Overseas Centres Research Articles

Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass and hypothermic circulatory arrest: Experience at a large tertiary institution

Objective: This study aimed to review the experience at a large regional tertiary centre of open radical nephrectomy (RN) with vena caval thrombectomy with cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) for the management of renal masses. Method: Data on patients with renal masses who had undergone RN and vena caval thrombectomy with CPB and HCA had been prospectively collected at two centres over a 19-year period (2000–2019). Twenty-three consecutive patients were identified and retrospectively analysed for operative and tumour characteristics and for postoperative outcome. Kaplan–Meier survival analysis was performed to compare patient outcomes based on tumour characteristics. Results: Median operating time was 358 minutes (interquartile range (IQR)=94 minutes), median bypass time was 117 minutes (IQR=28.5 minutes) and median circulation arrest time was 25 minutes (IQR=18.5 minutes). The median hospital length of stay was 11 days (IQR=5.3 days). Total complication rate was 52% ( n=12), consisting of four minor and eight major complications (Clavien–Dindo score >IIIa), including one intraoperative death. The overall five-year survival rate was 73% (11/15), with a median follow-up time of 53.1 months. Eleven (48%) patients were surgically cured, with a median follow-up time of 60.1 months (IQR=71.8 months). Disease recurrence was seen in eight (35%) patients, of whom four died. Patients who died survived for a median of 46.5 months. Median survival after the diagnosis of metastatic disease was seven months. Conclusions: We report the largest Australian cohort of RN with vena caval thrombectomy with CPB and HCA. We demonstrate outcomes comparable to major overseas centres, with an overall five-year survival rate of 73%. This suggests that even patients with extensive venal caval thrombus from renal masses can experience long-term survival benefit from RN and venal caval thrombectomy. Level of evidence: Level 3.

Eating psychopathology and psychosocial impairment in patients treated at a Singapore eating disorders treatment programme.

There is limited data on the psychopathology of eating disorders in Singapore. This study: (a) described levels of eating psychopathology and psychosocial impairment among individuals diagnosed with eating disorders at our hospital; and (b) compared the related psychopathology of these patients. Between 1 August 2010 and 31 July 2012, 257 individuals who met the diagnostic criteria for eating disorders completed the Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment questionnaire (CIA). A majority of participants were women and of Chinese ethnicity. Diagnoses included anorexia nervosa (AN; 41.6%), bulimia nervosa (BN; 29.6%) and eating disorder not otherwise specified (EDNOS; 28.8%). Mean age at presentation was 20.52 ± 7.14 years and mean body mass index was 17.84 ± 4.18 kg/m2. Individuals with AN were significantly younger at presentation and had shorter duration of untreated illness compared to those with BN and EDNOS. There were no significant differences in the CIA scores of the diagnostic groups. Participants with BN scored higher in all subscales of the EDE-Q than those with AN and EDNOS. Our sample scored lower in most subscales of EDE-Q when compared to treatment centres in Sweden, Australia and the United States. Our clinical sample reported lower scores of psychopathology compared to overseas centres. This could be attributed to the higher percentages of BN and EDNOS diagnosed in overseas populations. Individuals with AN showed higher levels of psychopathology in our study compared to patients from the United States.

Current strategies for endoscopic management of acute cholangitis

At the pancreatobiliary session of Endoscopic Forum Japan (EFJ) 2016, current strategies for the endoscopic management of acute cholangitis were discussed. The topics consisted of two major parts, namely endoscopic management of acute cholangitis caused by common bile duct stones (CBDS) and biliary stent occlusion. Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. Strategies for management of cholangitis due to CBDS were agreed upon, and the clinical guideline of acutecholangitis (Tokyo guidelines 2013) was accepted. The best timing for drainage in Grade 2 (moderate) cholangitis urgent or early (<24h) was inconclusive, and more data is required on this issue. Another controversy was the feasibility of one step stone extraction in the patient with cholangitis vsstone removal after the cholangitis had resolved. There were various opinions with regards to the management ofacute cholangitis due to stent occlusion, and the strategiesdiffered according to the stricture location (distal or hilar) and stent type initially placed (Covered or uncovered metal stent). Strategies for management of cholangitis caused by CBD stones are well established according to the TG13. More evidence is required before further recommendations can be made with regards to cholangitis due to stent occlusion. We aim to clarify this in the near future with questionnaires and consensus from experts.

