Driving fatigue

Doctors are very well acquainted with what it’s like to work long hours under pressure.

The experience begins in the undergraduate years with what seems like a Herculean effort to keep passing all of those exams.

By my second year as a medical student, I didn’t even sneeze when the anatomy lecturer said that we could be examined on anything at all from the 820 pages of Gardner, Gray and O’Rahilly’s textbook – that is, except for anything about teeth.

Looking for some respite, I quickly flicked through the pages to find that Chapter 61’s description of teeth was only eight pages long, leaving another 812 pages to memorize.

On my first day as a resident in a hospital with 300 beds I was rostered to do the 4pm to midnight shift in Casualty, with the last two hours in the hospital on my own.

That was until a phone call just before midnight to tell me that the night RMO had called in sick and that I’d need to work on my own until 8am.

Fast forward to life as a hospital registrar with the once-a-week 8am to 5pm (the next day) shift.

Or worse still, the monthly 8am Friday until 5pm Monday mix of on-duty and on-call.

The words “proximate” and “remote” don’t quite convey how gruelling the work was.

Of course, there was no possibility of complaining about the hours worked. The threat of not having a position in the following year would silence any complainers.

You are most vulnerable to fatigue when you don’t get enough sleep, you work at night, are awake for long periods of time, or some combination of the above.

But my experiences pale in comparison to the hours involved in some forms of surgery.

One well-known neurosurgeon recently found his gown dripping with saline and blood after a 14-hour operation.

He commented, “Oh my God, it looks like I wet myself”, only to then find himself the subject of an AHPRA investigation when his off-the-cuff comment was taken literally.

Thankfully, heavy vehicle drivers can attend to calls of nature in a more timely fashion, compliments of the Heavy Vehicle National Law (2012).

After 5¼ hours of work they can take a 15 minute break or, if they choose to keep working, they must have a 30 minute break after 7½ hours or at least a one hour break after 10 hours.

They also must have a full seven hours of rest every 24 hours, and can’t work for longer than a total of 12 hours in that period.

There are heavy penalties for not taking the stipulated rest breaks, and all of this is recorded in a National Driver Work Diary for verification.

That is, of course, everywhere in Australia except for Western Australia and the Northern Territory, where they presumably don’t drive long distances.

Oh, by the way, any hours spent waiting to be loaded and not resting in a bed are all counted as work hours.

The fatigue-regulated heavy vehicles that this legislation applies to includes any truck with a gross vehicle mass (GVM) over 12 tonnes and buses over 4.5 tonnes with a seating capacity of more than 12 adults (including the driver).

There are very good reasons for preventing fatigue on the road, as truck drivers are more than 12 times as likely to be killed on the job compared with the average worker.

This easily makes road freight transport Australia’s most dangerous job. It carries a 50 per cent greater risk than farming, which is our next most dangerous occupation.

The community expects that pilots and truck drivers are taking enough breaks to ensure they are performing well and are not fatigued.

Undoubtedly, fatigue management practices have improved in medical workplaces, but as I recall it, this change has always lagged behind other industries, which is just not good enough.

How can we ensure that people with lung cancer living in rural and remote areas are treated surgically when appropriate?

We have the will to improve cancer services for patients outside major cities but, thus far, not the way

In 2012, 30% of the Australians newly diagnosed with cancers other than non-melanoma skin cancer lived in rural and remote areas. Some rural locations have visiting cancer specialists or outreach services, others have telemedicine available to assist local clinicians, but many subspecialty surgical services are located only in major cities. Therefore, to have their cancers adequately staged and, if suitable, to have potentially curative surgery, most rural and remote cancer patients will have to travel to see an appropriately specialised surgeon. It is necessary to centralise cancer care to make it possible to give patients access to the full range of clinical expertise and to provide the surgical services needed to achieve the best outcomes.1,2 This desired level of centralisation is rarely available except in major cities.

