither patient suffered any sequelae of dry eye.

Conclusions: Although rare, lacrimal gland abscess may still occur and may require surgical drainage if spontaneous resolution does not occur.
Posterior uveitis in Hodgkin’s disease
Authors: Towler H , De La Fuente M , Lightman S
Published: March 2003

Purpose: To describe the features of posterior uveitis in patients who either developed or were known to have, biopsy‐proven Hodgkin’s disease (HD).

Methods: Four patients were identified who were attending the uveitis clinic. Their charts were reviewed retrospectively and information on their HD was obtained from other hospitals where necessary. Their case histories are presented.

Results: Two patients presented with uveitis prior to the diagnosis of HD and in the other two, the HD was thought to be in remission. The commonest ocular signs were of vitritis and discrete, white, chorioretinal lesions. No difference in the ocular findings were apparent between those who had a known diagnosis of HD and the those that did not.

Conclusions: HD can occur in the eye and can mimic posterior uveitis. In two of the patients, the uveitis preceded the diagnosis of HD and at the time of presentation all investigations were normal. No specific diagnostic features were apparent, though three of the patients had vitritis and chorioretinal lesions.
Psychiatrists' Recommendations for Improving Bicultural Training and Maori Mental Health Services: A New Zealand survey
Authors: Johnstone Kelly , Read John
Published: March 2003

Objective: In the context of Maori being over-represented as clients, and under-represented as professionals in New Zealand's mental health system, this study ascertained the beliefs of New Zealand's psychiatrists about issues pertaining to Maori mental health. The overriding objective was to gather recommendations as to how to improve bicultural training and mental health services for Maori.

Method: A questionnaire involving closed and open-ended questions was sent to 335 New Zealand psychiatrists.

Results: Of the 247 psychiatrists (74%) responding, 40% believed their training had prepared them to work effectively with Maori. Recommendations for improving training focused on the need for greater understanding of Maori perspectives of well-being. Recommendations for improving mental health services for Maori highlighted the need for more Maori professionals and for Maori-run services. No psychiatrists thought that pakeha clinicians should not work with Maori clients, but the majority (70%) recognised the need to consult with Maori staff when doing so. Twenty-eight psychiatrists (11.3%), all male, New Zealand born, and with 10 or more years clinical experience, believed that Maori were biologically or genetically more predisposed than others to mental illness. Several respondents offered other racist comments.

Conclusions: The high response rate and the many positive recommendations suggest a high level of constructive interest in these issues among psychiatrists. Comparisons with a simultaneous survey of psychologists are made. It is hoped that the recommendations might inform those responsible for training programs and for providing or purchasing mental health services.
The Trajectory of Psychiatric Disorders in Young People with Intellectual Disabilities
Authors: Tonge Bruce , Einfeld Stewart
Published: March 2003

Objective: This study addresses the question of how prevalence and patterns of psychiatric disorder change from childhood to adolescence in young people with intellectual disability (ID).

Method: A representative epidemiological sample of 582 young people with ID aged 4–19 years was surveyed in 1991–1992 and again in 1995–1996. The main measure of psychiatric disturbance was the developmental behaviour checklist (DBC), a 96 item parent/carer completed questionnaire with robust psychometric properties which provided an overall score, 6 subscale or syndrome measures of psychiatric disturbance and determined caseness.

Results: The findings confirmed that about 40% of young people with ID had psychiatric disorders which persisted over 4 years. Clinically significant change in symptoms with either deterioration or improvement occurred in around 14% of the sample.

Conclusion: Psychiatric disorder is 3–4 times more prevalent in young people with ID than in the general population. Less than 10% of these young people receive specialist services for a problem which is numerically as large as schizophrenia.
Successful Treatment of Behavioural Problems in Dementia Using a Cholinesterase Inhibitor: The Ethical Questions
Authors: Coulson Brett S , Coulson Brett S , Fenner Stephen G , Almeida Osvaldo P
Published: March 2003

Objective: To review the effect of cholinesterase inhibitors on the behavioural and neuropsychiatric symptoms of dementia and discuss the current clinical guidelines for the prescription of cholinesterase inhibitors in Australia.

Method: This paper reports the case of a patient with clinical diagnosis of dementia with lewy bodies (DLB) who was referred to an old age psychiatry service for the treatment of severe visual hallucinations and behavioural problems.

