"September 2002" Includes bibliographical references (leaves 301-318)

Coagulation has and continues to be one of the most important elements in medicine. Issues from a lack of hemostasis range from poorer clinical outcomes to sudden death. The evolution of treatments for hemostasis have evolved from the use of Tamponade with direct pressure and bandages, the use of materials such as cobwebs and dust, the use of heat with hot oil or heated irons, to the use of suture, glues, plasmas, staplers, and electricity. This evolution has continued to bring about the prophylactic use of technology in an effort to prevent blood loss. This change from reactive treatments to proactive continue to be on a localized or superficial basis. One of the largest opportunities to proactively reduce blood loss in surgical patients is during the resection of solid organs such as the liver, kidney, and spleen. Few options have existed to help improve hemostasis short of the complete occlusion of blood supplying the tissue such as in the Pringle Maneuver. Recent studies have begun to show that practices such as this may have a significant detrimental effect on morbidity. It has been found that by applying radio frequency electrical energy in a particular way that large amounts of tissue can be pre-coagulated prior to resection. A series of animal and human clinical work has been completed to help evolve and confirm the method and the device that was created and refined during this effort. During the course of this work fifty-three patients were treated at four institutions on three continents. Average blood loss for liver resections performed with this pre-coagulation technique using the developed device in a multicenter control trail was 3.35 ml/cm2 as compared to 6.09 ml/cm2 (p < 0.05) for resections performed using standard surgical techniques alone. Additionally, the transection time necessary was also reduced from mean value of 27 minutes (2 -- 219 minutes) to 35 minutes (5 -- 65 minutes). Patients treated included those suffering from liver cirrhosis, fatty liver disease, and post chemotherapy fibrosis. From this work the use of pre-coagulation with methods and device developed was shown to be safe and effective for reducing the amount of blood loss and transection time during liver resections.

This is an interdisciplinary research project in which the methods of Industrial and Product Design Engineering are focused upon a problem in Orthopaedics. One of the most controversial areas in Orthopaedics is the reconstruction of the anterior cruciate ligament (ACL). The current twin-instrument method for locating the ACL is difficult for surgeons with fewer than 500 surgical experiences. This was clearly demonstrated by Kohn, Busche and Cans (1995), and confirmed by Sommer, Friederich and Muller (2000), Sudhahar, Glasgow and Donell (2004), and Kuga, Yasuda, Hata et al. (2004). The above research indicates that the problem is not only one of anatomical location, but of how the operation takes place. The aim of the research was, therefore, to develop a new and improved surgical instrument and technique for locating the ACL anatomical landmarks. The research described in this thesis employs a number of design methods that can be used separately or in combination (hybrid process). They form the theory base that guides the design process. This allows the designer to engage in a flexible process that is effective in finding design solutions to the problem. Within this process, iterative case studies were employed in order to design a new surgical device for ACL reconstruction. The thesis describes a series of designed devices (case studies) that were iteratively developed and surgically tested, leading to a penultimate device. This latter device was tested via a number of surgical operations. The device provides a new method for externally locating the internal ACL attachment points. The research has resulted in a commercial association with Smith and Nephew Surgical Australia and BrainLAB AG Germany for the commercialisation of this technique. At the time of writing, the next stage of research and development is under way. This is using a frameless computer-aided image guidance system in the place of X-ray.

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

"September 2002" / Includes bibliographical references (leaves 301-318) / viii, 318 leaves : ill. (col.) ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003