Using linked New South Wales cancer registry and admitted patients’ data and death records for the years 2000–2008, with geocoded residential and institutional addresses, we showed that patients with potentially curable non-small-cell lung cancer (NSCLC) who lived farthest from the nearest accessible hospital with a thoracic surgical service were the most likely to be admitted to a general rather than to a specialist hospital and, as a result, the least likely to have potentially curative surgery.3 Similar findings have been reported in other regions, for example, the East Anglian region of England. Moreover, in NSW, lack of surgical treatment fully explained the lower rate of survival from lung cancer observed in patients living farthest from an accessible thoracic surgical service.4 Thus, distance from specialised surgical services puts NSCLC patients at a significant disadvantage.

There is policy-level awareness of the disadvantage experienced by rural and remote cancer patients. Australia’s “National Strategic Framework for Rural and Remote Health” states that the goal of cancer care is to ensure that rural patients have increased access to diagnostic testing, coordinated care, multidisciplinary team review, patient accommodation, and appropriate medical oncology and radiotherapy services locally. To achieve this goal, the federal government has dedicated $1.3 billion in its budget not only to building two comprehensive cancer centres in Melbourne and Sydney but also to enhancing or building ten regional cancer centres. These developments should greatly improve cancer diagnosis in rural and remote areas and some aspects of cancer treatment, but they will not remove the need for some patients to travel for specialised surgical assessment and surgery.

In recognition of this need as it relates to lung cancer, the National Health Pathways initiative5 has, since 2013, included a detailed lung cancer referral pathway that provides general practitioners with up-to-date advice on the closest specialist cancer services so that rural patients are referred early and to the right place. While welcome, it will require much more than just publishing and promoting information to ensure reliable rapid referral of patients with NSCLC to specialist assessment and care. The NSW Ministry of Health’s planning for surgical services in greater Sydney6 and Rural Surgery Futures7 recommend that surgery be collocated with other specialist cancer services. While action on these recommendations may improve access to multidisciplinary care in general, it is unlikely to make highly specialised surgical care, such as thoracic surgery for lung cancer, more readily available in rural and regional areas, because of the large populations required to sustain such services.

There are guidelines and programs aimed at increasing early and appropriate surgical referral for cancer patients and some evidence that they work. For example, guidelines for recognition of and referral for suspected lung cancer of the United Kingdom’s National Institute for Health and Care Excellence (updated in 2015) recommend immediate referral if a chest x-ray suggests cancer or if someone aged 40 years or older has unexplained haemoptysis; and urgent chest x-ray if a person has two or more of, or has smoked and has one of, cough, fatigue, shortness of breath, chest pain or weight loss.8 Potentially more discriminating algorithms for urgent chest x-ray than these are being developed and evaluated.9 Recent evaluations of urgent referral initiatives in the UK suggest that they increase cancer detection rates, reduce delays in diagnosis and reduce the risk of death from cancer.10,11

In summary, available evidence suggests that people living remotely in Australia have poorer outcomes from NSCLC because they are often not referred to specialist thoracic surgical centres where their disease will be adequately staged and, if appropriate, they will be offered potentially curative surgery.

Australian health policy supports rapid referral of patients with suspected lung cancer for expert assessment. However, at present, there is a substantial lack of well organised processes to ensure that such patients are referred and assessed appropriately. This must change.

[Correspondence] Blood shortages and donation in China

China has a relatively low blood donation rate compared with the mean global rate, resulting in long-term blood shortages. Blood shortages are fairly common in regions in which the demand for blood for health-care services is high, such as Beijing, and are seasonal, such as during the winter and summer when college students and migrant workers (the main blood donors) are on holiday. To address the challenges of ensuring that sufficient blood is available, the Chinese Government has released a series of incentive policies, such as priority services, which give donors non-monetary compensation and prioritise them to receive blood during shortages, and mutual help donation, which encourages patients undergoing elective surgeries to persuade their family members, relatives, and friends to donate blood in blood centres in exchange for the same amount of blood for them to use during their surgery.

[Editorial] The struggle for better research in surgery

Two decades ago, a Comment in The Lancet questioned the quality of research in surgery. What has changed since then? On the one hand, much has improved; on the other, little. Thanks to initiatives like the IDEAL Collaboration (an indirect outcome of the 1996 Comment), the recognition that evidence is needed to drive improvements in surgical care is broadly recognised; though imperfectly implemented. How evidence is acquired remains problematic, attributable to the paucity of universal outcome measures, a perceived undervaluing of technical skill, and widespread denial of equipoise.

