bluuebunny/crossref_metadata_2025 huggingface dataset:
COMMUNICATING WITH PATIENTS: SURGEONS' PERCEPTIONS OF THEIR SKILLS AND NEED FOR TRAINING
Authors: Girgis Afaf , Sanson‐Fisher Rob W. , McCarthy William H.
Published: January 2008

Background: This study assessed surgeons' current perceived level of competence in a number of interactional skills, their perceptions of the need for training and assessment in interactional skills, and their perceptions of the appropriateness of the format and content of two existing communication skills training packages.

Methods: Of 267 surgeons who were sent the survey, 63% (n= 143) of eligible respondents completed and returned it.

Results: More than three‐quarters of the sample identified the following skills as being important or very important in being a good surgeon: breaking bad news; preparing patients for surgical procedures; educating patients about their diagnosis and treatment, and increasing the likelihood that they will remember what they have been told; detecting anxiety and depression in patients, encouraging patients to express these and listening to their anxieties. More than half the sample felt at least competent at seven of the 10 interactional skills, but almost one‐third of the sample reported being ‘not or not at all competent’ at increasing patients' ability to remember what they have been told and at encouraging patients to express anxieties about their condition, and a further 13.3% reported a lack of competence at breaking bad news to patients about their diagnosis/prognosis. A higher proportion reported a lack of competence in providing bereavement counselling (59.6%), and gaining consent for organ donation (56.6%) and for autopsy (48.9%). The majority rated different aspects of the two communication skills training packages as either ‘good’ or ‘excellent’.

Conclusions: The survey identified a number of communication skills which are perceived by surgeons to be important and to require formal training and assessment.
COLONIC J‐POUCH AS A NEORECTUM: FUNCTIONAL ASSESSMENT
Authors: Chew Sun‐Beng , Tindal Donald S.
Published: January 2008

Background: Sphincter‐saving procedures are now commonly used for low rectal cancer but straight colo‐anal anastomosis seemed to produce poor functional outcome. The present study was therefore carried out to compare and contrast the functional outcome of colonic J‐pouch and straight colo‐anal anastomosis.

Methods: The clinical and functional outcome of 17 patients having a colonic J‐pouch‐anal anastomosis and 10 patients having a straight colo‐anal anastomosis were compared. They were compared in terms of age, sex, distal resection margin, Dukes stage, histological grade, morbidity/mortality and postoperative anal function.

Results: There was better bowel function in patients having J‐pouch‐anal anastomosis, especially in the early period after closure of the covering stoma. Bowel frequency in those patients who had a J‐pouch anastomosis was much less compared to those patients in the straight colo‐anal group in the 1st and possibly the 2nd year. There was a period of adaptation for the straight colo‐anal group which led to a bowel frequency approaching that of the J‐pouch group over 1–2 years. Differences in urgency, faecal continence, evacuation function, the use of drugs to slow bowel frequency and ability to discriminate between flatus and faeces were found to favour the J‐pouch group in the first postoperative year. The difference between the two groups diminished after that because the straight group improved, especially by the end of the 2nd year. During the study period, there were no constipation problems in the J‐pouch group, as noted in some other studies. This was probably associated with the 6‐cm length chosen for the pouch.

Conclusions: The use of colonic J‐pouch resulted in a significant decrease in stool frequency and more satisfactory anal function for the first postoperative year. This difference lessened during the second postoperative year. There was no demonstrable difficulty with rectal evacuation in the pouch patients.
MANAGEMENT DEFICIENCIES AND DEATH PREVENTABILITY IN 120 VICTORIAN ROAD FATALITIES (1993–1994)
Authors: McDermott Francis T. , Cordner Stephen M. , Tremayne Ann B.
Published: January 2008

Background: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: survival probability between 25 and 75%).

Methods: For 1993–94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre‐hospital, hospital and autopsy records.

Results: A total of 1175 problems were identified in 455 admissions to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre‐hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre‐hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non‐preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable.

Conclusions: Organizational and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.
LONG‐TERM RESULTS OF INTRAMEDULLARY PINNING OF FOREARM FRACTURES IN A DEVELOPING COUNTRY
Authors: Wal Anton
Published: January 2008

Background: Patients with fractured forearms who were treated with intramedullary Rush pinshails at Port Moresby General Hospital (Papua New Guinea) were studied.

Methods: Sixteen patients were reviewed 24 months after insertion of the pinshails.

Results: The results indicate that good outcomes could be achieved by the use of intramedullary pins in developing countries. There were no major specific short‐or long‐term complications (re‐fracture or non‐union). Disability in terms of pain and stiffness was noted in only three out of six patients with pins in situ. These were considered temporary disabilities.

Conclusions: The pins are much cheaper than plates and screws, require minimal expertise for insertion, and removal was performed under local anaesthetic as outpatient cases. They remain a valuable method for managing patients with forearm fractures in developing countries.
LASER THERAPY FOR MULTIPLE BlLlARY PAPILLOMATOSIS VIA CHOLEDOCHOSCOPY
Authors: Meng W. C. S. , Lau W. Y. , Choit C. L. , Li A. K. C.
Published: January 2008

Background: Multiple biliary papillomatosis is a rare tumour of the biliary tract but is capable of multicentric malignanttransformation. The complete removal of these tumours is difficult because it involves a field change of the biliary tract.

