News briefs

Severe head trauma mortality drops at Royal Darwin

Mortality rates for severe head trauma at the Royal Darwin Hospital are down 40% from the 79% rate reported in a study 10 years ago, according to the ANZ Journal of Surgery. The study reviewed clinical service between 2008 and 2013, highlighting the continuing challenge of remoteness to the delivery of emergency medicine and surgery in the Top End. Alcohol remains a major player in hospitalisation, with 57% of patients having evidence of alcohol involvement and 39% of patients with traumatic brain injury having alcohol as a factor in their presentations. Indigenous persons were also overrepresented, accounting for 39% of all procedures as well as being considerably younger by a median of 15 years than their non-Indigenous counterparts. Resident generalist surgeons are reliant upon interstate neurosurgeons, who provide ongoing education, training and support, both by way of outreach visits and by 24-hour telephone and teleradiology consultation over 2600 km away.

Maternal, neonatal tetanus eliminated in India

Maternal and neonatal tetanus has been reduced to less than one case per 1000 live births in India, according to a WHO report. Until a few decades ago, India reported 150 000 to 200 000 neonatal tetanus cases annually. According to Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, the Indian government used a mix of existing and new programs to make elimination possible. “India’s re-energized national immunization program and the special immunization weeks and the most recent ‘Mission Indradhanush’, helped ensure that children and pregnant women are reached with vaccines”, he said. “The ‘National Rural Health Mission’ promoted institutional deliveries with a focus on the poor. The ‘Janani Suraksha Yojana’ encouraged women to give birth in a health facility.” Maternal and neonatal tetanus in South-East Asia now exists in just a few districts of Indonesia.

Hazard alert for hip replacement component

The Therapeutic Goods Administration has issued a hazard alert for one model of the Profemur cobalt-chrome femoral neck (part number PHAC1254 – “long 8-degree varus”) due to the potential for the component to fracture. The manufacturer, Surgical Specialities, is also undertaking a recall of unimplanted stock. Component fractures are extremely rare; however, the manufacturer reported that there had been 27 reports of fracture of the PHAC1254 component in the approximately 9800 units sold worldwide over the previous 5 years. Only 32 units have been sold in Australia. “If you are treating patients who have had a hip replacement and are concerned about the above issue, advise them to be alert to the potential symptoms of a femoral neck component fracture (the sudden onset of symptoms such as pain, instability and difficulty walking or performing common tasks).”

Elevated lead levels in 30 NT children

The Northern Territory Health Department has confirmed that 30 children have been found with elevated blood lead levels in three separate locations across remote areas of the territory, the ABC reports. Children in Palumpa and Peppimenarti, in the West Daly region, and the Emu Point outstation, had higher than expected lead levels, probably due to contact with lead shot, used for shooting magpie geese, according to NT Health Minister John Elferink. NT Chief Health Officer Professor Dinesh Arya said that the children and their families were being interviewed to determine the cause, and all the children were receiving treatment from “specialist paediatricians”.

Ebola vaccination trial extended to Sierra Leone

The WHO reports that a new case of Ebola virus in Sierra Leone, after the country had marked almost 3 weeks of zero cases, has set in motion the first “ring vaccination” use of the experimental Ebola vaccine in the country. A swab taken from a woman who died aged around 60, in late August in the Kambia district, tested positive for Ebola virus. “The Guinea ring vaccination trial is a Phase III efficacy trial of the VSV-EBOV vaccine. Interim results published last July show that this vaccine is highly effective against Ebola. The ‘ring vaccination’ strategy involves vaccinating all contacts — the people known to have come into contact with a person confirmed to have been infected with Ebola (a ‘case’) — and contacts of contacts.”

Obituary – Dr Patricia Mackay

Dr Patricia Mackay’s outstanding contribution to the Australian community for more than 50 years, particularly her advances in patient safety and surgery, will be remembered following her death earlier this month.