Current situation of endoscopic biliary cannulation and salvage techniques for difficult cases: Current strategies in Japan.

In the pancreatobiliary session at Endoscopic Forum Japan (EFJ) 2015, current trends of routine biliary cannulation techniques and salvage techniques for difficult biliary cannulation cases were discussed. Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion. It was concluded that, currently, in Western countries, the wire-guided cannulation (WGC) technique is favored during initial cannulation attempts. However, the conventional technique using an endoscopic retrograde cholangiopancreatography catheter with contrast medium injection is still used as first choice at most Japanese high-volume centers. The WGC technique is used as the second choice at some institutions only. After failed biliary cannulation attempts, the initial salvage option preferred in most centers includes pancreatic guidewire placement, followed by precut techniques as the second salvage choice. Among several precut techniques, the free-hand needle knife sphincterotomy with cutting upwards from the pancreatic duct is most popular. Endoscopic ultrasonography-guided rendezvous technique is also carried out as a final salvage option at select institutions.

Book and Software Reviews

Chronic Abdominal Pain. An Evidence-Based, Comprehensive Guide to Clinical Management; Editor: Kapural Leonardo, New York, Springer; 2015; pp 261 ISBN 978-1-4939-1991-8. Obtainable from www.amazon.com Acupuncture through Zen. Somewhere in the alphabet soup of published therapies for abdominal pain might be some evidence-based treatments. Pain that could be organic or functional, cancer-related or non-cancer-related, with attendant primary, secondary, or tertiary gain, ranging in severity from no impairment to catastrophic disability, with a niche in virtually every medical specialty. Dr. Kapural has coordinated opinions in this volume from more than 60 clinical thought leaders in the field. They are mostly from the United States, but 15 are from overseas centers. They have sought to define the pathophysiology and management of abdominal pain of all types in this volume. Dr. Kapural himself is a highly respected and accomplished clinician and researcher, with some 70 papers retrieved with Ovid/PubMed searches. Many of these papers refer to his own particular interests in interventional management of spinal and abdominal pain. He states this preference clearly in the preface, believing there is …

Student Learning Support &amp; Technology in Distance Learning

Distance education is a vehicle for the transmission of knowledge to all the sections of society without any discrimination. Teachers &amp; learners are at a distant place, communicating with each other with the help of learning support system &amp; technology. The first National Open University is the Indira Gandhi Open University (IGNOU) established in 1985, when the Parliament of India passed the Indira Gandhi National Open University Act, 1985 (IGNOU Act 1985). IGNOU is run by the central government of India. It has 21 schools and a network of 67 regional centers, 2667 study centers, and 29 overseas centers (15 countries). IGNOU offers 226 academic programs comprising courses at certificate, diploma and degree levels. Distance education has given the new meaning to education &amp; adapts learner centered approach which provides fruitful results too.

Development of hand surgery services in Malaysia

Hand surgery in Malaysia began modestly with the correction of claw deformity in leprosy patients early in the last century, and began to evolve over the years into the treatment of injuries in plantation and industrial workers, at home and then in road crashes. With training of some of our surgeons in various overseas centres, particularly in the UK and then in USA and Singapore, hand and microsurgery began to be developed in General Hospital Kuala Lumpur and University Malaya Hospital, when they returned home. An international three-day conference on hand surgery in Kuala Lumpur in the mid-1980's created greater awareness on the topic and helped to bring hand surgery to the fore-front, with setting up hand clinics, training in micro-surgery, and so on, in the major hospitals in Kuala Lumpur initially. Today, there are dedicated hand surgeons, technicians and hand therapists in the major government and private hospitals throughout the country, providing excellent services in this specialised and demanding area of trauma and reconstructive surgery.