Methods: Exploration with choledochoscopy is a prerequisite for thorough assessment of the extent of involvement. Incorporation of laser ablation via a laser‐delivering fibre with choledochoscopy permits complete removal of the tumour.

Results:Repeated laser therapy via choledochoscopy through the T‐tube tract enables complete ablation of the tumour which changes the outlook of the prognosis. This is confirmed on subsequent cholangiography.

Conclusions:Laser therapy via choledochoscopy is a satisfactory mode of treatment for multiple biliary papillomatosis. It enables complete and precise ablation of the tumour which certainly changes the prognosis of this condition.
BILE DUCT IMAGING AND INJURY: A REGIONAL AUDIT OF LAPAROSCOPIC CHOLECYSTECTOMY
Authors: Merrie A. E. H. , Booth M. W. C. , Shah A. , Pettigrew R. A. , McCall J. L.
Published: January 2008

Background: The aim of the present study was to report details of practice with respect to bile duct imaging and bile duct injury.

Methods: A prospective audit of laparoscopic cholecystectomy (LC) was undertaken in the Otago region from the introduction of LC in 1991 through to December 1995. The audit includes all procedures done by all surgeons in public and private hospitals over the period without exclusion.

Results: Laparoscopic cholecystectomy was attempted in 929 patients and completed laparoscopically in 832 (89.6%). Intra‐operative cholangiography (IOC) was undertaken with increasing frequency over the study period, from 5.9% in 1991 to 32.2% in 1995. The overall IOC rate for individual surgeons varied from 4.5 to 47.6%. The use of peri‐operative endoscopic retrograde cholangiopancreatography (ERCP) increased with the introduction of LC but has plateaued at ˜6%. A total of 15.4% of patients with one or more clinical indicators of choledocholithiasis underwent LC without any form of bile duct imaging. Eight main bile duct injuries (0.86%) and a further 18 bile leaks occurred (total bile duct injury rate 2.8%). Intra‐operative cholangiography was attempted (unsuccessfully) in only one patient with main duct injury, although five of the eight injuries were recognized intra‐operatively.

Conclusion: This prospective regional audit demonstrates a gradual return to the use of IOC, a modest but stable reliance on peri‐operative ERCP, and a higher than expected rate of bile‐duct injury.
INTRAVESICAL THERAPY FOR THE TREATMENT OF NEUROGENIC BLADDER IN CHILDREN
Authors: Holland A. J. A. , King P. A. , Chauvel P. J. , O'Neill M. K. , McKnight D. L. , Barker A. P.
Published: January 2008

Background: Oral pharmacotherapy has been commonly used as an adjunct to clean intermittent catheterization (CIC) in the treatment of neurogenic bladder in order to achieve continence, but may be associated with unacceptable side effects. The authors' experience with sterile intravesical preparations of oxybutynin hydrochloride and ephedrine in children is reported here.

Methods: Patients requiring CIC for neurogenic bladder but with incontinence that was unresponsive to standard oral therapy or that was associated with severe systemic side effects were studied over a 1‐year period. Clinical, radiological and urodynamic assessments were made prior to commencing treatment with intravesical oxybutynin hydrochloride. Patients who remained incontinent with poor internal sphincter muscle tone had intravesical ephedrine added.

Results: Seven patients were involved in the study over a 1‐year period. Two patients became continent and one patient had an improvement in upper tract dilatation. One patient had a limited improvement with oxybutynin alone but became continent with the addition of ephedrine. Three patients had no response to treatment. There were few side effects.

Conclusion: Intravesical agents have a role in the management of paediatric neurogenic bladder for those children with significant adverse sequelae from oral pharmacotherapy who would otherwise require surgical intervention. Intravesical therapy is a safe technique in children with sterile preparations. Further investigation of this modality should be pursued.
WHERE THE SUN NEVER SHINES: ANORECTAL MELANOMA
Authors: Miller Brian J. , Rutherford Leigh F. , Mcleod G. Roderick C. , Cohen Jon R.
Published: January 2008

Background:Melanoma occurring in the anorectal region is recognized to be an uncommon tumour with a poor prognosis. Queensland has the highest incidence rate of cutaneous melanoma in the world. The purpose of the present study was to determine if the very high incidence of cutaneous melanoma in Queensland has any bearing on the incidence of anorectal melanoma, and to compare this with published studies from other parts of the world. An assessment of the authors' results in the treatment of anorectal melanoma was made by a review of patients presenting during the last decade throughout Queensland.

Methods: All cases of melanoma occurring in Queensland are accumulated in the Melanoma Register, administered by the Queensland Melanoma Project, and data from this were used to derive the results in the present study. Queensland population data were provided by the Australian Bureau of Statistics.