Results: Pharmacological treatment with olanzapine produced marked parkinsonism, agitation and confusion. A cholinesterase inhibitor, donepezil, was introduced. The introduction of donepezil was associated with cognitive improvement (mini-mental state examination [MMSE] increased from 23 to 27) and complete remission of behavioural symptoms.

Conclusion: That cholinesterase inhibitors may have a role in the management of behavioural symptoms of dementia and the current Australian PBS guidelines for prescribing cholinesterase inhibitors are clinically restrictive. This has clinical and ethical implications that need to be addressed by consumers, the medical community and regulating authorities.
First-Episode Mania: A Neglected Priority for Early Intervention
Authors: Conus Philippe , Conus Philippe , Mcgorry Patrick D
Published: March 2003

Objective: While first-episode (FE) psychosis has become an important field of research, FE affective psychoses, and mania in particular, have been relatively neglected. This paper summarizes current knowledge about FE mania and explores the potential for early intervention.

Method: The main computerized psychiatric literature databases were accessed.

Results: When functional as well as symptomatic variables are considered, the outcome of mania is not as good as was formerly believed, a characteristic which is already present from the first episode. Various factors (lower socio-economic status, younger age at onset of illness, poor adherence to treatment, presence of comorbidity) have been identified as possible predictors of poor outcome. The prognostic value of the presence of psychotic symptoms and their congruence to mood, as well as the diagnostic subgroup, is less well established. This literature review also reveals striking similarities between manic and schizophreniform first episodes. Poor functional outcome in a significant proportion of patients following the first episode, high risk of suicide, high prevalence of comorbid diagnoses, worse outcome with a younger age at onset and with longer delay until treatment is initiated, and finally early presence of neuro-anatomical changes, are observed in both syndromes.

Conclusions: This pattern justifies the development of early intervention strategies for FE manic patients and supports more exploratory research to identify prodromal symptoms, which might ultimately lead to even earlier focus on preventive interventions.
Changes in the Rate of Diagnosis of Major Depression in Adolescents Following Routine Use of a Depression Rating Scale
Authors: Rey Joseph M , Grayson David , Mojarrad Tayebeh , Walter Garry
Published: March 2003

Objective: Because major depression in adolescents often goes undiagnosed, it is useful to establish whether clinicians’ rates of making this diagnosis in a specialist adolescent mental health service change when a self-rating depression scale is routinely administered.

Method: A retrospective, naturalistic study examining the rate of diagnosis of major depression in a mental health service between 1993 and 1997. The intervention was the administration of the Center for Epidemiological Studies Depression Scale (CES-D) prior to initial assessment from September 1995 onwards. The proportion of clinical diagnoses of DSM-III-R or DSM-IV major depression was the outcome measure. Age, gender, ratings of depression and other confounding variables were used to control for changes in patient population over time.

Results: One thousand three hundred and ten adolescents aged 12 to 17 years assessed between 1993 and 1997 were included. After taking into account potential confounders, diagnosis of major depression was 2.8 times (95% confidence interval 1.8, 4.3) as likely when the CES-D was in use. Increase was more marked when adolescents were more disturbed overall. There was no evidence suggesting this was due to changes in diagnostic practices or in the patient population.

Conclusion: Availability to clinicians of a self-rating depression scale completed prior to assessment was associated with an increase in the frequency of diagnosis of depression in a specialist mental health service for adolescents.
Delayed-Onset Posttraumatic Stress Disorder: A Prospective Evaluation
Authors: Bryant Richard A , Harvey Allison G
Published: March 2003

Objective: Delayed onset posttraumatic stress disorder (PTSD) refers to PTSD that develops at least 6 months after the traumatic event. This study aimed to index the features of patients who develop delayed-onset PTSD.

Method: This study investigated delayed onset PTSD by prospectively assessing 103 motor vehicle accident survivors within 1 month of the motor vehicle accident for acute stress disorder, and subsequently assessing them for PTSD 6 months post-accident, and 2 years post-accident. Patients were initially assessed for symptoms of traumatic stress, anxiety, depression, and resting heart rate.