Outcomes of Renal Transplantation in Brunei Darussalam over a Twenty-Year Period (1993-2012).

Objectives. Brunei Darussalam has a high prevalence and incidence of end stage renal disease (ESRD). Up until 2012, all renal transplantations were performed in overseas centres, either as government-sponsored (living-related transplantation) or as self-sponsored (commercialized transplantation) ones. We hypothesize that graft and patient survival of Brunei renal transplant patients are on a par with international standards. Materials and Methods. Data of all renal transplant patients in Brunei were analysed over a twenty-year period from registry records and case notes. Comparative survival data from other countries were obtained from PubMed-listed literature. Results. A total of 49 transplantation procedures were performed in foreign centres between 1993 and 2012. 29 were government-sponsored and 20 were self-sponsored transplantations. The 5- and 10-year overall patient survival rates were 93.3% and 90.1%, respectively. The 5- and 10-year overall graft survival rates were 91.1% and 81.2%. There is no difference in the survival outcomes of government-sponsored and self-sponsored patients. Living-related (government-sponsored) and commercialised (self-sponsored) grafts had equivalent survival to those reported in the literature. Conclusion. Our survival data was on par with those achieved in many countries. We hope to use this information to convince local stakeholders and patients to favour transplantation as the preferred modality of RRT.

P26 The UK paediatric sleep videoconferencing circuit: from idea to reality!

BackgroundPaediatric sleep medicine is an expanding area of clinical practice. A recent report1 highlighted the heterogeneity in both service provision and training between UK paediatric sleep centres. It was felt...

Supporting surgical skills training in Brunei and Borneo

Our visit began in Brunei, officially known as Brunei Darussalam, located on the north coast of Borneo, in south-east Asia. With a population of only 400,000 and as the third-largest oil producer in south-east Asia and the fourth-largest producer of natural gas, Brunei has the fourth-highest gross domestic product per capita in the world. With no income tax, free education, free healthcare and petrol cheaper than bottled water, Bruneians have an enviable quality of life. Under the governance of the Ministry of Health (MoH), each state has its own government hospital and rural areas are served by the Flying Medical Services division. Impressively, if a treatment is not available locally, for example organ transplantation, the MoH arranges treatment at overseas centres, often in nearby Singapore or Malaysia.

Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres

It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed. All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05. There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity. In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.

Training of Pulmonologists in Overseas Centers: A Resident's Experience

Training in pulmonology at overseas centers may require a considerable effort, and although such an experience could even imply a financial burden for the trainee, the benefits far outweigh the material costs. The desire for personal and scientific growth should encourage young pulmonologists and medical residents to rotate outside Spain and become acquainted with other health care systems, customs, dynamics, and resources in order to obtain quality training and added value that will further enrich our specialty. Any pulmonologist wishing to undergo specialized training at an overseas institution will necessarily consider questions such as the relevance of the stay and its objectives, timing, availability of centers, eligibility, and funding agencies. Based on one resident's personal experience, we attempt to answer several of these questions.

Formación neumológica en centros extranjeros. A propósito de una estancia

Training in pulmonology at overseas centers may require a considerable effort, and although such an experience could even imply a financial burden for the trainee, the benefits far outweigh the material costs. The desire for personal and scientific growth should encourage young pulmonologists and medical residents to rotate outside Spain and become acquainted with other health care systems, customs, dynamics, and resources in order to obtain quality training and added value that will further enrich our specialty. Any pulmunologist wishing to undergo specialized training at an overseas institution will necessarily consider questions such as the relevance of the stay and its objectives, timing, availability of centers, eligibility, and funding agencies. Based on one resident's personal experience, we attempt to answer several of these questions.