Results:During the study period 1985–95 in Queensland there were 21 391 cases of cutaneous melanoma which occurred in an average population, during that time, of 2.89 million. During the same time there were nine cases of anorectal melanoma, giving a relative incidence therefore of 0.04%. This contrasts with published relative incidences of 0.2% for white people in North America, 11% for Southwestern Native Americans, and 14.2% for Northern Pakistan (P < 0.0001). However, the population‐based incidence rates of anorectal melanoma for Queensland, United States white people, Southwestern Native Americans and Northern Pakistan are not significantly different from each other. All patients in the present series presented with large tumours, and none survived beyond 25 months despite standard surgical and adjuvant therapy. Conclusions: The protection against cutaneous melanoma afforded by skin pigmentation is not apparent in the anal area. Anorectal melanoma is no more or less frequent in Queensland, even with the very high incidence rate of cutaneous melanoma. Sun exposure appears to be neither protective nor a risk factor. The outcome of therapy for this condition remains disappointing in the authors' experience.
AORTIC TRANSECTION
Authors: Cameron P. A. , Dziukas L. , Hadj A. , Hooper S. , Tatoulis J.
Published: January 2008

Background: Traumatic aortic transection is uncommon in those trauma patients reaching hospital alive.

Methods: The Victorian Major Trauma Study (VMTS) received data from 25 hospitals in Victoria, a State of 4.4 million people, and identified 1874 patients with blunt trauma and Injury Severity Score (ISS) greater than 15 over a 2‐year period (1 March 1992–28 February 1993 and 1 May 1994–30 April 1995). The Federal Office of Road Safety (FORS) examined coronial data from 1 January 1992 to 31 December 1992. These studies allowed a retrospective, population‐based review of experience with aortic transection.

Results: The VMTS identified 19 patients who reached hospital, with signs of life at the scene of the accident, during a 2‐year period. Of these, 8 left hospital alive: 4 without disability and 4 with disability related to non‐thoracic injury. The annual incidence of aortic transection for the State, based on FORS data, was 13 per 1 000 000, lower than other reported studies. Review of the management of patients in hospital confirmed the usefulness of initial chest X‐ray in diagnosis and the high incidence of associated injury.

Conclusions: The study raises a number of issues, including the question of direct referral of patients with severe chest injury to hospitals with cardiothoracic facilities, increased use of transoesophageal echocardiography in diagnosis and increased use of immediate laparotomy and thoracotomy in certain patients.
COMPUTERS IN MEDICAL EDUCATION 1: EVALUATION OF A PROBLEM‐ORIENTATED LEARNING PACKAGE
Authors: Devitt Peter , Palmer Edward
Published: January 2008

Background: A computer‐based learning package has been developed, aimed at expanding students' knowledge base, as well as improving data‐handling abilities and clinical problem‐solving skills. The program was evaluated by monitoring its use by students, canvassing users' opinions and measuring its effectiveness as a learning tool compared to tutorials on the same material.

Methods: Evaluation was undertaken using three methods: initially, by a questionnaire on computers as a learning tool and the applicability of the content; second, through monitoring by the computer of student use, decisions and performance; finally, through pre‐ and post‐test assessment of fifth‐year students who either used a computer package or attended a tutorial on equivalent material.

Results: Most students provided positive comments on the learning material and expressed a willingness to see computer‐aided learning (CAL) introduced into the curriculum. Over a 3‐month period, 26 modules in the program were used on 1246 occasions. Objective measurement showed a significant gain in knowledge, data handling and problem‐solving skills.

Conclusions: Computer‐aided learning is a valuable learning resource that deserves better attention in medical education. When used appropriately, the computer can be an effective learning resource, not only for the delivery of knowledge, but also to help students develop their problem‐solving skills.
POSTMASTECTOMY RADIOTHERAPY: TIME FOR A RETHINK?
Authors: Rodger Alan
Published: January 2008

There is no consensus regarding the use of radiotherapy after mastectomy. Further clinical trials are needed to determine the indications for its use. Thus concludes the radiotherapy section in the NHMRC Clinical Practice Guidelines for the Management of Early Breast Cancer.1 In this issue of the journal Boyages and Langlands2 review two recently published clinical trials.3,4 Do these two trials now provide sufficient new evidence to allow us to delineate evidence‐based guidelines for postmastectomy radiotherapy or is more evidence required?
POSTMASTECTOMY RADIATION THERAPY: BETTER LATE THAN NEVER
Authors: Boyages John , Langlands Allan
Published: January 2008

The value of radiotherapy as an adjunct to surgery, in the management of breast cancer, has been proclaimed by some workers, condemned by others and doubted by many.1
RECURRENT BENIGN PAROTID TUMOURS: THE LESSON NOT LEARNT YET?
Authors: Patel Nirmal , Poole Alan
Published: January 2008

Background: To study the behaviour of recurrent benign parotid tumours, recurrence characteristics and problems faced with the removal of these lesions.

Methods: We reviewed the charts of the work of a single surgeon between 1971 and 1996.

Results: There were 24 patients (13 women, 11 men) with a mean age of 44 years at re‐operation. Mean follow‐up period was 10 years (range 1–22 years). There were 21 recurrent pleomorphic adenomas, two monomorphic adenomas and one patient with recurrent oncocytoma. Nine patients had solitary recurrence with a mean size of 14 mm, 15 patients had multiple recurrences with a mean size of 8 mm. There was malignant transformation of a previously benign lump in one patient. Three patients presented with a second or third recurrence. Overall facial nerve paralysis was 53% (38% temporary and 15% permanent). Frey's syndrome occurred in four patients (17%).