[Perspectives] Casting the body

It was sheer coincidence that I visited my own general practitioner (GP) on the same day I went to see the Health and the Body exhibition at the Royal College of General Practitioners (RCGP) in London, UK. The timing turned out to be apposite. We are used to exposing our bodies—and sometimes our minds—in the privacy of a GP’s surgery. But here, in the entrance hall of the RCGP’s headquarters, newly opened to the public, striking artworks force visitors to confront medical taboos and bodily differences that are more often hidden from public view.

[Perspectives] The medicine of Alex Higgins

Alex Higgins died aged 61 years. He had not expected to live so long. The greatest snooker player of his generation, he drank and smoked too much, and rested too little; broke too many hearts, including his own; and lived on the brink of ecstasy or disaster. He gambled with his money, his relationships, and his life. Having survived overdoses, a fall from a second-storey window, and knife and axe attacks, Alex Higgins had the last rites read over him after cancer surgery in 1998. Defying medical opinion, as was his custom, he lived another 12 years.

Govt targets big savings in Medicare crackdown

Main points

Medicare crackdown to save $66 million
Axing, amending MBS items delivers $56 million

The Federal Government expects to save more than $120 million by cracking down on Medicare waste and fraud and axing obsolete service items.

As the Government intensifies its hunt for savings, Health Minister Sussan Ley has announced she will toughen Medicare compliance activities and expects to save $66.2 million over the next four years by using advanced data analysis techniques to “better detect fraud, abuse, waste and errors in Medicare claims”.

The Health Department said it will audit an extra 500 providers each year, and will use sophisticated software to identify irregular payments and behaviours.

It said similar methods used by private insurers had in some instances achieved a 10-fold increase in the number of non-compliant activities detected.

The Government expects to achieve a further $56 million in savings by removing and amending listings on the Medicare Benefits Schedule.

In the first instalment of savings delivered by the MBS Review Taskforce led by Professor Bruce Robinson, the Budget has revealed the Government expects to save $5.1 million over the next four years by deleting 24 items and restricting access to two others.

These include gall bladder x-rays, larynx biopsies, the injection of hormones to manage habitual miscarriage and the use of x-rays to diagnose deep vein thrombosis.

In addition to these changes, the Government estimates it will save $51.4 million by axing a further 60 items identified by the Medical Services Advisory Committee and replacing them with around 30 new items.

These items include skin patch tests used by dermatologists, hip arthroscopy changes, fat grafting in spinal surgery and skin flap items for small excisions.

While the AMA supports work to modernise the MBS and remove obsolete or dangerous items, it is wary that it is being used by the Government as primarily a cost-cutting exercise.

Professor Robinson told an AMA-hosted forum earlier this year that his task was “not to save money. The Government may make savings, but I hope that the money is reinvested in health”.

AMA President Professor Brian Owler acknowledged the review was like to deliver some savings, but warned the medical profession’s goodwill and support for the process was contingent on any savings made being “held within health, to provide better services to patients”.

Against the $122 million of Medicare savings identified in the Budget, the Government announced it would spend $33.8 million over four years on tests for Indigenous people whose eyesight is threatened by diabetic retinopathy.

In addition, the Government has allocated $3 million over the next four years to provide for magnetic resonance imaging for breast cancer patients where conventional techniques fail to show the source of the tumour.

Adrian Rollins

[Perspectives] The ship of hope

As the African Mercy docks at the port, a long queue is already forming. The people who will wait in line all day are ill, some severely so. For the African Mercy is a surgery ship, run by the charity Mercy Ships, providing free operations for some of the world’s poorest people. The Surgery Ship (video) follows a team of Australian volunteers on board during the ship’s 2012–13 visit to Guinea.

What is new in the surgical management and prevention of breast cancer?