Born in New Zealand in a small town south of Dunedin, Dr Mackay started her medical journey at the Otago Medical School. In an interview with Dr Christine Ball in 2008, Dr Mackay said that at medical school she was assigned to undertake a caesarean section by herself, and despite the obstetrician saying she shouldn’t worry about anaesthetic because the baby was dead, the baby turned out to be alive. Dr Mackay said this moment made her career.

Dr Mackay made the move to Australia to take the post-graduate examination. She started as a clinical assistant at the Alfred and Royal Melbourne Hospital. Dr Mackay had a long and proud history at the Royal Melbourne Hospital. She was the first female appointed as Head of Anaesthesia in 1984, a position she held until 1992. Dr Mackay established the first acute pain management unit in Victoria while at the Royal Melbourne Hospital.

She was among a small group of anaesthetists who founded the Australian Patient Safety Foundation and started the Anaesthetic Incident Monitoring Study, a national anonymous collection of incidents with the objective of finding out things that went wrong. The study continues to this day.

Dr Mackay held Secretary and Treasurer positions before taking on the role as President of the Australian Society of Anaesthetists from 1966-1968. She served as chair of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity from 1991 until 2005.

In 1999, the AMA granted a life membership to Dr Mackay, and she was awarded the AMA Women in Medicine Award in 2001. She was also awarded the Australian and New Zealand College of Anaesthetists Medal. In 2008, Dr Mackay was awarded a Medal of the Order of Australia – for service to medicine in the field of clinical anaesthesia, particularly as a contributor to the improvement of quality and safety of patient care, and to the community.

Dr Mackay made remarkable contributions to medicine, especially her efforts in patient safety. She was a wonderful role model for generations of anaesthetists, both male and female, and her passion and dedication to the profession will not be forgotten.

Kirsty Waterford

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury [Research]

Background:

Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (≥ 70 yr) on treatment decisions and outcomes.

Methods:

We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004–2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (< 70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre.

Results:

Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p < 0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p < 0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p < 0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p < 0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22–1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19–0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p < 0.001).

Interpretation:

We found chronological age to be a factor influencing treatment decisions but not at the 70-year age threshold that we had hypothesized. Older patients waited longer for surgery and had a substantially higher in-hospital mortality despite having less severe injuries than younger patients. Further research into the link between treatment delays and outcomes among older patients could inform surgical guideline development.

[Comment] Multimodal treatment of non-small-cell lung cancer

In The Lancet, Miklos Pless and colleagues1 report a prospective randomised trial of induction chemotherapy followed by accelerated radiotherapy and surgery, compared with induction chemotherapy followed by surgery, to treat patients with stage IIIA/N2 non-small-cell lung cancer. 232 patients were enrolled in 23 study centres and were randomly assigned to the study groups in a 1:1 ratio. Median event-free survival, the trial’s primary endpoint, was similar in the two groups (12·8 months, 95% CI 9·7–22·9 in the chemoradiotherapy group and 11·6 months, 8·4–15·2 in the chemotherapy group), as was overall survival (37·1 months [22·6–50·0] and 26·2 months, 19·9–52·1, respectively).

[Comment] Endobronchial valves in a highly parsed emphysema population

Lung volume reduction surgery is a thoracic surgical procedure whereby the hyperexpanded lungs of patients with severe emphysema are reduced in size by surgical excision of, ideally, the areas that are most severely destroyed.1,2 This operation, usually done bilaterally and almost always by video-assisted thoracoscopy, substantially improves pulmonary function, dyspnoea, and quality of life in appropriately selected patients. Several clinical series show about a 50% mean improvement in forced expiratory volume in 1 s (FEV1),3 and increased survival has been shown in one subgroup of patients.

Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study [Research]

Background:

Practice guidelines recommend that imaging to detect metastatic disease not be performed in the majority of patients with early-stage breast cancer who are asymptomatic. We aimed to determine whether practice patterns in Ontario conform with these recommendations.

Methods:

We used provincial registry data to identify a population-based cohort of Ontario women in whom early-stage, operable breast cancer was diagnosed between 2007 and 2012. We then determined whether imaging of the skeleton, thorax, and abdomen or pelvis had been performed within 3 months of tissue diagnosis. We calculated rates of confirmatory imaging of the same body site.