Conclusions: Recurrent benign parotid tumours are uncommon if superficial parotidectomy (SP) is the performed initially; recurrence rates are between 0–4%. The recurrences are usually slow growing and require lengthy follow‐up. Pre‐operative diagnosis of a lump in the region of previous excision is useful in treatment planning. Malignant transformation in previous benign lump should be considered and fine needle aspiration biopsy may help in diagnosis. Facial nerve injury is more likely if the tumour is deep, in multiple sites or involves extensive scar tissue. Radiotherapy is controversial, it should be considered if there has been tumour spillage following re‐operation.
FUNCTIONAL RECOVERY AND TIMING OF HOSPITAL DISCHARGE AFTER PRIMARY TOTAL HIP ARTHROPLASTY
Authors: Wang Allan , Ackland Timothy , Hall Sonia , Gilbey Helen , Parsons Richard
Published: January 2008

Background: Early discharge programmes in hospitals are encouraged to increase financial efficiency and bed availability, but standards of clinical care must not be compromised. Criteria for safe hospital discharge must be established and objective data are needed to assess how rapidly patients can achieve these discharge criteria.

Methods: A prospective study was performed on 65 patients (mean age = 71 years) scheduled for primary total hip arthroplasty (THA). The Modified Barthel Index (MBI) was measured pre‐operatively and postoperatively at set intervals to assess recovery of function after THA. A score of 90 out of possible 100 was used as discharge criterion and indicated that the patient was functionally independent for safe hospital discharge. In addition, combined score for thigh flexion and extension isokinetic peak strength was recorded for each patient before and after surgery. The number and nature of comorbidities and complications were also recorded.

Results: The length of hospital stay in this sample varied from 5 to 39 days. The MBI scores increased rapidly between days 3 and 5, then began to plateau from day 8 onwards. Based on the MBI, 58% of patients were fit for discharge at or before day 8. The remainder were fit for discharge from day 10 onwards (mean = 14.2 days). The latter group who required an extended hospital stay were older (P= 0.003), had more identified comorbidities (P= 0.01) and were weaker in their hip musculature prior to surgery (P= 0.01), compared to those who were discharged by day 8. A logistic regression analysis indicated that the pre‐operative MBI score and hip strength score were strong predictors of timing for hospital discharge.

Conclusions: A clinical pathway with functional milestones laid out over 8 days would be an appropriate criterion for the discharge of the majority of patients. However, approximately 40% of the patients presented in this study required longer hospital stay before the criteria for safe discharge could be achieved. These patients can be identified pre‐operatively by screening their MBI and composite hip strength scores.
LAPAROSCOPIC DIAGNOSIS OF ABDOMINAL TUBERCULOSIS
Authors: McLaughlin S. , Jones T. , Pitcher M. , Evans P.
Published: January 2008

Abdominal tuberculosis (TB) is an uncommon condition in Western societies although Europe and America have noted an increase of this condition in immigrants and AIDS patients. This report documents three diagnosed cases of abdominal TB over 12–month period in Melbourne western suburbs teaching hospital which services large migrant population. We also review the literature on this condition. If migrants present with diffuse abdominal symptoms, the diagnosis of abdominal tuberculosis should always be considered. Laparoscopy should replace diagnostic laparotomy as the definitive diagnostic tool.
HOW SHOULD WE INTRODUCE HIGH‐DOSE CHEMOTHERAPEUTIC STRATEGIES INTO THE ADJUVANT MANAGEMENT OF HIGH‐RISK BREAST CANCER IN AUSTRALASIA?
Authors: Back M. , Delaney G. , Denham J. , Graham P. , Hamilton C. , Morgan G. , O'Brien P. , Yuile P.
Published: January 2008

Background: Development of bone marrow support techniques has altered the standard chemotherapeutic management of haematological malignancies, and these techniques are now being increasingly utilized in solid tumours. In breast cancer, survival benefits have resulted from conventional dose adjuvant chemotherapy, but outcomes remain poor in many women with high‐risk disease. Improved response rates with high‐dose chemotherapy (HDC) in metastatic disease have led to the investigation of these techniques in adjuvant therapy of high‐risk localized disease. In some high‐risk patient subgroups survival is extremely poor, with 5‐year rates below 30%. Improved adjuvant strategies for patients in these subgroups are therefore urgently required. In Australasia, oncology departments are currently considering accrual of women with high‐risk disease into the International Breast Cancer Study Group (IBCSG) 15–95 Trial investigating HDC/stem cell transplantation.

Methods: The present paper reviews the available data on the efficacies and toxicities of currently available high‐dose chemotherapeutic strategies; discussing methodological considerations relevant to their introduction and safe use in the adjuvant setting in Australia and New Zealand.

Results: Although response rates with HDC in metastatic disease are encouraging, the clinical effectiveness of current HDC regimens in adjuvant management has not been established and is limited by significant toxicity.