Feasibility of combining e‐health for patients with e‐learning for students using synchronous technologies

This paper is a report of a project to introduce and evaluate methods for using information and communication technologies to involve academic staff, students, and patients in a common synchronous e-learning environment. Although there is no strong evidence for this, there may be benefits in 'efficiency' and for patients and students from shared e-learning. Asynchronous e-learning methods in nursing education are well-established, but synchronous methods have received less attention. However, if feasible, because they are more akin to face-to-face contact, they may be more suitable for patients and may provide a quicker development path for e-learning. We evaluated three synchronous technologies: (1) non-commercial satellite interactive television (TV); (2) Internet videoconferencing; and (3) webcasting, through feasibility studies of 'TV-style' panel discussions on health topics and seminars with interaction with viewers by e-mail, inter-site research meetings with face-to-face interaction, user surveys and literature reviews. Interactive satellite TV required the booking of rooms with specialized receiving equipment. This limited accessibility contributed to the high cost per participant. Videoconferencing proved acceptable for cross-site research meetings and is proposed for joint meetings for doctoral students with overseas centres but has the same access issues as interactive satellite TV. Webcasting is accessible to most users with Internet access and provides a feasible means of delivery of synchronous interactive material. Reported live webcasts have had audiences of thousands. Presentation formats: panel discussions with mixed patient-professional membership and mixed patient-professional audiences were acceptable to participants but engaging academic staff and students was problematic. This may be overcome with webcasting but there may still be barriers such as timetabling and students' concerns about learning in the same 'live' environment as patients. Limitations in accessibility have been demonstrated for both satellite broadcasts and videoconferencing. Webcasting proved the most acceptable way of supporting a common synchronous environment. Having identified a feasible synchronous method we can now investigate hypothesized benefits for staff, students, and patients of combined e-health e-learning.

Assessment of risk for the development of pre‐eclampsia by maternal characteristics and uterine artery Doppler

To develop a method for the estimation of patient-specific risk for the development of pre-eclampsia by combining maternal history and uterine artery Doppler. Prospective multicentre observational study. Antenatal clinics in seven hospitals in the UK and three overseas centres. Unselected women with singleton pregnancies attending for routine antenatal care. Doppler studies of the uterine arteries were performed using colour flow mapping and pulsed wave Doppler at 23 weeks of gestation. The mean pulsatility index (PI) of the two uterine arteries was calculated. Doppler and maternal history variables were combined to develop a model for risk assessment. The incidence of pre-eclampsia was used to derive the prior risk for this complication. The posterior risk was derived by multiplying the prior odds with likelihood ratios (LRs) derived from independent risk factors identified from the maternal history, and the LR estimated from the heights of the frequency distributions of mean PI in affected and unaffected pregnancies. Pre-eclampsia. There were 17,480 women recruited to the study, in which 17,319 (99.1%) of these Doppler examination of both uterine arteries were completed, and outcome data were available in 16,806 (97.0%). Pre-eclampsia occurred in 369 (2.20%) cases. Significant independent prediction of pre-eclampsia was provided by mean PI, ethnic origin, body mass index (BMI), parity, cigarette smoking, history of hypertension and family or personal history of pre-eclampsia. Models were derived allowing calculation of patient-specific risk for development of pre-eclampsia. For a false-positive rate of 25%, the detection rate of pre-eclampsia by screening using maternal history was 45.3%, with uterine artery Doppler it was 63.1% and with combined assessment it was 67.5%. Combining risk factors in the mother's history with Doppler of the uterine arteries allows calculation of patient-specific risk for the development of pre-eclampsia.

Central Queensland University's Course Management Systems: Accelerator or brake in engaging change?

&lt;p&gt; Central Queensland University (CQU) is a highly complex institution, combining campuses in Central Queensland and distance education programs for Australian domestic students with Australian metropolitan sites for international students and a number of overseas centres, also for international students. In common with many other universities, CQU has recently reviewed its course management systems (CMSs). In doing so, CQU has signalled its desired strategic position in managing its online learning provision for the foreseeable future.&lt;/p&gt; &lt;p&gt;This paper analyzes that strategic position from the perspective of the effectiveness of CQU’s engagement with current drivers of change. Drawing on online survey results, the authors deploy Introna’s (1996) distinction between teleological and ateleological systems to interrogate CQU’s current position on CMSs – one of its most significant enterprises – for what it reveals about whether and how CQU’s CMSs should be considered an accelerator of, or a brake on, its effective engagement with those drivers of change. The authors contend that a more thorough adoption of an ateological systems approach is likely to enhance the CMS’s status as an accelerator in engaging with such drivers. &lt;/p&gt; &lt;P&gt;&lt;STRONG&gt;Keywords: &lt;/STRONG&gt;Australia, course management systems, enterprise systems, open and distance learning, teleological and ateleological systems&lt;BR&gt; &lt;/P&gt;