There are many terms used to describe pressure ulcers: pressure sores, decubitus ulcers, bedsores, and pressure necrosis or ischaemic ulcers. Essentially they all describe damage to the patient's skin and underlying tissue. The nursing literature abounds with information about the risk, grading, prevention and treatment of pressure ulcers. These ulcers are a problem in hospital and long term care facilities, and are a major cause of morbidity. In the hospital setting they contribute to an extended length of stay and by doing so 'block' the bed for use by another patient. The ulcers are difficult to treat, are an ongoing cause for pain and discomfort for the patient and can be a strain on hospital finances. Pressure ulcers are not unique to modern times, as they have been discovered on the remains of an Egyptian mummified body (Armstrong & Bortz 2001). This would suggest that the problem dates back to the Pharoahs, and has continued to be a challenging problem throughout the centuries (Bridel 1992). The escalating costs of treating these ulcers today, has brought about an emphasis on the risk factors, prevention and the appropriate interventions, rather than an acceptance of these ulcers as a tolerable ondition (Bridel 1992). In the operating room, nurses are faced with unique challenges when caring for their patients. This is due to difficulty in caring for patients under the influence of the anaesthesia required for surgery, long periods of forced immobility and the inability of the patient to perceive pain and discomfort from the pressure of the hard surface of the operating room table. These problems are increased by nurses' inability to gain access to the patient because of the sterile drapes required to cover the patient for surgery. Armstrong and Bortz (2001) present information from one study in which it is stated that surgical patients have 90% greater chance of developing pressure ulcers than medical patients. One reason for this may be due to the limited information available in regard to the most effective support surface to place on top of the operating room table. This gap in information is problematic for operating room nurses as it limits their ability to select the most effective item of equipment, and determine if the chosen equipment reduces pressure on tissue intra- operatively. The most effective operating room table mattress used and the skills and knowledge of the operating room nurse about the aetiology and prevention of pressure ulcer prevention, are important aspects of nursing care and can influence patient outcomes. The potential for complications to occur may be dependent on single or combined factors such as the patient's age, disease processes, nutritional status and mobility. Preparatory and supportive nursing interventions for surgical procedures based on best available evidence, nursing experience and patient preference, can reduce the incidence of pressure ulcer development in the perioperative environment. This doctoral portfolio contains four separate sections related and linked together by a common theme - pressure ulcer prevention in the perioperative environment. This first section of the portfolio situates the topic and provides a brief overview of the portfolio. The second section is a critical review of the literature pertaining to the most commonly used operating room table mattresses, and the effectiveness of these mattresses in the prevention of pressure ulcer development. This review highlighted a lack of quality research in this area, and while many evaluations have been undertaken to determine the effectiveness of perating room table mattresses, the results are contradictory concerning the patients, exposures and interventions. Because of issues related to the methodological quality of published research in this area a systematic review using meta- analysis was not possible rather a critical review of the research literature is used. The third section of the portfolio reports on a hermeneutic ethnography of the perceived skills and knowledge of nurses in the prevention of pressure ulcer development in the perioperative environment. This study was designed to determine if pressure ulcer prevention forms an aspect of the everyday practice of perioperative nurses. This review has highlighted the need for operating room nurses to review practices when caring for patients in the perioperative environment particularly in respect of pressure ulcer prevention. The fourth and final section of the portfolio summarises the research and provides recommendations for nursing practice and further research in the area of pressure ulcer prevention in the perioperative environment. / Thesis (D.Nurs.)--Department of Clinical Nursing, 2004.

Patients who have undergone treatment that has included the surgical implantation of a prosthetic device can become dissatisfied for many reasons. One cause for dissatisfaction is any adverse event where there is a demonstrable causal nexus with the failure of a device that is defective or at risk of being so. The magnitude of therapeutic product failure is considerable and therapeutic goods such as Vioxx, Thalidomide, silicon-gel-filled breast implants, contaminated blood products, cardiac pacemakers and valves, and orthopaedic devices are testimony to this. Many of these events have exposed a greyish area of Australian law that balances medical negligence with consumer protection and contract law. Australian product liability legislation that regulates the use of therapeutic goods is a complex amalgam of law that has at its foundations the Trade Practices Act 1974 (Cth) and the Therapeutic Goods Act 1989 (Cth). When a surgical device fails there can be exposure to liability. This thesis explores those important issues that can impact on individuals or on organisations and it is evident that where issues of product liability concern implanted surgical devices the current regulations for consumer protection may not always be the most appropriate. It is evident that there is a culture of under-reporting of adverse events to a Therapeutic Good Administration that does not have the resources to investigate the cause for failure of a surgical device. Furthermore, there is a potential for bias and conflict of interest in an environment where the regulator depends on the regulated for the funding of its existence. Other issues include the complex and often undesirable consequences of those partnerships that can evolve with the development of an implantable device and with the undertaking of clinical trials, the role of the learned intermediary, that interface between manufacturer and consumer, and the role of the expert witness, that interface between justice and injustice. These and other matters that can significantly influence any debate of implantable surgical device product liability are explored and recommendations are made that might form the basis of a Therapeutic Goods (Safe Medical Devices) Amendment Act.