Conclusions: The introduction of HDC strategies for high‐risk breast cancer in Australia encounters difficulties both in trial design and potential clinical practice.
CLINICAL AND RADIOLOGICAL PREDICTORS OF COMPLETE EXCISION IN BREAST‐CONSERVING SURGERY FOR PRIMARY BREAST CANCER
Authors: Kollias J. , Gill P. G. , Beamond B. , Rossi H. , Langlois S. , Vernon‐Roberts E.
Published: January 2008

Background: Local recurrence after conservative surgery for breast cancer usually results from growth of residual cancer adjacent to the excised primary tumour or from multicentric disease. Complete local excision (CLE) confirmed histologically is essential to ensure that the risk of local recurrence is minimal. This study was undertaken to determine that clinical or radiological factors may assist the surgeon at the time of surgery to achieve this aim.

Methods: A retrospective review of 101 cases treated by conservative surgery identified 70 cases of CLE and 31 of incomplete local excision (ILE). Clinical, surgical and histopathological data were taken from hospital records. Mammographic features and those of specimen X‐rays were evaluated without knowledge of the histopathological outcome of surgery.

Results: Complete excision was significantly associated with type of operation (lumpectomy vs wide local excision/quadrantectomy, P < 0.003), absence of calcification (P < 0.03) and the presence of a mass on mammography (P= 0.05). Tumour size (> 2.5 cm) and the presence of extensive ductal carcinoma in situ (DCIS) were associated with incomplete excision (P= 0.0005). No relationship was demonstrated with patient age, breast size, breast density, tumour grade, receptor status, axillary nodal status or spicules on X‐ray and completeness of excision. Specimen X‐ray had a positive predictive value of 94% with CLE.

Conclusions: Clinical and pre‐operative mammographic parameters are important for predicting CLE for breast cancers treated by breast‐conserving surgery. Specimen radiology for palpable lesions can confirm excision of the cancer and permit re‐excision of breast tissue at the time of initial surgery. Its role in determining CLE should be further evaluated.
TREATMENT OF LARGE, PERSISTENT LYMPHOCOELES USING AN ARGON BEAM COAGULATOR AND TALC
Authors: Vrouenraets B. C. , Thompson J. F. , McCarthy W. H.
Published: January 2008

Background: Lymphocoele formation can be a troublesome surgical complication after lymph node dissection and mobilization of large skin flaps. Occasionally, lymphocoeles persist for prolonged periods despite repeated aspiration. Treatment by sclerotherapy has been recommended, but this requires a prolonged treatment time and often causes intense pain.

Methods: The technique used to treat large, persistent lymphocoeles involved ‘painting’ the lymphocoele wall with an argon beam coagulator after evacuating its contents. Sterile talc was then distributed liberally through the cavity, a closed suction drain placed and the wound closed.

Results: The procedure was completely successful in each of the four patients treated. After a mean follow–up period of 11 months (range 6–15 months) no lymphocoele recurrence has occurred.

Conclusions: Use of an argon beam coagulator and talc reliably achieves rapid, definitive obliteration of large, persistent lymphocoeles.
RESOURCE CONSTRAINTS AND MORAL PRESSURES: CAN WE STILL AFFORD OURSELVES?
Authors: Little Miles
Published: January 2008

We have reaached phase of diminishing returns in medicine. Increasing costs produce smaller and smaller incremental benefits in health status. Medical scientists continue to work within the ideology of the Enlightenment, whereby advances in knowledge will eventually lead to control of health and welfare. The enormous costs of this ideology have led to two new ideologies: those of economic rationalism and managerialism. At the public level, the Western liberal emphasis on the value of individual life is generally held to justify the amount of public money spent on health. Those who frame health policy are influenced to some extent by this ideal, but we cannot continue to develop costly interventions without constraint. To overcome this impasse, we might accept that economic rationalism provided proper base for health care; or we might redefine disease so that more people were excluded from treatment programmes; or we might agree to limit medical research in costly areas; we might change our ethical thinking to emphasize classical utilitarianism; or we might undertake systematic studies of community values and opinions to find out what people really want from their health and welfare services. There are serious ethical problems with each of these solutions, except for the last: the idea of modifying services to take note of community values. Testing community values is difficult, but there are ways of doing it, and there have been some exercises in which the process has been undertaken with some success. The recent Constitutional convention suggests that it may even be possible in Australia.
PAINFUL JUSTICE: AN ETHICAL PERSPECTIVE ON THE ALLOCATION OF TRAUMA SERVICES IN AUSTRALIA
Authors: Sloane Andrew
Published: January 2008

Australia faces general and particular problems in the just distribution of trauma services, such as proliferation of expensive technologies, economic and geographic limitations on their provision, and inequities in allocation. The ethics of shalom in which people live in harmonious relationships with each other, the world and God provide moral framework for the discussion of the allocation of health care. Ethics deal with people and their relationships, which entails examining the nature and consequences of an action or policy and the character of the persons and institutions involved. The goal of health care, including trauma services, is not to ‘fight disease’ or to improve the health of the community, but to return people to proper functioning as people‐in‐relationships, as far as this is practicable. In applying this to the equitable provision of trauma services in Australia, we should distinguish between sustenance rights and community–provided mercies. The former are basic services that we need in order to function meaningfully in the community, and to which we are entitled (eg., basic health care). The latter are other benefits that we as members of the community choose to provide for each other, but to which we are not entitled per se (eg., ICU, Tertiary Trauma Centres). We should do all we reasonably can to ensure that all people receive their healthcare sustenance rights, that healthcare mercies are equitably distributed, and that the person–orientation of health care is maintained in the face of ‘technological imperatives’.
INGUINAL HERNIA REPAIR: A COMPARISON BETWEEN LOCAL AND GENERAL ANAESTHESIA
Authors: Subramaniam P. , Leslie J. , Gourlay C. , Clezy J. K. A.
Published: January 2008

Background: A comparative analysis of outcomes of inguinal hernia repair performed under local (LA) and general anaesthesia (GA) by a single surgeon using a standardized technique of anterior transversalis repair was performed. Ninety‐three cases were examined, 56 of which were cases of LA hernia repair.