Results:

Of 26 547 patients with early-stage disease, 22 811 (85.9%) had at least one imaging test, and a total of 83 249 imaging tests were performed (mean of 3.7 imaging tests per patient imaged). Among patients with pathologic stage I and II disease, imaging was performed in 79.6% (10 921/13 724) and 92.7% (11 882/12 823) of cases, respectively. Of all imaging tests, 19 784 (23.8%) were classified as confirmatory investigations. Imaging was more likely for patients who were younger, had greater comorbidity, had tumours of higher grade or stage or had undergone preoperative breast ultrasonography, mastectomy or surgery in the community setting.

Interpretation:

Despite recommendations from multiple international guidelines, most Ontario women with early-stage breast cancer underwent imaging to detect distant metastases. Inappropriate imaging in asymptomatic patients with early-stage disease is costly and may lead to harm. The use of population datasets will allow investigators to evaluate whether or not strategies to implement practice guidelines lead to meaningful and sustained change in physician practice.

Surgeons apologise for extreme culture of bullying

The Royal Australasian College of Surgeons has apologised for discrimination, bullying and sexual harassment by surgeons.

The apology comes after a draft report and recommendations were released by an Expert Advisory Group (EAG), commissioned by RACS in response to reports of bullying behaviour in the surgical field.

The report found there is culture of bullying that is considered a ‘rite of passage’ within the College with the intent to prepare trainees for surgery.

Although the report admits that not all surgeons behave ‘badly’, there are individuals or groups who wield power and are repeat offenders. There is a lack of accountability structures in place which results in a major stumbling block for change.

“The EAG Report has identified that many of those affected have not felt they could trust the College to complain,” RACS President, Professor David Watters said in a video message.

“These behaviours have been too long tolerated and have compromised the personal and professional lives of many in the health workforce,” he said.

The report found that 49% of Fellows, Trainees and International Medical Graduates (IMGs) report being subjected to discrimination, bullying or sexual harassment. It also found that 71% of hospitals reported discrimination, bullying or sexual harassment in their hospital in the last five years, with bullying the most frequently reported issue.

EAG Chair, Hon. Rob Knowles AO said: “We have been shocked by what we have heard. The time for action has come.”

Woman told to ‘get tubes tied’

The report found that minority groups, particularly trainees and women, were the main targets of bullying.

Women were subjected to sexual harassment including demands for sexual intercourse and were not considered suitable for surgery by many of the bullies. Survey respondents reported discrimination for pregnancy and for asking surgeons for part time hours or time off to care for sick children.

The report noted comments from survey recipients such as:

“I was told I would only be considered for a job if I had my tubes tied.”

“I was expected to provide sexual favours in his consulting rooms in return for tutorship.”

“I felt sure I was marked down because I didn’t respond to my supervisor’s sexual advances.”

Racial discrimination was a recurrent theme, the EAG reports, with active measures to exclude surgeons from practice in Australia. Survey respondents reported incidents of abuse such as:“They want you out of the country or they want you dead.”

“I still fear that he could ruin my reputation and destroy my life”

The report talked about the fear encountered by surgeons, even in participating in the survey itself. Most of the fear was about career loss, particularly how much time, effort and expense had gone into their career thus far. One respondent wrote: “Reputation is everything…public hospital appointments depend on reputation.”

Respondents felt that power and lack of accountability had led to the issues that exist today. They felt that there was a lack of accountability from top surgeons as well as a lack of accountability and action from hospital administrators.

“There is a hierarchical system which is often dictated by senior consultants behaving in a chauvinistic manner, which I believe has been handed down over time. The acceptance/tolerance of appalling behaviours in the past has no doubt enabled the tradition of bullying/narcissism to continue,” a survey respondent wrote.

Report recommendations

The report has five key recommendations, which include undertaking a review of process in relation to complaints, provide avenues of support including mentoring programs and contact officers.