Adult Oral Health Programme: The Effect of Periodontal Treatment and the Use of a Triclosan Containing Toothpaste on Glycaemic Control in Diabetics Abstract Aim: The aim of the research study is to establish an adult oral health programme for diabetics in Majuro, Republic of the Marshall Islands in order to determine the impact of non-surgical periodontal treatment followed by the use of a triclosan containing dentifrice on the maintenance of periodontal health and glycaemic control in type 2 diabetic patients. Hypothesis: Non-surgical periodontal treatment results in improved periodontal health and better glycaemic control in diabetics and use of a triclosan containing toothpaste is effective in maintaining this improvement in diabetics. Methods: An adult oral health programme was created, within which was conducted a two-group randomised clinical trial to address the hypothesis that non-surgical periodontal treatment results in improved periodontal health and better glycaemic control in type 2 diabetics and that the use of a triclosan containing toothpaste is effective in maintaining this improvement in diabetics. In this double blind controlled trial, sixty adult patients (aged 35 to 65 years) with type 2 diabetes mellitus having a minimum of 16 teeth received non-surgical periodontal treatment. Half of the patients were randomly assigned to use a triclosan containing toothpaste, Colgate Total, and the other group a non-triclosan toothpaste, Colgate Fluoriguard. The study evaluated the improvement in periodontal health by recording Probing Pocket Depth (PPD) on 6 sites of each tooth, and the number of sites bleeding on probing (BOP) at baseline, and at 6 months and 12 months after treatment. The second part of the study evaluated the impact of improvement of periodontal health on glycaemic control in type 2 diabetics by measuring HbA1c and RBS, and also assessing the levels of C-Peptides and CRP at baseline, and at 6 months and 12 months after treatment. The study also evaluated the effectiveness of a triclosan containing toothpaste in maintaining the improvement in periodontal health after non-surgical periodontal treatment. Results: The results showed that it was feasible to establish an oral health programme for the diabetics and could improve their periodontal health, and that toothpaste containing triclosan is effective in maintaining the improved periodontal heath in type 2 diabetics. Mean PPD dropped from 2.35mm to 1.95mm in the triclosan group and from 2.49mm to 2.24 mm in the non-triclosan group and the mean number of BOP sites dropped from 4.9 to 2.8 in the triclosan group and from 4.7 to 3.2 in the fluoriguard at 12 month visits. However, the results did not show improvement of HbA1c nor RBS levels in either group. C-Peptide levels increased and C-Reactive Protein levels decreased in both groups, however, not to significant levels at 12 month visits. Conclusion: The results of this research study lead to the conclusion that treating periodontal infection has effect of periodontal health of type 2 diabetic patients and following-up with simple personal oral hygiene of regular tooth-brushing helps maintain their periodontal health. This programme also proved that this type of oral health programme is feasible and valuable for diabetics in isolated places like the Marshall Islands, where infrastructure, personnel and resources are limited to treat microvascular and macrovascular complications of diabetes. As for the effectiveness of treating periodontal infections on glycaemic control of diabetics, this study failed to support the hypothesis that non-surgical treatment plus triclosan containing toothpaste would lead to better glycaemic management through improved periodontal health.