Breast cancer is the most common malignancy in Australian women. Cancer Australia predicted there would be 15 740 new cases and 3065 deaths from breast cancer in 2015.1 Ideally, treatment is multidisciplinary, with cooperation between a range of medical, nursing and supportive care specialties combining to give each woman access to the best available individualised treatment. With refinements and developments in therapy and the reasonably widespread use of screening, breast cancer survival rates continue to steadily improve, with the overall 5-year survival now about 90%.1 Recent incremental improvements in survival and reduced morbidity have resulted from refinement of therapies related to the understanding of breast cancer subtypes (luminal A, luminal B, human epidermal growth factor receptor 2 [HER2]-enriched, and triple negative)2 and the more personalised application of adjuvant therapies to those most likely to benefit. Commercially available gene expression profiling tools add to that refinement and will hopefully soon become publicly funded in Australia.

As survival has improved, the focus of surgical management has rightly undergone a major evolution to recognise the importance of aesthetic and other quality-of-life outcomes, including less extensive axillary surgery and sentinel node biopsy for most patients. If the best treatment for breast cancer is thought of as a package of care, rather than a series of independent therapies, then understanding the multifaceted implications of each component allows for increased flexibility in delivery of care and a range of benefits for the patient. To facilitate flexibility in decision making, the maximum amount of information has to be available at the time of diagnosis. This means high-quality breast imaging, which may include tomosynthesis and breast magnetic resonance imaging, as well as core biopsy of the tumour, with tumour phenotype identification including an estimate of grade and oestrogen receptor (ER), progesterone receptor (PR) and HER2 immunohistochemistry. This information facilitates multidisciplinary discussion of all possible options before commencing any therapy.

In this article, I highlight areas that demonstrate the major changes occurring in breast surgery to meet the challenges presented in this environment of steady improvements in outcome.

The role of the surgeon in multidisciplinary management

Cancer Australia recommends all breast cancer patients be managed by multidisciplinary teams, which includes presentation at a multidisciplinary meeting (MDM) at diagnosis and again at any major intersection of treatment.3 The multidisciplinary input into individual cases helps to alleviate the biases that individual specialists may have. The members of the multidisciplinary team comprise representatives from the relevant medical, nursing and supportive care specialties, including radiological and histopathology specialists. Surgeons are the most common source of new patients presented at MDMs, as most patients newly diagnosed with breast cancer require surgery and those presenting with distant metastatic disease may come to a surgeon first. It is the surgeon’s responsibility to present an accurate history and explain the planned or completed operative intervention, including margins and lymph node assessment. It is often the surgeon who is responsible for relaying the recommendations from the MDM back to the patient. Patients should be notified if there are any outlying opinions expressed in the MDM, even if there was general consensus.

Neoadjuvant chemotherapy

Based on the various patient and tumour factors, it can be confidently predicted at presentation that some patients will need chemotherapy as part of their multidisciplinary treatment. Multiple randomised controlled trials assessed in several meta-analyses and a Cochrane review4–6 have demonstrated equivalence in overall survival and loco-regional control for neoadjuvant chemotherapy (NACT; chemotherapy before surgical treatment) compared with adjuvant chemotherapy, providing all planned therapies are used. The extent of tumour response to NACT is a very powerful indicator of prognosis, with patients who achieve a pathological complete response having the best prognosis.

Persistent anxiety that giving NACT prevents the oncologist from knowing the exact size, grade and lymph node status of the tumour has largely been overcome by improvements in breast imaging and information available from core biopsy at diagnosis to define phenotype based on grade, ER, PR and HER2 status. Despite having no proven survival advantage, NACT has benefits that lead to better aesthetic and quality-of-life outcomes for the patient. However, in Australia, the benefits of NACT are not being fully realised and it is underused.7 Its potential benefits include:

a higher rate of breast conservation surgery (BCS) and improved aesthetic outcomes for patients who are already suitable to receive BCS;
lower rates of axillary lymph node (ALN) involvement and most likely lower rates of ALN dissection;
time for genetic testing before deciding on BCS or possibly bilateral mastectomy if a BRCA gene mutation is identified;
time for the woman to consider her surgical preferences, including contralateral surgery, and to seek multiple opinions;
demonstration of the tumour’s chemosensitivity to the drugs being given; and
enrolment in clinical trials evaluating new drugs or new drug combinations, including trials specifically investigating the role of additional chemotherapy for patients with significant residual disease after receiving NACT.