They say the college should provide for greater measures of accountability, develop training and awareness programs to help lead and influence and continue to review their structures for more inclusive practice.

Professor David Watters says the college fully accepts the recommendations and will publish an Action Plan by the end of November that addresses the issues raised.

“All Fellows, Trainees and International Medical Graduates (IMGs) will need to champion and model the high standards of behaviour we expect of others,” he said. “There is no place for discrimination, bullying or sexual harassment in surgical practice, surgical training or the health sector more broadly,” Professor Watters said.

Read the full report on the RACS website.

The Draft Report is now open for comment about errors of fact or suggestions for action that will strengthen the EAG’s recommendations. Comment can be emailed to eag@surgeons.org by 18 September 2015, before the EAG finalises its recommendations to the College on 21 September 2015.

Latest news:

[Comment] Type 2 diabetes: multimodal treatment of a complex disease

Type 2 diabetes is becoming the plague of the 21st century. With the so-called diabesity epidemic the disease threatens to reduce life expectancy for future generations globally. Surgery for diabetes has been marketed as an effective treatment option for patients with obesity and type 2 diabetes. Different surgical procedures have been used successfully, with some changing the anatomy of the stomach, bypassing parts of the gut, or using devices. These trials have provided an intriguing model to study the role of the gut in maintaining glucose homoeostasis.

Medibank saga remains unpreventable

The full page ads last week in some capital city papers may have heralded ‘peace in our time’ in the dispute between Medibank Private and Calvary Health, but the big insurer’s approach to safety and quality in our hospitals is still in question by hospitals, doctors, and patients.

While Medibank and Calvary may have finally signed a contract, the detail of the belated agreement remains top secret.

While the AMA agrees that any commercial details should remain private, it is in the public interest that any agreement over Medibank’s draconian list of 165 preventable events should be disclosed.

Calvary CEO, Mark Doran, told Adelaide radio that Medibank Private had agreed to engage with the Australian Commission on Safety and Quality in Health Care on what they believe are preventable events, and that they will act on the call for an independent clinical review process. But that’s about all we get to know at this stage.

AMA Vice President Dr Stephen Parnis said that Medibank’s ‘trust us, we’ll do the right thing by you’ response is not good enough.

“I’m a doctor and I don’t say that sort of thing to patients anymore,” Dr Parnis said.

“I’ve got to give them the specifics. And I think Calvary and Medibank Private need to do the same here.

“We’d like to understand exactly what the arrangements are with regard to that long list of 165 complications, which Medibank was erroneously calling mistakes, to understand what is going on with those as a result of this new agreement.

“The concern, of course, is that if you’re insured it’s the detail that tells you what you’re covered for and what you’re not covered for.

“The treating doctors need to understand what their patients will be covered for so that they can treat them in the appropriate setting.

“Up to now it’s been hardball by Medibank.

“The AMA rarely intervenes in these sorts of disputes but, because it has such wide-reaching implications for the health system, both private and public, we have regarded this as essential that, one, it gets sorted out, and, two, that it is done in a transparent way.

“It is positive that the Commission for Safety and Quality in Health Care is now involved.

“The Commission does things the right way when these complications are being assessed to try and reduce risk, rather than what was happening with Medibank saying these are not complications, they’re mistakes, and if they occur we’re not funding them or we’re dramatically reducing our funding.

“So we need more detail here because it doesn’t just affect Calvary and it doesn’t just affect Medibank Private. Every other player in the health system is watching on here.

“If this sets a good precedent, wonderful. If it doesn’t, then it’s going to have repercussions for everyone.”

John Flannery

Latest news:

[Comment] Hospital readmission after surgery: no place like home

The benefits of concentrating surgery within a region into high-volume, so-called centres of excellence are well known, including improved outcomes and reduced costs. However, the potential downsides have received less attention. Concerns have been raised that regionalisation could potentially threaten patient outcomes by compromising continuity of care, especially when the patient travels far from home.1 Although this concern is widely acknowledged, there has not previously been rigorous evidence to support it.