Results: Five patients displayed PTSD 2 years post-trauma without meeting PTSD criteria 6 months posttrauma. Delayed onset cases were characterized by elevated psychopathology scores and resting heart rate levels within the initial month and elevated psychopathology 6 months posttrauma.

Conclusions: These findings suggest that cases of delayed onset PTSD suffer subsyndromal levels of posttraumatic stress prior to the diagnosis of PTSD. These findings challenge the notion of PTSD developing after a period without symptoms.
The Written Report in Consultation–Liaison Psychiatry: A Proposed Schema
Authors: Alexander Timothy , Bloch Sidney
Published: March 2003

Objective: The consultation–liaison psychiatry (CLP) written report serves several crucial functions; it therefore needs to be presented in a meaningful format to its readers. Surprisingly little has been written about its optimal nature. Our aim is to offer a schema which promotes effective communication.

Methods: We have reviewed pertinent literature, consulted with CLP colleagues and convened a focus group that a number of them attended.

Results: The core functions of the CLP report are to offer the referrer (and other relevant professionals) key comprehensible findings, recommendations for treatment and advice for follow up. Additional purposes are educational, archival and medico-legal. Our schema contains eight sections: Who is the patient? Why you referred the patient to us at this particular time? What did we find? Who are the patient's family and other supports? How do we understand these findings? What do we recommend regarding management? What further clinical developments have ensued? and What do we recommend regarding psychosocial follow-up? We provide guidelines concerning the content of each section and illustrate the use of the schema with two clinical cases.

Conclusions: The functions of the CLP report are not satisfied through conventional psychiatric-history note taking. Our related yet different framework is inclined to be a more effective means to convey necessary clinical data and treatment recommendations.
Distributing Mental Health Care Resources: Strategic Implications from The National Survey of Mental Health and Wellbeing
Authors: Meadows Graham , Burgess Philip , Bobevski Irene
Published: March 2003

Objective: This paper considers mental health services resource distribution under the Australian second national mental health plan, with its direction to mental health services to be more inclusive of people with higher prevalence psychiatric disorders. We consider inequalities in mental health in Australia, and describe the performance of the composite census variable employed in the Victorian mental health funding distribution formula, the index of relative socioeconomic disadvantage (IRSED), in predicting disorder rates and perceived needs for care.

Method: We review data sets generated through the National Survey of Mental Health and Wellbeing (NSMHWB) for their utility in development of resource distribution formulae. We present analyses from the 10 641 cases examined in the household survey to explore the role of the IRSED in predicting prevalence rates of anxiety, affective, substance misuse and other disorders, as well as perceived need for care.

Results: Recent epidemiological studies provide some additional sources of data to guide resource distribution, although the available data sets are found not to be optimized for examination of this issue. Greater levels of socioeconomic disadvantage of areas are associated with increased rates of morbidity in metropolitan areas, with different patterns for different disorder groups. The influence of the IRSED is more complex outside the major cities.

Conclusions: The descriptive epidemiological data now available, despite significant investment, are relatively crude instruments for this current purpose. The findings support the case for using the IRSED as a proxy indicator for morbidity for the high prevalence disorders, but only within metropolitan areas. This examination confirms the existence of significant inequalities in mental health between Australian urban areas with different socioeconomic characteristics.
THE ROLE OF PERITONEAL IMMUNITY AND THE TUMOUR‐BEARING STATE ON THE DEVELOPMENT OF WOUND AND PERITONEAL METASTASES AFTER LAPAROSCOPY
Authors: Mathew George , Watson David I. , Ellis Tanya S. , Jamieson Glyn G. , Rofe Allan M.
Published: March 2003

Background: The effect of the tumour‐bearing state and alterations in peritoneal immune function on the incidence of port‐site and peritoneal metastases was investigated after laparoscopy with and without CO2 pneumoperitoneum.

Methods: A suspension of viable adenocarcinoma cells was introduced into the left upper quadrant of the peritoneal cavity of syngeneic tumour‐bearing rats at laparotomy, laparoscopy with CO2, and gasless laparoscopy. Control rats did not have pre‐existing tumours. A group of non‐tumour‐bearing rats were also injected intraperitoneally with endotoxin 4 h before intraperitoneal tumour cell injection. Six days later the peritoneal cavity and surgical wounds were examined for macroscopic evidence of implanted tumour. Peritoneal macrophages were obtained from tumour‐bearing rats subjected to different laparoscopic procedures and the activation state measured following exposure to lipopolysaccharide in vitro.