Methods: A retrospective analysis of the patient hospital record was performed with particular attention to intra‐operative and postoperative analgesia requirements.

Results: An overall series complication rate of 6.5% (6/93) is reported. Only one of 56 LA patients (2%) required more than 24 h of narcotic analgesic injections compared to 11% (4/37) in the GA group (P < 0.05). The mean total postoperative parenteral narcotic requirement in the LA group was 86 ± 14 mg of pethidine as compared to the GA group who had a mean total requirement of 121 ± 17 mg of pethidine (P > 0.08).

Conclusions: The LA infiltration technique is an effective method for inguinal hernia repair. This series demonstrates benefits in terms of length of hospital stay and a lower incidence of postoperative parenteral narcotic analgesic requirement although when postoperative parenteral narcotics were required by the LA group of patients, the difference in mean total pethidine requirement was not statistically significant.
CELLULAR POTASSIUM DEPLETION PREDISPOSES TO HYPOKALAEMIA AFTER ORAL SODIUM PHOSPHATE
Authors: Hill Andrew G. , Teo Wee , Still Andrew , Parry Bryan R. , Plank Lindsay D. , Hill Graham L.
Published: January 2008

Background: Oral sodium phosphate has become an attractive alternative to polyethylene glycol for colonic cleansing preparatory to elective colorectal surgery. Its use, however, has been associated with hypokalaemia. The authors of the present study tested the hypothesis that patients with cellular depletion of potassium are at significant risk for hypokalaemia with oral sodium phosphate bowel preparation.

Methods: In 23 patients, total body potassium was measured by whole‐body counting and intracellular water volume was measured by bioimpedance analysis before oral sodium phosphate bowel preparation. Patients were divided into those whose serum potassium fell to 3.5 mmol/L or lower (Group 1) and those whose did not after sodium phosphate treatment (Group 2).

Results: The fall in serum potassium concentration over the period of oral sodium phosphate administration was significantly negatively correlated with intracellular potassium concentration measured prior to administration (r=‐0.65, P= 0.0009). In Group 1, serum potassium concentration fell from 4.1 ± 0.1 (standard error of the mean (SEM)) mmol/L to 3.2 ± 0.1 mmol/L (P± 0.0001) while in Group 2 there was no significant change in this concentration (4.0 ± 0.1 vs 3.9 ± 0.1 mmol/L) as a result of sodium phosphate treatment. Intracellular potassium concentration prior to administration of sodium phosphate was significantly lower in Group 1 (117 ± 9 mmol/L vs 143 ± 7 mmol/L, P < 0.05).

Conclusions: Caution should be exercised when treating patients with oral sodium phosphate who are considered to be cellularly depleted of potassium. These patients are at risk of hypokalaemia after this treatment.
IMPROVEMENTS IN PARATHYROID SURGERY IN THE INTACT 1–84 PTH ASSAY ERA
Authors: Carnaille B. , Oudar C. , Pattou F. , Quievreux J. , Proye C.
Published: January 2008

Background: Measurement of intact 1–84 parathormone (PTH) level by immunometric assays has been an important tool in the medical management of hypercalcaemia. The aim of the present study was to evaluate its practical contribution in the diagnosis and surgical treatment of primary hyperparathyroidism.

Methods: The results of surgery were compared (number of failed and inadequate cervicotomies, number of overlooked cervical glands) in two groups of primary hyperparathyroid patients operated on without (group I, n= 624) and with (group II, n= 360) intact PTH evaluation. The postoperative intact PTH level was measured 1–50 months after surgery in 109 unselected normocalcaemic patients. The benefit of intact PTH assay was studied in borderline patients. We tried to settle a correlation between parathyroid resected weight and intact PTH pre‐operative level in different subsets of the disease.

Results: The sensitivity for the diagnosis of primary hyperparathyroidism was 86.6% for intact PTH level alone, and 95.9% when plotted with synchronous serum total calcium. Hyperfunctional adenoma was incidentally discovered in 14 asymptomatic normocalcemic normo‐PTH patients. The predictive positive value of intact PTH assay for the diagnosis of primary hyperparathyroidism was 99.3%. Intact PTH assay often affirmed the diagnosis of primary hyperparathyroidism in borderline cases. The postoperative intact PTH measurement was not a good indicator for evaluating the late outcome in seemingly cured patients. Sharp but statistically significant correlation was found between the resected weight and the intact PTH level. The discovery of a small adenoma in a patient with high intact PTH level, bone disease and low vitamin D level should raise suspicion of a second hyperfunctioning gland.

