Sankar Sinha

Mesh plug repair for paraumbilical hernia.

BACKGROUND The standard method of repair of paraumbilical hernia (PUH) is by the Mayo technique, using a double-breasted flap of the rectus sheath. The reproducibility of this technique in the hands of others is highly variable. The present study describes and evaluates the application of a Prolene mesh plug in the repair of PUH. The use of a mesh plug in hernia repair is not a new concept with previous investigators yielding consistently excellent results in the repair of femoral and inguinal hernias. METHODS The study is a retrospective analysis of hospital records and telephone interviews of 34 patients having undergone PUH repair using the mesh plug technique in the period March 1998- May 2002. There were 20 males and 14 females with a median age of 53 years (range 34-86 years). Seventy-six percent (26) of the patient sample was obese (median BMI 33). Whenever possible local anaesthetic was used. Principal outcome measures studied were post-operative complications, recurrences, length of stay in hospital, post-operative analgesia, duration of drain, return to normal activities and patient satisfaction. RESULTS Post-operative complications encountered included one case of seroma and a single wound infection with recurrence. Ninety-seven percent (32) of patients were satisfied with the procedure. CONCLUSION Mesh plug repair can be performed with minimal postoperative complications, low recurrence rate, minimal post-operative pain and achieving excellent patient satisfaction. Prosthetic mesh plug repair under local anaesthetic could become the standard treatment for PUH in adults.

Peptide α-amidation activity in human plasma: relationship to gastrin processing

OBJECTIVE AND DESIGN C‐terminal amidation is an essential processing step towards bioactivation of many peptides including gastrin. This reaction is catalysed by peptidylglycine α‐amidating mono‐oxygenase (PAM, EC 1.14.17.3) which converts the glycine extended precursors on their carboxyl termini to the des‐glycine amidated peptide products. In the case of gastrin, most of the amidation is thought to occur in the antrum. However substantial quantities of glycine extended gastrin and PAM are present in plasma. It is unclear whether circulating PAM reflects the secretory activity of the gastrin secreting cell or whether PAM is involved in the post‐secretory processing of gastrin. The aim of the present study was to relate the circulating amidation activity to the plasma concentrations of glycine extended and amidated gastrins.

A leg ulcer clinic: audit of the first three years.

This study documents the establishment in 1994 of a leg ulcer clinic in Hobart, Tasmania. Information relating to patient demographics, results of treatment and costs required to successfully operate the clinic were studied prospectively. Over a 40-month period, 345 patients attended the clinic on 1154 occasions. Ulcers were classified as venous (59%), arterial (19%), mixed venous and arterial disease (13%), pressure injury (3%), traumatic injury (2%) or rheumatoid disease (1%). A wide range of dressings and bandages were used during treatment. The clinic cost an average of A

Interns' Day in Surgery: improving intern performance through a simulation‐based course for final year medical students

42,683 per annum to run. This information has the potential to be of use as a guide for any organisation planning to open a similar clinic.

Anatomical variations of the renal arterial vasculature: An Australian perspective

The transition from final year medical student into the first year of clinical practice is known to be associated with anxiety and stress that ultimately affects job performance. Studies have shown that much of this stress and anxiety results from a junior doctors lack of confidence in performing a number of basic tasks. We investigated if implementation of a half‐day simulation‐based course in the final year medical students results in increased confidence in performing these tasks.

Barriers and enablers to patient recruitment for randomised controlled trials on treatment of chronic wounds: A systematic review

Variations of the renal arteries have been studied and published across various population groups, but similar information for the ethnically diverse nation of Australia is lacking. This study describes the pattern of renal artery anomalies in a section of the Australian population based on computed tomography (CT) angiograms of the abdomen and cadaveric dissection.

Modified TIME-H: a simplified scoring system for chronic wound management

Randomised controlled trials represent the gold standard in intervention efficacy evaluation. However, suboptimal recruitment affects completion and the power of a therapeutic trial in detecting treatment differences. We conducted a systematic review to examine the barriers and enablers to patient recruitment for randomised controlled trials on chronic wound treatment. Review registration was under PROSPERO 2017:CRD42017062438. We conducted a systematic search of Ovid MEDLINE, EBSCOhost CINAHL, Ovid Cochrane Library, Ovid EMBASE, and Ovid PsycINFO databases in June 2017 for chronic wound treatment randomised controlled trials. Twenty‐seven randomised controlled trials or qualitative studies met the inclusion criteria. Among the 24 randomised controlled trials, 21 were assessed as low quality in relation to recruitment, and 3 were assessed as high quality. All 27 studies reported barriers to recruitment in chronic wound randomised controlled trials. The reported barriers to recruitment were: study‐related, patient‐related, clinician‐related, health system‐related, and/or operational‐related. No study reported recruitment enablers. To enhance randomised controlled trial recruitment, we propose the need for improved integration of research and clinical practice. To alleviate the problems arising from inadequate reporting of randomised controlled trials, the Consolidated Standards of Reporting Trials Statement could include an additional item on recruitment barriers. This approach will allow for increased awareness of the potential barriers to recruitment for Randomised controlled trials (RCTs) in both wound management and other health care research.