Results: In the control rats, tumour implantation in the surgical wounds and peritoneum was significantly greater in the rats that had undergone laparoscopy with CO2. The presence of a pre‐existing tumour was associated with increased tumour spread in all treatment groups and at most sites. Injection of endotoxin also resulted in increased tumour spread. Peritoneal macrophages from control and tumour‐bearing rats who underwent laparoscopy with CO2 produced significantly less TNF‐αin vitro, compared to gasless laparoscopy or laparotomy.

Conclusions: Carbon dioxide insufflation enhances tumour spread and implantation. The underlying immune or metabolic status of the host, as influenced by the tumour‐bearing state or modification of the peritoneal environment, also has a marked independent effect on tumour spread and implantation. The immune and metabolic status of the peritoneum including the extent of macrophage activation is implicated in this effect.
SERUM LEVELS OF INSULIN‐LIKE GROWTH FACTOR BINDING PROTEIN‐3 IN BENIGN AND MALIGNANT BREAST DISEASE
Authors: Holdaway I. M. , Mason B. H. , Lethaby A. E. , Singh V. , Harman J. E. , Maccormick M. , Civil I. D
Published: March 2003

Background: The insulin‐like growth factors IGF‐I and IGF‐II and their major binding protein IGFBP‐3 influence the growth of breast cancer cells in vitro. Some benign non‐breast tumours appear to be associated with increased serum IGFBP‐3 levels which would tend to reduce bioactive‐free IGF concentrations. The present study investigates whether this pattern also occurs in neoplastic breast disease.

Methods: Serum IGF‐I, IGF‐II and IGFBP‐3 were measured by specific radioassay in 12 women with benign breast disease, 31 patients with breast cancer and in age‐matched controls.

Results: The mean (± SD) serum IGFBP‐3 concentration was higher in benign breast disease (3.6 ± 0.7 mg/L) than in controls (2.7 ± 0.6 mg/L) or in breast cancer patients (2.7 ± 0.5 mg/L) (P = 0.001). Serum IGF‐I and IGF‐II levels were not significantly different among the groups. However, the index of free unbound IGF measured as the molar ratio of IGF‐I plus IGF‐II divided by IGFBP‐3 was significantly lower in benign breast disease than in the other subjects.

Conclusions: Either the production or clearance of IGFBP‐3 is altered in benign breast disease so that there is less free IGF available to cells. This may serve to protect against malignant transformation in patients with benign breast disorders.
STERILIZATION OF HIV WITH IRRADIATION: RELEVANCE TO INFECTED BONE ALLOGRAFTS
Authors: Campbell D. G. , Li P.
Published: March 2003

Background: Bone allograft banks commonly sterilize frozen bone by irradiation. The dose–response relationship for HIV is calculated and the dose required to inactivate the bioburden of virus that may be present in allograft bone is determined.

Methods: A virus titre experiment is performed using irradiated frozen HIV. The virus is maintained on dry ice (approximately –70°C) and is exposed to a cobalt 60 source with 0–40 kGy irradiation at 5 kGy intervals. Lymphocyte cell cultures are exposed to serial dilutions of the irradiated virus. The virus titre is quantified by cytological changes of HIV infection and p24 immunofluorescence.

Results: There is a linear relationship between the virus titre and the radiation dose delivered. The inactivation rate of irradiated virus was 0.1134 log10 tissue culture infective doses 50/mL per kGy (95% confidence intervals, 0.1248–0.1020). The irradiation dose required to inactivate the HIV bioburden in allograft bone is 35 kGy. The irradiation dose required to achieve a sterility assurance level of 10–6 is 89 kGy. This dose exceeds current recommendations for sterilizing medical products and the current practice of many bone banks.

Conclusions: It is concluded that gamma irradiation should be disregarded as a significant virus inactivation method for bone allografts.
ATLS: ARE WE TRAINING THE WRONG PEOPLE?
Authors: Hughes Geoff , Price Andrew
Published: March 2003

Background: Despite the evolution, expansion and popularity of emergency medicine as a medical specialty in the United Kingdom (UK), emergency departments are still primarily staffed by senior house officers (second and third year graduates), particularly at weekends and at night.