Conclusions: Intact PTH assay was a main contributor to the surgical management of primary hyperparathyroidism, reducing the number of unnecessary cervicotomies and enabling the cure of all cases of primary hyperparathyroidism except those due to mediastinal glands. It raised unanswered problems in the late postoperative course.
TANDEM URETEROCYSTOPLASTY
Authors: Ahmed Saeed , Neel Khalid Fouda , Sen Sudipta
Published: January 2008

Background: Bladder augmentation may be undertaken by using various gastrointestinal segments but their use is associated with a multitude of well‐recognized complications. The mega‐ureter has proven to be a satisfactory alternative; in patients with bilateral mega‐ureters, both ureters may be used for this purpose.

Methods: Seventeen patients had augmentation ureterocystoplasty, including three in whom both distal ureters were used in tandem. The latter included two patients with neurogenic bladder and one with bladder exstrophy.

Results: Satisfactory augmentation was achieved in all patients undergoing tandem ureterocystoplasty. The neurogenic bladder patients are managed by urethral clean intermittent catheterization (CIC) and the exstrophy patient is managed by CIC of an appendico‐vesicostomy (Mitrofanoff). All are continent.

Conclusions: The mega‐ureter provides an excellent source of augmentation material in patients with small non‐compliant bladders. In those with bilateral mega‐ureters, consideration should be given to using both ureters in tandem to achieve the maximum possible bladder capacity.
CLINICAL MANAGEMENT AND TREATMENT OUTCOMES OF MERKEL CELL CARCINOMA
Authors: Wong Kenneth C. , Zuletta Fred , Clarke Stephen J. , Kennedy Peter J.
Published: January 2008

Background:

Merkel cell carcinoma (MCC), first described in 1972, is an uncommon, highly malignant tumour of skin. Its aetiology is unknown although the tumour occurs most frequently in sun‐exposed sites. This skin cancer is characterized by a high incidence of metastases, local and regional recurrence and has a high mortality. Few survival data beyond 3 years are available. Treatment strategies include wide local excision of the primary and lymph node dissection, as indicated together with adjuvant radiotherapy. The tumour has also been shown to be chemosensitive. Definitive treatment is inconclusive due to the relative rarity of this malignancy.

Methods:

A retrospective study was undertaken between the years 1985 and 1996 of 33 patients with MCC at Concord Repatriation General Hospital (CRGH). Demographic details were noted, together with the site and appearance of the primary lesion and the sites and date of metastases. The response and outcome to various modalities of treatment were documented.

Results:

There were 27 men and six women with an average age of 80 years (range: 60–86 years). The primary lesion in the present series most often resembled a basal cell carcinoma (BCC), with 53% occurring in the head and neck region. Twenty‐seven patients (82%) developed metastastic disease, with an average interval of 13.4 months between diagnosis of the primary lesion and the development of metastases. The incidence of locoregional recurrence in the present series was 42%. Radiation combined with surgery achieved locoregional control in 15 of 19 patients with primary, regional or recurrent locoregional disease. Fourteen patients died of MCC and five others from unrelated causes. The 14 survivors have a mean survival of 54 months with six patients surviving more than 5 years.

Conclusions:

Local excision together with regional lymph node clearance as indicated, combined with adjuvant radiation treatment was associated with an improved survival. The role of chemotherapy remains unclear.
BREAST CANCER OUTCOMES AT THE STRATHFIELD BREAST CENTRE
Authors: Loveridge Katrina H. , Kennedy Catherine W. , Janu Norman C. , Carmalt Hugh L. , Gillett David J.
Published: January 2008

Background:

Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer death in women. This report presents outcomes from a multidisciplinary breast clinic established in 1989 with the specific aim of providing a rapid, integrated assessment service for patients with breast disease.

Methods:

A prospective data collection and analysis using a Microsoft AccessTM (Microsoft Corp., North Ryde, NSW, Australia) database was established and has collected information on all patients presenting for diagnosis or ongoing management of breast cancer. Data on survival were obtained by routine follow‐up visits or contact with the patient'general practitioner.

Results:

Patient age, mode of presentation and histopathology were similar to other population‐based studies in Australia. Ninety‐three per cent of the patients had a diagnosis confirmed on the day of consultation. The average time between diagnosis and surgery was 11.9 days. Breast preserving surgery was attempted in 68% and achieved in 50% of cases, 67% of patients had one stage surgery. Five‐year disease‐free survival was 74% and is comparable with other reports.

Conclusions:

The centralization of services and expertise has enabled us to provide efficient service and achieve internationally comparable outcomes.
NON‐OPERATIVE TREATMENT OF BREAST ABSCESSES
Authors: Tan S. M. , Low S. C.
Published: January 2008

Background:

Breast abscesses are conventionally treated by incision and drainage. This often requires general anaesthesia and a hospital stay. Non‐operative treatment by needle aspiration and oral antibiotics is reported as a viable alternative.

Methods:

All patients who presented with breast abscesses and who were assessed by one surgeon between November 1995 and January 1997 were managed using a conservative approach and they are the subjects of this study.

Results:

Twenty‐one consecutive patients were seen over a period of 26 months. All had non‐lactational breast abscesses. Nineteen patients were successfully treated by needle aspiration and antibiotics while two patients required incision and drainage. The mean size of the aspirated abscesses was 3.5 cm (range 1–15 cm) and required an average of 2.4 aspirations (range 1–5). Of those treated by aspiration, three patients developed recurrent abscesses, two of which were successfully managed by repeat aspiration while one patient eventually required surgery.

