New surgical approaches for total hip arthroplasty (THA) are being developed to reduce muscle damage sustained during surgery, in the hope to allow better muscle functioning afterwards. The goal of this study was to compare the muscle sparing anterior (ANT) approach to a traditional lateral (LAT) approach with three-dimensional motion analysis. Kinematics and kinetics were obtained with an infrared camera system and force plates. It was hypothesized that (1) the ANT group would have closer to normal range of motion, moments and powers, compared to the LAT group, and that (2) the ANT group would have higher peak hip abduction moment than the LAT group. Forty patients undergoing unilateral THA for osteoarthritis between the ages of 50 and 75 (20 ANT, 20 LAT) were asked to perform three trials of walking, stair ascent and stair descent. Patients were assessed between six to twelve months postoperatively. Twenty age- and weight-matched control participants (CON) provided normative data. Results indicated that both THA groups had gait anomalies compared to the CON group. Both THA groups had reduced hip abduction moment during walking (CON vs. ANT: p<0.001; CON vs. LAT: p=0.011), and the ANT group had a significantly lower hip abduction moment compared to the LAT group (p=0.008). Similar results were observed during stair descent, where the ANT group had reduced peak hip abduction moment compared to the CON group (p<0.001) and the LAT group (p=0.014). This indicates that the anterior approach did not allow better gait and stair climbing ability after THA. It is therefore thought that other variables, such as preoperative gait adaptations, trauma from the surgery, or postoperative protection mechanisms to avoid loading the prosthetic hip, are factors that might be more important than surgical approach in determining the mechanics of THA patients after surgery.

This research has been defined in response to the Winnipeg children's hospital (WCH) challenges such as long waiting times, delays and cancellations in surgical flow. Preliminary studies on the surgical flow revealed that definition and implementation of successful process improvement projects (PIPs) along with application of an efficient master surgical schedule (MSS) are efficient solutions to the critical problems in WCH. In the first phase of this work, a process improvement program including three major PIPs, is defined and implemented in WCH in order to improve the efficiency of the processes providing surgical service for patients. In the second phase, two new multi-objective mathematical models are presented to develop efficient MSSs for operating room department (OR) in WCH.

Consolidation of Acute Care Surgical Services (ACSS) as a response to multiple challenges in providing timely and high-quality emergency services is a growing interest among healthcare policymakers. However, very little is known about patient experiences within this system. This study explores patient perceptions of their acute care surgical experiences within a consolidated ACSS program. A qualitative study guided by the tenets of Appreciative Inquiry was conducted. Data were collected by means of semi-structured interviews and personal stories. Thirteen participants were involved, seven females and six males of varying ages; all underwent emergency surgeries including appendectomy, cholecystectomy, and small bowel obstruction surgery. Findings suggest that clear and effective communication, excellent nursing care, timely access to surgical services, continuity of care, patient safety, transfer to an Acute Care Surgical (ACS) site, communication regarding transportation, and process of admission to an ACS site play important roles in patient experiences within a consolidated ACSS.

Background: Vagus nerve stimulation is increasingly applied to treat epilepsy, psychiatric conditions and potentially chronic heart failure. After implanting vagus nerve electrodes to the cervical vagus nerve, side effects such as voice alterations and dyspnea or missing therapeutic effects are observed at different frequencies. Cervical vagus nerve branching might partly be responsible for these effects. However, vagus nerve branching has not yet been described in the context of vagus nerve stimulation. Materials and methods: Branching of the cervical vagus nerve was investigated macroscopically in 35 body donors (66 cervical sides) in the carotid sheath. After X-ray imaging for determining the vertebral levels of cervical vagus nerve branching, samples were removed to confirm histologically the nerve and to calculate cervical vagus nerve diameters and cross-sections. Results: Cervical vagus nerve branching was observed in 29%of all cases (26% unilaterally, 3% bilaterally) and proven histologically in all cases. Right-sided branching (22%) was more common than left-sided branching (12%) and occurred on the level of the fourth and fifth vertebra on the left and on the level of the second to fifth vertebra on the right side. Vagus nerves without branching were significantly larger than vagus nerves with branches, concerning their diameters (4.79mm vs. 3.78mm) and cross-sections (7.24 mm2 vs. 5.28mm2). Discussion: Cervical vagus nerve branching is considerably more frequent than described previously. The side-dependent differences of vagus nerve branching may be linked to the asymmetric effects of the vagus nerve. Cervical vagus nerve branching should be taken into account when identifying main trunk of the vagus nerve for implanting electrodes to minimize potential side effects or lacking therapeutic benefits of vagus nerve stimulation.