How can clinical anatomy teaching be rationalized

OBJECTIVE Chronic wound assessment requires a systematic approach in order to guide management and improve prognostication. Following a pilot study using the original TIME-H scoring system in chronic wound management, modifications were suggested leading to the development of the Modified TIME-H scoring system. This study investigates the feasibility and reliability of chronic wound prognostication applying the Modified TIME-H score. METHOD Patients referred to the hospitals outpatient wound clinic over a 9-month period were categorised into one of three predicted outcome categories based on their Modified TIME-H score. RESULTS This study shows a higher proportion of patients in the certain healing category achieved healed wounds, with a higher rate of reduction in wound size, when compared with the other categories. The three categories defined in this study are certain healing, uncertain healing and difficult healing. CONCLUSION The Modified TIME-H score could be a useful tool for assessment, patient-centred management and prognostication of chronic wounds in clinical practice and requires further validation from other institutions. DECLARATION OF INTEREST The authors have no conflict of interest to declare.

Refractory amiodarone-associated thyrotoxicosis: an indication for thyroidectomy.

A recent article by John Farey and his colleagues on behalf of the Australian Medical Students’ Association has rekindled the debate as to how, when and what anatomy to teach medical students. In recent years, the teaching of anatomy within the medical curriculum has undergone major changes, including a reduction in teaching hours – mainly the cadaveric dissection component – in order to accommodate emerging disciplines such as genetics and molecular biology, and an increased emphasis in public health, epidemiology and communication skills. Introduction of problem-based learning (PBL) has led to the fragmentation of anatomy teaching, which is a sequential subject that requires basic knowledge as its foundation. The consequences of these changes to recent medical graduates and postgraduate students have been highlighted in several recent publications. The observations regarding the examination results of surgery fellowship trainees (where a high failure rate in the basic sciences occurred within the University of Sydney graduate cohort upon the drastic reduction in anatomy teaching at that school, a trend now reversed by a very substantial increase in anatomy teaching) is a sentinel wake-up call for all medical schools. In the current climate, there is a need for more effective pedagogy to developaclinical anatomycoursewithemphasisonunderstanding rather than endless memorization, which is the common belief among students. A core course of clinical topographical anatomy (including regional and systemic approaches), coupled with an appropriate process of assessment, should precede the students’ progress to a PBLmodel that supports a preferred process of inquiry-based learning. Students profit most when multiple, problem-oriented modalities are integrated. The core anatomy course should also be vertically integrated and reinforced with PBL during the entire undergraduate curriculum. The call for a core National Anatomy Curriculum requires critical consideration. This is already occurring, though not in Australia, but in the American Association of Clinical Anatomists and the Anatomical Society of Great Britain and Ireland. As ‘the anatomy and anatomical problems of safe clinical practice, even at a junior level, are similar everywhere’ – there is no need to reinvent the wheel. However, there is a need to define with clarity the depth of core knowledge, skills, values and attitude required by the graduating medical students that must be possessed for safe clinical practice. This is a daunting but I believe, is attainable goal, if we, the anatomical educators, work collaboratively in a format similar to the Stanford Medicine 25. The continuing argument between dissection and prosection is unlikely to bring back old methods of dissection-based anatomy teaching, especially within the context of ‘time-poor, four-year graduate programs’. The elective Anatomy by Whole Body Dissection Course at the University of Sydney is commendable but unlikely to be replicated in all medical schools for the entire cohort of students. Topp suggested prosected cadaver materials for undergraduate teaching and presented convincing arguments in favour of this. The dissection-based anatomy teaching may suit those pursuing postgraduate training in the surgical specialties. The latter idea seems to be the reasonable approach. The teaching of anatomy by surgeons, surgical trainees and nearpeer tutors has multiple benefits including the teaching of anatomy in the context. Near-peer teaching also provides a strategy for vertical integration and encourages deeper learning in anatomy. The College of Surgeons can promote the teaching of anatomy to undergraduates by trainee surgeons by formalizing this process as part of its training requirements, as suggested earlier. The tertiary hospitals can also contribute in this regard by following the example described by Taylor and Keay. After all, improved anatomical knowledge leads to safe patient care and reduces medical litigation. The concern expressed regarding the assessment of anatomy deserves serious consideration. Assessment is known to increase students’ motivation to learn anatomy, and anatomy assessment through integration of factual knowledge with the principles of problem-solving in different formats should be considered. Also, a national Annotated Multiple Choice Question bank facilitated by the Australian and New Zealand Association of Clinical Anatomists would be an important step in the right direction. Finally, more research is needed to provide sufficient evidence underpinning most of the claims alleged to be exerting negative influence on anatomical knowledge of medical students.