Methods: A telephone and postal survey of Advanced Trauma Life Support (ATLS)® training completed by this cohort of doctors indicates that UK courses are failing to train adequate numbers.

Results: It can thus be argued that ATLS is not being disseminated to the relevant grass‐roots of medical care, where it is likely to be of the most benefit.

Conclusions: The present study discusses possible reasons for this and offers constructive solutions to the problem. Although the matters discussed in this study refer to UK medical practice, they may be of relevance and interest to Australasian practitioners. Is EMST in Australasia training the appropriate group of doctors?
THE JOHN GRAHAM EXTRICATION PRIZE: ITS HISTORY AND IMPORTANCE
Authors: Miller BRIAN J.
Published: March 2003

Background: The Early Management of Severe Trauma (EMST) course is unique in providing instructive exposure to techniques used in the extrication of severely injured victims from difficult locations using a role play method. Dr John C. Graham FRACS, vascular surgeon in Lismore, was responsible for the initiation of this concept in 1989. Since this component of the trauma course is not used in the Advanced Trauma Life Support (ATLS)® course in the USA, from which the EMST course was derived, the purpose of the present study is to determine the opinions of all EMST course directors as to the value of including an extrication scenario station in the EMST course in its current form in Australia and New Zealand.

Methods: The extrication station as devised by John Graham consists of four 40 min scenarios offered to all 16 participants of an EMST course in groups of four. The participants are required to extricate a moulaged victim from a difficult location within the time available in the most skilful and expeditious manner. A prize is offered for the group performing the task best. A survey of the 45 EMST course directors was undertaken by questionnaire. Replies were anonymous.

Results: There was a good response rate of 87%. Ninety‐two per cent of responding directors routinely used an extrication station. Two directors used the station occasionally and only one director never used it. The most frequently cited reason for use was that the participants come to appreciate commonly encountered problems in extrication, and how EMST principles are applied in the field. Second, the station allows the use of teamwork. Third, it adds entertainment to the course overall. There was a prize awarded by every course director for the winning group of participants. Ninety per cent of these prizes were named the ‘John Graham Extrication Prize’.

Conclusions: The extrication station is considered constructive by the great majority of EMST directors. Both historical and competitive aspects are important since most directors still award a named prize for this station. The extrication station promotes a feeling of cohesion among Faculty and participants on an EMST course. The station is a memorable event for many participants and should be retained as a uniquely Australasian contribution to the course.
NITRIC OXIDE BIOSYNTHESIS AND MALONDIALDEHYDE LEVELS IN ADVANCED BREAST CANCER
Authors: Alagöl H. , Erdem E. , Sancak B. , Turkmen G. , Camlibel M. , Bugdayci G.
Published: March 2003

Background: Nitric oxide (NO) is a free oxygen radical studied in many tissues. Its tumour killing structure is shown especially by macrophages. The end products of NO are nitrite and nitrate. Their plasma levels are used biochemically to determine nitric oxide synthase (NOS) activity. The proliferative capacity of cancer cells accompanies the alteration in oxidant–anti‐oxidant status. The risk of breast cancer is decreased in association with an increased level of polyunsaturated fatty acids in the erythrocyte membranes. The more the anti‐oxidant capacity increases, the more the transformed cells grow. Malondialdehyde (MDA) is a lipid peroxidation marker, and low plasma levels of MDA are associated with advanced stages of breast cancer.

Methods: In the present study, the alteration of serum plasma levels of nitrate, nitrite and MDA were determined in patients with stage IIIB breast cancer and controls.

Results: It was found that products of NO biosynthesis were higher and plasma MDA levels were lower in patients with breast cancer.

Conclusions: It can be stated that in advanced breast cancer, the NO radical production is increased while the lipid metabolism is altered, and these changes can be related to an alteration in oxidant–anti‐oxidant status.
THE COST OF ELECTIVE AND EMERGENCY REPAIR OF AAA IN PATIENTS UNDER AND OVER THE AGE OF 80
Authors: Bagia J. S. , Robinson D. , Kennedy M. , Englund R. , Hanel K.
Published: March 2003

Background: As Australia’s population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained.

Methods: A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN‐DRG) costs.