Bakgrund: Bröstcancer är den mest förekommande cancersjukdomen bland kvinnor världen över. Den vanligaste behandlingen mot sjukdomen är kirurgi, vilken innefattar mastektomi där hela bröstvävnaden tas bort eller lumpektomi där endast en del av bröstvävnaden avlägsnas. Det kirurgiska ingreppet kan medföra negativa konsekvenser för kvinnorna ur ett fysiskt, emotionellt och socialt perspektiv. Det kan även påverka kvinnors kroppsuppfattning samt hur kvinnorna ser på sig själva.  Syfte: Att belysa kvinnors kroppsuppfattning efter kirurgisk behandling där hela eller delar av bröstet tas bort till följd av bröstcancer.  Metod: En litteraturöversikt innehållande 12 kvalitativa artiklar som belyser kvinnors kroppsuppfattning efter genomförd kirurgisk behandling. Samtliga inkluderade artiklar kvalitetsgranskades, söktes igenom efter likheter samt skillnader och sammanställdes sedan iform av subkategorier och huvudkategorier i resultatet.  Resultat: Åtta olika subkategorier framkom: känsel, attack mot kroppsuppfattningen, identitet och feminitet, attraktion, minskad kvinnlighet, yttre fasad, normer och ideal och rädsla. Dessa föll in under de tre huvudkategorierna: kvinnans kroppsuppfattning i relation till jaget, till andra och den sociala omgivningen. Slutsats: Kvinnorna upplevde en negativt förändrad kroppsuppfattning sompåverkade identiteten samt feminiteten. Utöver kirurgins inverkan på kvinnan själv påvisades även att kvinnans relationer till närstående samt den sociala omgivningen hade påverkats till följd av den upplevda förändrade kroppen. Klinisk relevans: Denna litteraturöversikt kan leda till en ökad medvetenhet och förståelse av kvinnors kroppsuppfattning efter kirurgisk behandling hos sjuksköterskor. Detta kan i sin tur leda till att kvinnorna upplever bättre stöd och omvårdnad efter genomförd kirurgi efter bröstcancer. / Background: Breast cancer is the most occurring cancer form among women worldwide. The most common treatment of breast cancer is surgical treatment, which involves mastectomy where the whole breast tissue is removed or lumpectomy where only a part of the breast tissue is removed. The surgical operation can imply negative consequences for the woman in a physical, emotional and social perspective. It can also affect women´s body image as well as how they look upon themselves. Aim: To describe women’s body image after surgical treatment following breast cancer. Method: A literature review of 12 qualitative articles that illustrate woman’s body image after completed surgical treatment. All articles where assessed regarding quality and was profoundly searched through for similarities and differences, which compiled into subcategories and main categories presented in the results. Result: Eight different subcategories were found: feeling, an attack against the body image, identity and femininity, attraction, decreased femininity, the external facade, social norms and ideals and fear. These were divided into the three main categories: the woman’s body image in relation to myself, others and the social surroundings. Conclusion: The women experienced a negative change in their body image that influenced their identity and femininity. In addition to the impact of the surgery on the woman herself, the result also showed an impact on the relationships to people those who are close to them as well as the interactions within the society. Clinical Implication: This literature review can lead to an increased awareness and understanding of women’s body image after surgical treatment amongst nurses. In turn this can further lead to women feeling better support and care after surgical treatment following breast cancer.

This dissertation explores some of the conditions of possibility underpinning contemporary breast cancer discourse, which is imbued with harsh moral, social and spiritual nuance. I have therefore explored a set of questions concerned with the past state of things in breast cancer care that laid the foundation for present approaches. I wanted to know how it became possible to speak what we now regard as the only truth about breast cancer. I wanted to understand how this truth was determined; who determined it, and who or what gave them the right to assert that their truth was the only truth. I wanted to acquire insight into the ways that thinking about and managing breast cancer based on this truth came to dominate the post-modern consciousness (rather than other, perhaps equally valid ways). And if it was possible, I wanted to open up a space for thinking differently about breast cancer. Finally, I wanted to test the fit of the ideas of the philosopher-historian, Michel Foucault, to these questions. Foucault's notions of discontinuity, discipline, the gaze, normalising judgements and to a lesser extent, some aspects of power/knowledge and the ethics of the self are here tested on the surgical archive of breast cancer, which housed the discourse that best represented Western societal beliefs about the disease, and which had been invested by society with the greatest authority in its conception and management. The analytic framework - modes of consciousness - suggested by Foucault provided a coherent structure with which to explore the archive. I found that there are numerous elements in the archive instrumental in cementing the conditions of possibility for breast cancer discourse in our own time. This dissertation demonstrates that, as is the case in the present day, these were based on unstable truths about breast cancer that were a result of a complex of sociocultural and political norms rather than an objective truth.

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.

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.

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.