Oncoplastic breast surgery

Oncoplastic breast surgery (OBS) combines the principles of breast oncological surgery, to achieve adequate staging and local control of breast cancer, with aesthetic techniques, including some borrowed from plastic surgery. These involve a range of simple through to complex rearrangements of breast volume (volume displacement) or breast volume replacement, where adjacent or remote tissues are used for various types of flap reconstructions, to maintain breast shape. OBS techniques can increase the proportion of patients who can achieve BCS and improve its aesthetic results, lowering the need for patients to have a mastectomy. Some of the techniques, such as therapeutic mammoplasty, may lead to better aesthetic outcomes if a contralateral symmetry procedure is also performed, opening up the possibility of improving the patient’s pre-operative aesthetic appearance without compromising cancer treatment. A range of OBS techniques that may be used are listed in the Box. Many breast surgeons who have embraced OBS concepts are also performing breast reconstruction (BR) as a natural extension of the broader range of aesthetic surgical skills.

Immediate breast reconstruction

BR is recognised to improve both quality of life and recovery from the psychological trauma of a mastectomy. In New York, BR is a legislated right;8 in the United Kingdom, the National Institute for Health and Care Excellence recommends it be made available when medically appropriate,9 as does Cancer Australia.10 Despite this, reported rates of BR in Australia (8%–12%) have remained low compared with similar countries, such as the UK (21%) and United States (up to 25%).11–13 In the UK, structural reform regarding what constitutes a breast unit and advances in the training of new breast surgeons, in particular oncoplastic breast surgeons, has led to significant progressive improvements in the BR rate, as documented in the National Mastectomy and Breast Reconstruction Audit.11 Plastic and reconstructive surgeons continue to be the main providers of BR services in Australia, particularly for highly specialised free flap reconstructions. However, with an expanding number of breast surgeons with training in OBS techniques, breast oncology surgeons are more often performing immediate BR (IBR), mostly using implant-based techniques. Increasingly, patients are having skin-sparing, skin-reducing or nipple-sparing (total skin-sparing) mastectomy and IBR with implants, performed as either a one-stage or two-stage procedure by the breast surgeon. The one-stage, direct-to-implant reconstruction techniques (rather than two-stage, with an initial expander implant, followed by a permanent implant at a second operation) are facilitated by the expanding range of acellular dermal matrices derived from porcine, bovine or cadaveric human sources or synthetic mesh materials. As a result of these changes, some Australian centres are now reporting rates of IBR over 40%.14 As more breast surgeons become trained in these techniques, the expectation is that the national rate of BR will increase.

Risk reduction and preventive treatments

Much information is available to inform patients (and their physicians) about their risk of breast cancer. Influences on risk include family history of breast or ovarian cancer, length of endogenous and exogenous hormonal exposures during life, prior breast biopsy samples showing atypia, breast density, alcohol use and body mass index (BMI). Women can be assigned a risk category using various risk calculation tools that are generally based on a combination of these factors. For example, Cancer Australia offers an online tool, Familial Risk Assessment — Breast and Ovarian Cancer (FRA-BOC), that categorises risk level as 1 (normal), 2 (moderately elevated) or 3 (significantly elevated) based on a woman’s family history.15

The breast surgeon can instigate strategies to reduce a woman’s risk of developing breast cancer. The full range of options, as outlined below, should be discussed with the patient.

Lifestyle changes

Lifestyle changes to reduce risk of breast cancer are to reduce BMI, increase exercise, eat less fatty food and red meat, and consume less alcohol. Women, especially those at elevated risk, should limit prolonged exposure to exogenous hormones, especially combined hormone replacement therapy. It would be reasonable for every woman to get a breast cancer risk assessment, including mammographic breast density, around the age of 40 years and adjust lifestyle factors and frequency of screening accordingly.