Conclusions:

The majority of non‐lactational breast abscesses seen in clinical practice can be treated without surgery by a combination of needle aspiration and antibiotics.
THYROID CANCER: PREDISPOSING CONDITIONS, GROWTH FACTORS, SIGNAL TRANSDUCTION AND ONCOGENES
Authors: Clark Orlo H.
Published: January 2008

This article summarizes much of the information that is available on factors, such as oncogenes and tumour suppressor genes, that cause thyroid neoplasms and cancers to develop, grow and invade.
THE MANAGEMENT OF ANTERIOR ABDOMINAL STAB WOUNDS IN AUSTRALASIA
Authors: Cameron Peter , Civil Ian
Published: January 2008

Background:

The low incidence of stab wounds in Australasia has led to a more operative approach for the management of anterior abdominal stab wounds. A survey of Australasian surgeons interested in trauma was undertaken to analyse current practice.

Methods:

Ninety‐seven early management of severe trauma surgical instructors (known as ATLS® in Australasia) were surveyed using a four‐part, single‐page questionnaire.

Results:

Sixty‐five instructors completed the survey. Thirty‐nine instructors stated that they would admit patients with stab wounds even if the wound appeared superficial or ‘skin only’. For 14 surgeons the decision to perform a laparotomy was dependent on fascial penetration and for 17 the decision depended upon peritoneal penetration. Six felt that all but the most superficial wounds should have a laparotomy. Laparoscopy, diagnostic peritoneal lavage and other investigations were also thought to be helpful. Thirteen surgeons felt that the presence of peritonism or tenderness were the most important determinants. There was no hospital protocol for 44 respondents and there was a wide variation in individual approach to this problem. However, all agreed that peritonism and haemodynamic instability were indications for immediate laparotomy.

Conclusions:

There is still a low threshold for laparotomy in Australasia and this approach is not without risks. However, the alternative of using serial observation should be regarded as an active form of management and protocols must be established to ensure regular repeat examinations by experienced personnel. The low incidence of abdominal stab wounds in Australasia makes this approach difficult. A safe approach for the Australasian situation is described.
MEASURING SURGICAL WOUND INFECTION: REPLY
Authors: Collopy B. T.
Published: January 2008

The Australian Council on Healthcare Standards (ACHS) Care Evaluation Program (ECEP) is not flexible in its indicator definitions and in its aggregated national database, rejects information not collected in accordance with the CEP/College definitions. Nosocomial infection indicators have a rejection rate of almost 30%. The CEP, however, has no control over the individual healthcare facility'case‐finding methods. Notwithstanding that lack of control, the data received have been remarkably consistent (reproducible) over the first 4years of the programme.
THE VALUE OF SURGICAL PRACTICE GUIDELINES: COMMENT
Authors: Hughes P. D.
Published: January 2008

In the article, ‘The Value of Surgical Practice Guidelines’, Bruce Barraclough states ‘the guidelines are not a protocol’.1 However, I disagree. Such guidelines rapidly become protocol and pressure is placed on clinicians to follow such cookbook medicine. The National Cancer Control Initiative (NCCI), a Federal Department of Health‐funded organizations set up to advise the Federal Minister for Health, has been conducting workshops around the country.
AMPUTATION THROUGH THE AGES: THE OLDEST MAJOR SURGICAL OPERATION
Authors: Magee Reginald
Published: January 2008

Amputation has been practised since neolithic times for punitive, therapeutic and ritualistic reasons. Until the development and adoption of general anaesthesia, it was the most major operation to which a surgeon could aspire and a speedy technique was essential. Many famous names have been associated with this operation in both military and civilian surgery.

amputation,

surgical history.
Pasture Improvement, Stocking Rates and Rural Investment
Authors: Holden J. S.
Published: January 2008

Research Fellow in the Institute of Applied Economic Research and is a review of some result from part of the institute's Primary Production Research Project. The study was the subject of a paper presented to the annual conference of the Australian Agricultural Economic Society in February 1969 and will be published by the Institute as Technical Report No. 2.
The Institute's Short‐term Forecasts
Authors: Ironmonger D. S.
Published: January 2008

It is based on a paper presented to the 41st Congress of the Australian and New Zealand Association for the Advancement of Science, Adelaide, in August 1969. It has been revised to include references to forecasts made in the October 1969 issue of the Review.
Labour Markets form the Microeconomic perspective: Implicit Contract Theory
Authors: Sloan Judith , Wooden Mark
Published: January 2008

This paper deals with a recent development in labour economics ‐ that of implicit contract theory. A major impetus to its development has been the existence of involuntary unemployment and wage rigidity. In reality, there have been two streams of development ‐ one associated with the name of Okun which focusses on the fixed costs of employing labour and the importance of reputation for reliability on the part of employers. The other emphasises differences in risk‐aversion between employers and workers, viewing the implicit contract as a form of risk shifting. Both theories provide insights into the workings of labour markets, in particular, the pervasiveness of long‐term employment relations. although difficulties arise in terms of the enforceability of contracts. The broader literature on internal labour markets in useful in this context.