BACKGROUND:In addition to technical expertise, surgical competence requires effective non-technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non-technical skills considered essential for a competent surgeon. This study sought to compare the non-technical skills of experienced surgeons who completed their training before the introduction of SET with the non-technical skills of more recent trainees.METHODS:Surgical trainees and experienced surgeons undertook a simulated scenario designed to challenge their non-technical skills. Scenarios were video recorded and participants were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system. Participants were divided into subgroups according to years of experience and their NOTSS scores were compared.RESULTS:For most NOTSS elements, mean scores increased initially, peaking around the time of Fellowship, before decreasing roughly linearly over time. There was a significant downward trend in score with increasing years since being awarded Fellowship for six of the 12 NOTSS elements: considering options (score -0·015 units per year), implementing and reviewing decisions (-0·020 per year), establishing a shared understanding (-0·014 per year), setting and maintaining standards (-0·024 per year), supporting others (-0·031 per year) and coping with pressure (-0·015 per year).CONCLUSION:The drop in NOTSS score was unexpected and highlights that even experienced surgeons are not immune to deficiencies in non-technical skills. Consideration should be given to continuing professional development programmes focusing on non-technical skills, regardless of the level of professional experience.

An important factor that may influence an individual's performance is self-efficacy, a personal judgement of capability to perform a particular task successfully. This prospective study explored newly qualified surgeons' and surgical trainees' self-efficacy in non-technical skills compared with their non-technical skills performance in simulated scenarios.Participants undertook surgical scenarios challenging non-technical skills in two simulation sessions 6 weeks apart. Some participants attended a non-technical skills workshop between sessions. Participants completed pretraining and post-training surveys about their perceived self-efficacy in non-technical skills, which were analysed and compared with their performance in surgical scenarios in two simulation sessions. Change in performance between sessions was compared with any change in participants' perceived self-efficacy.There were 40 participants in all, 17 of whom attended the non-technical skills workshop. There was no significant difference in participants' self-efficacy regarding non-technical skills from the pretraining to the post-training survey. However, there was a tendency for participants with the highest reported self-efficacy to adjust their score downwards after training and for participants with the lowest self-efficacy to adjust their score upwards. Although there was significant improvement in non-technical skills performance from the first to second simulation sessions, a correlation between participants' self-efficacy and performance in scenarios in any of the comparisons was not found.The results suggest that new surgeons and surgical trainees have poor insight into their non-technical skills. Although it was not possible to correlate participants' self-belief in their abilities directly with their performance in a simulation, in general they became more critical in appraisal of their abilities as a result of the intervention.

Objective: This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges.Background: A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena.Methods: A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management.Results: From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths.Conclusions: Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.

OBJECTIVE:To assess differences in effectiveness between silver dressings and other types of dressings in chronic wound management in the community setting.METHOD:The study used client data retrospectively collected as part of routine care management. The cohort comprised 2687 clients who received 3716 episodes of care between September 2005 and January 2006. Outcome measures were the length of time for which clients received care from community nurses for each wound and the number of visits required.RESULTS:The median number of visits was statistically significantly higher for the silver-dressing users than for users of other dressings (31 versus 11, p<0.0001), while the median treatment duration was also greater (97 days versus 39 days, p<0.0001). In addition, the interval between visits was significantly shorter in the silver dressing group (p<0.001).CONCLUSION:These results question the effectiveness of silver dressing materials in the management of chronic wounds in a community care setting. However, these results need to be substantiated by prospective randomised controlled clinical trials to produce more reliable evidence.

Objective:To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature. Methods:Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded. Results:Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization. Conclusions:Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Background: An audit of surgical treatment of early breast cancer was introduced nationally in 1999. In August 2002, the Australian Safety and Efficacy Register of New Interventional Procedures − Surgical, under the auspices of the Royal Australasian College of Surgeons, assumed responsibility for managing this audit. This article provides an update of audit activities, now known formally as the National Breast Cancer Audit (NBCA), including a description of the new governance structure and the development of a secure online surgical audit system. Methods: Major changes have taken place in the design and governance of the NBCA during the last two years. Two committees have been established to oversee the audit. A clinical advisory committee comprises experts from a number of fields including breast surgery, oncology, government, and from peak breast cancer and consumer bodies. A technical advisory committee oversees many of the technical issues that have arisen with the development of an online data entry system. The online system of data entry was developed and launched to surgeons in May 2004. Results: There are now 28 000 cases of primary breast surgery in the audit. Around 250 surgeons are currently participating, an increase of over 50 surgeons since May 2004. Surgeons can review their data using the online system and compare their own results by generating reports which graph their own results against national aggregate data. Conclusions: There has been a significant increase in the volume of data received since the launch of the secure online system. The governing committees are working towards creating a clinical audit which will provide an improved data entry system and better reporting for all participating surgeons. The NBCA can also serve as a template on which to base other surgical audits.