Systemic therapies

Tamoxifen and other selective ER modulator drugs (SERMs), such as raloxifene, can moderate breast cancer risk by about 50% if used for 5 years, and are often offered to women in FRA-BOC risk categories 2 and 3. The possible negative impacts of these drugs include exacerbation of menopausal side effects and a slightly higher risk of thromboembolic events and uterine cancer (especially with tamoxifen).16 Aromatase inhibitor drugs are likely more effective than SERMs for prevention, but they only work in post-menopausal women and can have more pronounced menopausal symptoms, particularly arthralgia, and can worsen osteopenia.17

Bilateral prophylactic mastectomy

Risk management in the setting of a proven BRCA1 or BRCA2 gene mutation is a special situation requiring a multidisciplinary approach that includes genetic and gynaecological oncology expertise. For these women, risk-reducing bilateral salpingo-oophorectomy halves breast cancer risk, as well as minimising ovarian or fallopian tube cancer risk, and is recommended at an appropriate age (based on each woman’s individual circumstances). These women also receive greater benefits from risk-reducing medication and bilateral prophylactic mastectomy (BPM) than do non-mutation carriers.18 Situations exist where BPM is performed on non-BRCA mutation carriers, usually when a high level of risk has been otherwise established and after full discussion of the real, rather than perceived, risk of developing breast cancer and the complications of the procedure. Many more women initially present for a discussion of BPM but never have it after consideration of these factors.

Contralateral prophylactic mastectomy

Several studies have reported increased rates of contralateral prophylactic mastectomy (CPM) at the time of diagnosis with a unilateral breast malignancy.19 This is largely driven by patient preference, as many patients request CPM. When it is explained that this additional procedure does not affect overall survival, that the rates of complications are just as high for the procedure in the normal breast as the diseased breast, and that any complications may lead to delay in receiving important cancer therapy, most patients choose not to have, or at least to defer, the CPM. However, even when it is understood that CPM does not improve survival, it is still often requested. The reasons for this seem to be largely related to anxiety about the potential for having to go through treatment, especially chemotherapy, again, and the impact this will have on the patient’s family and quality of life. There is also a realisation that many women will be offered a contralateral symmetry procedure (most often reduction mammoplasty) if IBR is performed, so the logical argument presented, usually by the patient, is that she may as well remove and reconstruct both breasts. This is especially the case where deep inferior epigastric artery perforator and transverse rectus abdominis myocutaneous flap reconstructions are the patient’s preferred method of BR, as these flap reconstructions can only be performed once. Improvements in IBR, including those described above, have facilitated this increasing trend in CPM. The breast surgeon must fully inform patients of the potential negative impacts of CPM to try to moderate this demand and ensure that well informed decisions are made.

The importance of auditing and measuring high-quality breast surgical cancer care

As has been highlighted, breast surgery is increasingly complicated and there is pressure on established breast surgeons to expand their skill base and provide many of the options discussed here. The only Australian organisation representing breast surgeons as a craft group is Breast Surgeons of Australia and New Zealand (BreastSurgANZ; http://www.breastsurganz.org). Since its formation in 2010, it has been compulsory for full members of BreastSurgANZ to audit all their cases of breast cancer by contributing de-identified data to the BreastSurgANZ Quality Audit. This invaluable quality assurance tool allows members to assess their rates for five key performance indicators (KPIs) on the audit portal (https://www.bqa.org.au). By meeting threshold recommendations for these KPIs, the surgeon provides evidence that he or she is offering the best available cancer care. BreastSurgANZ is now auditing compliance of its membership, checking that individual surgeons are auditing all their cases and assessing their rates for the KPIs. It is not unreasonable for referring doctors or patients to ask their breast surgeon if he or she is meeting these KPIs or participating in an equivalent audit if the surgeon is not a BreastSurgANZ member.