Results: Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30 000) and group D patients ($60 000). In comparison with AN‐DRG calculated costs, the true costs of groups A and B were equivalent to AN‐DRG costs. In the emergency groups, how‐ ever, there were marked discrepancies between the true cost ($61 000) and that calculated by the DRG ($25 000) in group D, with similar differences seen in group C to a lesser extent.

Conclusion: Emergency repair of AAA is significantly more expensive and has a high mortality in the over‐80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.
DONOR SITE MORBIDITY IN THE ILIAC CREST BONE GRAFT
Authors: Hill Nicola M. , Geoffrey Horne J. , Devane Peter A.
Published: March 2003

Background: Open iliac crest bone grafting is a common surgical procedure with recognized short‐term complications. The present paper documents the medium‐ to long‐term complications and level of patient satisfaction following the procedure.

Methods: Seventy‐three patients undergoing an open iliac crest bone graft over the past 6 years at Wellington Hospital were retrospectively reviewed. All patients completed a postal questionnaire which assessed their current pain, sensory changes in and below the scar, scar appearance and overall appearance with the bone graft donor site.

Results: Sixteen patients (21.9%) reported pain, 11 patients (15%) stated that their scar was sensitive to touch and 19 patients (22%) reported a degree of sensory change below the scar. Six patients (8.2%) felt that the scar appearance was totally unacceptable. Overall satisfaction, however, was high with 70 patients (95.8%) ‘fairly satisfied’ or ‘totally satisfied’ with their iliac crest donor site.

Conclusions: Bone grafting from the iliac crest is a relatively benign procedure in terms of patient satisfaction, and the most significant morbidity is pain.
THE BLOOD SUPPLY OF THE BILIARY DUCTAL SYSTEM AND ITS RELEVANCE TO VASCULOBILIARY INJURIES FOLLOWING CHOLECYSTECTOMY
Authors: Vellar IVO D.
Published: March 2003

Background: Cholecystectomy remains the only satisfactory treatment for symptomatic gall bladder stones. Unfortunately, in some cases the operation is complicated by vasculobiliary injury. The present study was undertaken to investigate the blood supply of the normal biliary system, to simulate vasculobiliary injuries described after cholecystectomy, and to determine the possible effects of the vascular injury on biliary reconstruction.

Methods: The blood supply of the biliary system in nine normal livers was investigated by injection of the coeliac axis and superior mesenteric arteries with coloured gelatin. The specimens were dissected under magnification and drawings prepared. Injection dissection studies were also carried out in eight specimens in which various vasculobiliary injuries encountered after cholecystectomy were simulated.

Results: The bile ducts possess an arterial plexus on their surface which is supplied from below by ascending marginal vessels derived from the postero‐superior pancreaticoduodenal artery. These marginal vessels end above in the right hepatic artery or its branches. The right and left hepatic ductal systems are supplied by the right and left hepatic arteries and their sectoral or segmental branches. The right and left hepatic arteries communicate freely via the hilar plate arterial plexus. This collateral system allows the blood supply to the right hepatic duct to be maintained after ligation of the right hepatic artery and interruption of the common hepatic duct or excision of the confluence.

Conclusion: A knowledge of the blood supply of the normal biliary system and the collateral hilar plate arterial plexus forms the anatomical foundation for successful reconstructive surgery, not only in vasculobiliary injuries following cholecystectomy, but also for a wide range of hepatobiliary procedures.
RADIATION EXPOSURE DURING FLUOROSCOPY: SHOULD WE BE PROTECTING OUR THYROIDS?
Authors: Tse V. , Lising J. , Khadra M. , Chiam Q. , Nugent R. , Yeaman L. , Mulcahy M.
Published: March 2003

Background: Recent reports on thyroid cancer among Australian orthopaedic surgeons prompted the present study which sought to evaluate the effectiveness of lead shielding in reducing radiation exposure (RE) to the thyroid region during endo‐urological procedures.

Methods: Radiation exposure to the thyroid region of the surgeon and scrubbed nurse was monitored for 20 consecutive operations over a 6‐week period by thermoluminescent dosimeters (TLD). A TLD was placed over and underneath a thyroid shield of 0.5 mm lead equivalent thickness to monitor the effect of shielding.