<p>Det har länge varit känt att patientens perioperativa position kan orsaka symtom som förmodas uppstå genom tryck och sträckningar. Positionen vid laparosko-piska operationer anses öka risken för symtom och därför är perioperativ om-vårdnad av betydelse. Syftet var därför att undersöka hur frekvent positions- relaterade symtom förekommer vid laparoskopiska ingrepp och vilken betydelse de har för patienten. Studien genomfördes som en deskriptiv tvärsnittstudie och datainsamlingen gjordes med hjälp av symtomskattning och semistrukturerade intervjuer. Totalt 60 respondenter i åldern 19 till 75 år deltog i studien som pågick under åtta månader. Resultatet visade att en fjärdedel av respondenterna drab-bades av nytillkomna eller förvärrade symtom. Dessa uppmärksammades postoperativt eller några dagar efter operationen och var oberoende av ingrepp, perioperativ tid eller armarnas position. Några av respondenterna upplevde smärta och domningar i nacke, axlar och händer som ledde till inskränkningar i det dagliga livet och krävde hjälp av närstående. Det är viktigt att fortsätta arbetet med att förebygga positionsrelaterade skador, för att förhindra postoperativa symtom, genom att placera patienten så nära ett neutralläge som möjligt och ge denne möjlighet att känna efter hur det känns före nedsövning.</p> / <p>It has long been assumed that a patient’s perioperative position can cause symp-toms which appear from pressure and strains on the body. The position in lapa-roscopic surgery is considered to increase the risk of symptoms, perioperative care is therefore important. The scope of this study was therefore to survey how frequent symptoms associated with the patient’s position occur and why they are important to the patient. The survey was made as a descriptive cross-section study. The data collection was made by way of patients own estimates of their symptoms and by semistructured interviews. 60 respondents aged between 19 and 75 took part in the study. The result showed that a fourth of the respondents experienced new or aggravated symptoms. These were observed postoperatively or a few days after surgery and were independent of operations, perioperative time or position of the arms. Some of the respondents felt pain and numbness in the neck, shoulders and hands which led to restrictions in their daily life and required help from someone close. It is important to continue working with preventing postoperative symptoms, by placing the patient as close to a neutral position as possible and give her the possibility to feel comfortable before the anesthetization.</p>

<p>Even if popliteal artery aneurysm (PAA) is the most common peripheral aneurysm, no single surgeon or institution has enough patients to study this disease with appropriate scientific methods, and no population-based investigation exists. </p><p>PAA epidemiology, treatment, management, and outcome were studied in a population-based study of 571 patients (717 legs) primarily operated on for PAAs and 100 episodes of preoperative thrombolysis in Sweden between 1987 and 2002. Patients were identified in the Swedish Vascular Registry and case-records were reviewed. Information on amputation and survival was obtained for all patients, and 190 patients were re-examined with ultrasound, after mean 7.2 years (range 2-18)</p><p>Median age was 71 years; 5.8% were women. Patients with unilateral PAA had AAA in 28%, increasing to 38% when PAAs were bilateral. Crude survival was 91.4% at one and 70% at five years, significantly lower than among age and sex matched controls. The cumulative incidence for operation of PAA in Sweden was estimated to 8.3/million person year. One-year amputation-rate was 8.8 %, increasing to 11% after follow-up (7.2 years). Independent risk factors for amputation within one year were poor run-off, age, emergency procedure, and prosthetic graft. Run-off was improved by preoperative thrombolysis among 87% of legs, when acute ischemia. After surgical repair with a medial approach the risk of late expansion of the aneurysm was 33%, with a posterior approach 8% , p=0.014. Among 190 re-examined patients, 108 (57%) had at least one additional aneurysm at index-operation, increasing to 131 (68%) at re-examination, the total number of aneurysms increasing by 42% (from 244 to 346).</p><p>Conclusions: Multiple aneurysms are common among patients operated on for PAA. Preoperative thrombolysis improves run-off and decreases the amputation-rate in PAAs with acute ischemia. Vein grafts do better than prosthetic grafts, especially when a long bypass is needed. Posterior approach, when possible, reduces the risk of late expansion. A complete examination of the aorto-iliac and femoro-popliteal arteries is warranted at the time of surgery. All patients should be kept under life-long surveillance in order to detect and treat newly developed aneurysms timely. Normal arterial segments should be re-examined after three years.</p>