OBJECTIVE:Australian cases of endovascular aneurysm repair (EVAR) performed between 1999 and 2001 have been evaluated to determine the mid-term (6 months to 5 years) safety and efficacy of the procedure. This study looks at predictors of success, based on mid-term follow-up data. DESIGN OF STUDY:This study uses results obtained from a prospective semi-voluntary register (audit) of Australian data obtained from surgeons in the private and public sector. RESULTS:Peri-operative mortality for patients enrolled in the audit was 1.8%. Ninety-three percent of procedures were technically successful (890/961). Nearly 13% of patients have had re-interventions (mostly endoluminal) at follow-up. Analysis of audit data shows that the likelihood of experiencing post-operative complications or requiring additional procedures increases with ASA rating, increasing age, large pre-operative aneurysm size, aneurysm angle >45 degrees and number of co-morbid conditions diagnosed. CONCLUSIONS:This study confirms satisfactory mid-term results in a, national rather than unit specific, setting. Predictors of clinical failure or need for re-intervention include large aneurysm size, neck angulation >or=45 degrees and short infrarenal neck.

Objective. An audit was established in November 1999 by the Australian Government Department of Health and Ageing to determine the mid- to long-term safety and efficacy of endoluminal graft repair (ELG) of abdominal aortic aneurysm (AAA). The audit has been undertaken by the Australian Safety and Efficacy Register for New Interventional Procedures-Surgical (ASERNIP-S). This study reviews contemporary Australian practice, based on audit data supplied to ASERNIP-S.Design of study. This study is a prospective voluntary register (audit) of Australian data obtained from the private and public sector. Data were collected for ELG repairs performed between 1 November 1999 and 16 May 2001. Follow-up is continuing.Results. Seventy-nine vascular surgeons have contributed data on 950 patients (816 male, 134 female, of median age 75.5 (range 36-94)). The mean aneurysm size was 57.5 mm (+/- 10.2) and 44% of procedures were performed on aneurysms less than 55 mm in diameter. Fifty four percent of patients were considered suitable for open repair. Most ELG procedures were performed in an angiography or endovascular suite, under general anaesthetic using an open technique via the femoral arteries. Perioperative mortality was 1.7%, mostly from cardiac causes. Prior to discharge 7.2% of patients experienced an endoleak and 18.6% had systemic complications. The average length of stay was 7.4 days (median 5 days). Unsuccessful exclusion of the aneurysm occurred in 6.7% of cases.Conclusions. Endovascular repair of AAAs is a well accepted procedure and is performed by the majority of vascular surgeons in Australia. Australian surgeons arc taking a rather aggressive approach to the management of aortic aneurysms, particularly in the moderate to higher risk patient groups. Mortality rates are low, given the elderly population in question and morbidity rates acceptable. ASERNIP-S is continuing to collect follow-up data for this patient cohort.

Various guidelines on pressure ulcer prevention and management have been produced but their recommendations are not always applied to practice. Does the literature provide any evidence on how they can best be implemented?

BACKGROUND:The Australian Safety and Efficacy Register for New Interventional Procedures - Surgical (ASERNIP-S) was contracted by the Commonwealth Department of Health and Aged Care to audit the procedure of endoluminal repair of abdominal aortic aneurysm. The purpose of the audit was to examine the safety and efficacy of the endoluminal graft (ELG) and, where possible, compare it to the open procedure. The first 12 months of data collection has now been completed. An overview of these results and some of the problems associated with the establishment of this audit are given.METHODS:The administrative infrastructure to support the audit is based at the ASERNIP-S office in Adelaide. To achieve high compliance rates, regular contact was maintained with surgeons. A reference group of senior vascular surgeons was established to provide expert support to the audit.RESULTS:By December 2000, ASERNIP-S had collected data on approximately 85% of privately performed ELG procedures during the first year of the audit. The early mortality rate was 1.3% in the endoluminal group compared to 2.6% in the open group. The rate of procedural complications was 15% in both groups, but the percentage of systemic complications was higher following the open repair. Aneurysm size and the number of pre-existing conditions had a statistically significant relationship to the variation in the number of complications for ELG patients.CONCLUSIONS:Good compliance has been obtained from vascular surgeons for submission of the operative data sets. ASERNIP-S aims to follow this group of patients closely to assess the medium to long-term durability of this procedure.