Results: Eight percutaneous nephrolithotomies, seven retrograde pyelograms and ureteric stentings and five ureteroscopies for calculous disease were monitored. Total exposure time was 63.1 min. For the surgeon, the total cumulative RE over and under the lead shield was 0.46 and 0.02 mSv, respectively, equating to a 23‐times reduction in RE if shielding was used. This effectively reduced RE to almost background levels, which was represented by the control TLD exposure (0.01 mSv).

Conclusion: Although RE without thyroid shields did not exceed current standards set by radiation safety authorities, no threshold level has been set below which thyroid carcinogenesis is unlikely to occur. Because lead shields are easy to wear and can effectively reduce RE to the thyroid region to near‐background levels, they should be made easily available and used by all surgeons to avoid the harmful effects of radiation on the thyroid.
BREAST CANCERS INVISIBLE ON MAMMOGRAPHY
Authors: Foxcroft L. M. , Evans E. B. , Joshua H. K. , Hirst C.
Published: March 2003

Background: A proportion of the cancers ‘missed’ at mammography are invisible even with the benefit of hindsight. The aim of the present study was to identify a group of women with proven breast cancer whose mammograms did not show a suspicious lesion even in retrospect (i.e. the truly mammographically occult cancers), and to compare them with mammogram‐positive cancers.

Methods: A total of 1757 breast cancers was diagnosed at the Wesley Breast Clinic’s Screening or Diagnostic Services between July 1987 and August 1997. One hundred and twenty cases were identified where, after independent review by two of the authors, no mammographic abnormality could be found in the region where the cancer was subsequently found. These 120 cases were compared with 1548 cancers considered to have a lesion visible on mammography, whether benign, indeterminate, suspicious or malignant in appearance.

Results: In 90% of the mammogram‐negative cancers, a clinical abnormality led to further investigation, while the remainder were found incidentally on ultrasound. There were a higher proportion of dense breasts, and of women aged 40–49, in the mammogram‐negative cancers than in the mammogram‐positive cancers. The mammogram‐negative cancers were of smaller size overall, but three of them were surprisingly large (7–11 cm). In both the mammogram‐positive and ‐negative cancers ~ 60% were ductal invasive cancers.

Conclusions: Where factors are present that make mammographically occult malignancy more likely (e.g. age 40–49 and dense breasts), women may be targeted for further investigation by other modalities. This is essential in the presence of a clinical abnormality.
ROLE OF AXILLARY SURGERY IN EARLY BREAST CANCER: REVIEW OF THE CURRENT EVIDENCE
Authors: Spillane Andrew J. , Sacks Nigel P. M.
Published: March 2003

Background: Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence‐based recommendations on current management.

Methods: A review was undertaken of the English language medical literature, using MEDLINE database software and cross‐referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy.

Results: Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla.

Conclusions: Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.
Absolute Risk of Breast Cancer for Australian Women with a Family History
Authors: Taylor Richard , Boyages John
Published: March 2003

Background: The purpose of the present paper was to estimate the absolute risk of breast cancer over the remainder of a lifetime in Australian women with different categories of family history.

Methods: Age‐specific breast cancer incidence rates were adjusted for screening effects, and rates in those with no family history were estimated using the attributable fraction (AF). Relative risks from a published meta‐analysis were applied to obtain incidence rates for different categories of family history, and age‐specific incidence was converted to cumulative risk of breast cancer. The risk estimates were based upon Australian population statistics and published relative risks. Breast cancer incidence was from New South Wales women for 1996. The AF was calculated using prevalence of a family history of breast cancer from data on Queensland women. The cumulative absolute risk of breast cancer was calculated from decade and mid‐decade ages to age 79 years, not adjusted for competing causes of death.

Results: Lifetime risk is approximately 8.6% (1 in 12) for the general population and 7.8% (1 in 13) for those without a family history. Women with one relative affected have lifetime risks of 1 in 6–8 and those with two relatives affected have lifetime risks of 1 in 4–6. The cumulative residual lifetime risk decreases with advancing age; by age 60 years all groups with only one relative affected have well above a 90% probability of not developing breast cancer to age 79 years.

Conclusions: These Australian risk statistics are useful for public information and in the clinical setting. Risks given here apply to women with average breast cancer risk from other risk factors.