Training breast surgeons in Australia and New Zealand

New breast surgeons are now mostly trained within a structure overseen by BreastSurgANZ. This requires 2 years of subspecialty training after attaining a Royal Australasian College of Surgeons Fellowship in General Surgery. Training increasingly aims to expose post-Fellowship trainees (PFTs) to at least two different breast units to enable them to see a broader range of techniques. In addition, PFTs are required to complete a log book, attend PFT training days, complete clinical ultrasound and communications courses, and participate in OBS Level 1 and Level 2 courses conducted by BreastSurgANZ or equivalent organisations overseas. Commencing this year, BreastSurgANZ and the University of Sydney have collaborated to develop a Graduate Certificate in Surgery (Breast Surgery).20 This provides a knowledge curriculum to assist breast surgeons with meeting the challenges of contemporary breast surgical practice.

Box –
Examples of oncoplastic breast surgery procedures

Description

Notes

Volume displacement techniques

Dual plane mobilisation

Simple, done in most low-volume resection cases by mobilising the breast parenchyma off the subcutaneous and deep tissues, closing the defect and redraping the skin over it

Round block techniques

Circumareolar incision, wedge resection, then volume redistribution

Grisotti flap reconstruction

For central tumours where the NAC has to be removed

Batwing mastopexy

Simple technique for central upper-pole tumours; results in mammoplasty

Tennis racquet method

Simple sectorial resection, with repositioning of the NAC

Therapeutic mammoplasty

Range of techniques and pedicles ± secondary pedicles to resect tumour and perform reduction mammoplasty and reshaping; often requires contralateral procedure

Volume replacement techniques

Latissimus dorsi miniflap; rarely free flaps (eg, TRAM, DIEP or SGAP flap)

Pedicled or free flap — importing muscle and/or overlying fatty tissues into the breast defect to reshape breast after significant volume resection (> 15–25% of breast volume)

TDAP, LICAP, AICAP, SAAP or SEAP flap

All variations on the theme of importing local fatty tissues into the breast defect on random or pedicled flap

AICAP = anterior intercostal artery perforator. DIEP = deep inferior epigastric artery perforator. LICAP = lateral intercostal artery perforator. NAC = nipple-areolar complex. SAAP = serratus anterior artery perforator. SEAP = superior epigastric artery perforator. SGAP = superior gluteal artery perforator. TDAP = thoracodorsal artery perforator. TRAM = transverse rectus abdominis myocutaneous.

Low back pain enhanced by psychological factors

Psychological and social stressors often enhance the symptoms of low back pain, experts say.

Associate Professors Leigh Atkinson, from Wesley Pain and Spine Centre in Brisbane, and Andrew Zacest from Royal Adelaide Hospital wrote in the Medical Journal of Australia that the high incident of low back pain is best understood in a biopsychosocial framework.

They say the pain from an injury is compounded by other issues such as work dissatisfaction, family stress, depression and at times secondary gain.

Compensation and third party insurance can impact pain and prolong rehabilitation. Furthermore, a study of workers compensation patients receiving surgery found the outcomes were poor.

“The incidence of persistent post-operative pain syndrome was as high as 40% and … there was a 50% success rate, at best, from the first operation, 30% from the second and 15% from the third,” the authors explained.

High expectation of successful surgical outcomes

Low back pain in the most common symptom seen in primary care, however patients often have high expectations from modern medicine.

“Not uncommonly, the patient attends the surgical consultation with an expectation that the problems can be fixed,” the authors wrote.

However despite an escalation in numbers performed, surgeries on low back pain remain controversial.

In the past 11 years, there has been a 267% increase of spinal fusion surgeries in the US and there has also been a disproportionate increase of surgeries in private hospitals compared to public.

There is a large array of techniques for spinal fusion however despite them all having different technical complications, there is little evidence of one providing better outcomes than another.

Multiple Cochrane studies have confirmed insufficient evidence of the effectiveness of spinal fusions, one in 2005 finding “variable clinical outcomes ranging between 16% and 95%.”

The authors believe an increased there needs to be a national audit of patient centred outcomes for spinal fusion.

“While the spinal fusion procedure remains controversial, it would be valuable for spinal surgeons to undertake a national audit of patient-centred outcomes for the procedure, similar to the excellent audit carried out for hip and knee arthroplasties by the Australian orthopaedic surgeons,” they concluded.

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