BACKGROUND:Ultrasound-assisted lipoplasty (UAL) has been associated with particular types of complications and uncertain long-term effects arising from interactions between ultrasonic energy and living tissue. The present review seeks to address these issues.METHODS:Search strategy Three search strategies were devised to retrieve literature from Medline, Current Contents, Embase and Cochrane Library databases up until April 2000. Study selection Inclusion of papers was largely determined using a predetermined protocol. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials, case series or case reports. Data collection and analysis Thirty-six papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding and chance. Other papers were also included to provide background material.RESULTS:There was little high-level evidence available comparing UAL and suction-assisted lipoplasty (SAL), with no conclusive evidence that UAL has a safety benefit, although low-quality evidence suggests that UAL is associated with reduced surgeon fatigue as well as increased operating times, slower aspiration rates and an increased learning curve. There is inadequate evidence to determine whether the theoretical potential for DNA damage from ultrasound is realized in the clinical setting.CONCLUSIONS:The evidence base for UAL is inadequate to determine the procedure's safety and efficacy. The potential for DNA damage must be investigated with appropriate in vivo animal models. Recommendations for the safe use of UAL are discussed.

The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) project has been established to form a register of new surgical procedures which have been assessed for their safety and efficacy. The ASERNIP-S project systematically reviews the evidence and produces recommendations on the future use of surgical procedures in clinical practice. Further data may be collected to provide information on the outcomes of procedures in use in Australia. Horizon Scanning of new and emerging techniques and technologies complements the ASERNIP-S process. This research identifies procedures that will impact on clinical practice in the near future. Dissemination of information from ASERNIP-S assessments, both locally and internationally, is important for quality improvement. The ultimate aim is for appropriate changes in practice to ensure the highest quality of Australian healthcare.

The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) project has been established to form a register of new surgical procedures which have been assessed for their safety and efficacy. The ASERNIP-S project systematically reviews the evidence and produces recommendations on the future use of surgical procedures in clinical practice. Further data may be collected to provide information on the outcomes of procedures in use in Australia. Horizon Scanning of new and emerging techniques and technologies complements the ASERNIP-S process. This research identifies procedures that will impact on clinical practice in the near future. Dissemination of information from ASERNIP-S assessments, both locally and internationally, is important for quality improvement. The ultimate aim is for appropriate changes in practice to ensure the highest quality of Australian healthcare.

It has been proposed that the reduction in n-butyrate oxidation by colonic epithelial cells observed in ulcerative colitis may be related to exposure to reduced forms of sulfur derived from dissimilatory sulfate reduction by luminal microflora. This study aims to compare stool sulfide concentrations in control and colitic subjects. Control subjects had significant colorectal disease excluded by virtue of their selection. Patients with ulcerative colitis were stratified by disease extent and activity, and by salicylate drug use. Stool sulfide was measured using a direct spectrophotometric method on NaOH (free sulfide) and zinc acetate (total sulfide) stool slurries. Fifteen control and 19 colitic subjects were studied. There was no significant difference in stool sulfide between control and colitic patients (free sulfide, control = 0.52 (0.17), colitic = 0.45 (0.10), t = 0.36, P = 0.71, total sulfide, control = 1.33 (0.21), colitic = 0.96 (0.15), t = 1.44, P = 0.16). Disease extent or activity did not significantly influence stool sulfide. These results do not support a primary etiologic role for luminal sulfide in ulcerative colitis.

Human colonocyte detoxificationDetoxification or biotransformation of drugs and xenobiotics are usually linked with liver metabolism, yet colonocytes of the gastrointestinal tract have an equal capacity to mediate these processes. 1 2This brief overview specifically discusses the ability of human colonocytes, but not other tissues, to detoxify chemical agents and relates pertinent findings to ulcerative colitis and some aspects of colon cancer.Failure to detoxify, leading to epithelial cell damage, or an exaggerated capacity to biotransform, leading to carcinogen formation in colonocytes, have been the main implications in disease processes.In general, two categories of detoxification processes are recognised (table 1) 3 4 : phase I reactions concern oxidation, reduction and hydrolysis within the cytosol, and phase 2 reactions require ATP and concern conjugation with a donor substrate synthesised in the cell.Both reactions need enzymes such as oxidoreductases, hydrolases, transferases, and lyases.Amongst these may be subclasses, genetic polymorphism and variability of enzyme activity in organs and along the gastrointestinal tract.Particularly, diVerences in enzyme activity in the proximal and distal colon may occur. 5 6 Biochemists, pharmacologists, toxicologists, molecular biologists, geneticists, oncologists, and gastroenterologists are involved in this field of study, from each of which information is now drawn together.Many new toxicological advances made with liver and lung tissues still have to be applied to colonocytes and would be a fruitful area of future research.The subject of clinical gastrointestinal toxicology 7 makes it possible to bridge a gap between colonic disease, genetics and the ability to detect initiating or promoting factors in ulcerative colitis and colon cancer. Cytoplasmic oxidases and reductasesCytochrome P-450 are a superfamily of haem containing mono-oxygenases 8 acting in the metabolism of foreign compounds, as well as synthesis of steroids and bile components.The P-450 superfamily of enzymes is composed of families and subfamilies of enzymes based on amino acid diVerences.P-450 are designated by CYP followed by a number designating the family (1-27) and a on July 11, 2023 by guest.

A role for colonic sulfide in the pathogenesisand treatment of ulcerative colitis (UC) has emergedbased on biochemical, microbiological, nutritional,toxicological, epidemiological, and therapeuticevidence. Metabolism of isolated colonic epithelial cellshas indicated that the bacterial short-chain fatty acidn-butyrate maintains the epithelial barrier and thatsulfides can inhibit oxidation of n-butyrate analogous to that observed in active UC. Sulfurfor fermentation in the colon is essential forn-butyrate formation and sulfidogenesis aids disposal ofcolonic hydrogen produced by bacteria. The numbers of sulfate-reducing bacteria and sulfidogenesisis greater in UC than control cases. Sulfide is mainlydetoxified by methylation in colonic epithelial cellsand circulating red blood cells. The enzyme activity of sulfide methylation is higher in red bloodcells of UC patients than control cases. Patients withUC ingest more protein and thereby sulfur amino acidsthan control subjects. Removing foods rich in sulfur amino acids (milk, eggs, cheese) has proventherapeutic benefits in UC. 5-Amino salicylic acidreduces fermentative production of hydrogen sulfide bycolonic bacteria, and aminoglycosides, which inhibit sulfate-reducing bacteria, are of therapeuticbenefit in active UC. Methyl-donating agents are acategory of drugs of potential therapeutic use in UC. Acorrelation between sulfide production and mucosal immune responses in UC needs to be undertaken.Control of sulfidogenesis and sulfide detoxification maybe important in the disease process of UC, althoughwhether their roles is in an initiating or promoting capacity has yet to be determined.

BACKGROUND:Several lines of evidence suggest a possible role for reduced forms of sulphur (including sulphide) in ulcerative colitis. The aims of this study were to assess the metabolic profile of colonic epithelial cells after treatment in vivo with hydrogen sulphide and correlate this with mucosal histological appearances.METHODS:Adult Sprague-Dawley rats had antegrade Roux-en-Y colostomies fashioned to allow access to the 'in-flow' bowel. Animals were treated with 2 mL sodium hydrosulphide (10, 20, 30 mmol/L) or saline control twice daily via the stoma for four (acute experiments) and 90 (chronic experiments) days. Isolated colonic epithelial cell suspensions prepared from such animals were incubated in the presence of [1-14C]-labelled n-butyrate (5 mmol/L) or [6-14C]glucose (5 mmol/L). Metabolic performance was measured radiometrically (14CO2 production) and enzymatically (ketone body production and lactogenesis). The histological appearances of treated mucosa were scored for acute inflammatory changes.RESULTS:There was a highly significant reduction in 14CO2 production from both n-butyrate and glucose in all groups compared to the control in both acute and chronic experiments. There was no difference between groups with respect to histological appearance and no evidence of acute inflammation in any specimen.CONCLUSIONS:Sodium hydrosulphide impairs rat colonic epithelial metabolic performance in vivo, but does not produce mucosal inflammation.