On Vitro Activity Of Pefloxacin And Other Antibiotics Against Grm Negative Bacteria in Ibadan, Nigeria

Gram negative organisms have continued to generate much interest in bacterial infections in the university College Hospital, Ibadan (UCH), because most of them are multiple drug resistant, and are resistant to many antibiotics available. The present study confirms an increasing percentage of common isolate resistant to Gentamacin, Augmentin and Azithromicin. Pefloxacin (Abaktal), a new generation guinolong and Ofloxacin showed strong activity against all isolates tested with MIC values within the range of those reported as sensitive from many overseas centres. Pefloxacin is valuable antibiotic for treatment of severe infection in our environment. Nigerian Quarterly Journal of Hospital Medicine Vol. 9, No. 1 (1999) pp. 54-57

From German 1 to German Studies 001: A Chronicle of Curricular Reform

In 1995, the Department of German Studies at Stanford University embarked upon a review of its objectives, curriculum, and staff deployment. At one level, such a review was mandated. The Stanford Language Center had been created to monitor the newly enhanced language requirement and had ordered that each language program articulate the language and cultural expectations that all graduates of a first-year program were to meet. At the same time, given the national enrollment crunch in German, declining local enrollment meant administrative pressures to carry a more appropriate student/teacher ratio. Adding to general enrollment declines were department-internal declines-30% across first year; 60% from first to second year. Accompanying the tensions caused by weak enrollment figures under the university microscope came additional university-level pressure in the form of encouragement to increase tenureline faculty participation in the beginning undergraduate curriculum. Compounding these pressures were university constituency issues: laments from students studying abroad that they were not prepared with idiomatic oral language for the overseas experience, complaints from instructors at overseas centers that students lacked adequate cultural-historical background, and criticisms from faculty colleagues that language departments in general could not be relied upon to prepare students for the real world. These were overt conditions pushing toward curricular revisions. While these external pressures were indeed extant and influential, a set of intellectual dissonances in the department added to our sense of urgency for curricular reform. What the department offered then to learners was the traditional mix of grammar-based sequences through the first year, to be repaired at the beginning of the second year, a second-year program that introduced some cultural/literary material but nevertheless focused on language development, and a set of underenrolled literature courses. Little had changed in language instruction since 1962.1 However, much had changed about the beliefs and the theoretical perspectives held by the faculty and being taught to the graduate students. In fact, the perspectives were tied up in cultural studies, in German intellectual thought, in popular and contemporary culture, and in second language acquisition research. The intellectual dilemma became one of bringing theory and practice into balance and harmony. There was a clear need to change a number of things in the basic German program at Stanford. First, the same language program (documented by the use of consecutive editions of the same textbook) had been in place for at least thirty years. The language program was relatively non-reflective of developments in second language learning pedagogical practices (documented by the growing size of the Xeroxed course reader with authentic materials). Second, graduate students were asked to teach the German language according to a structured model illustrated by materials that were grammatically sequenced at the sentence level. Ironically, though, the students were in a graduate program-a German studies program-that pointed them toward intellectual models that were not

Management of seminoma of the testis: recommendations based on treatment results.

The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine 'best practice' management protocols based on our results and a review of the relevant literature. (i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department. Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5-10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10 cm), the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment. Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IIA and IIB (5-10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.

The influence of flow cytometric gating strategy on the standardization of CD34+ cell quantitation: an Australian multicenter study. Australasian BMT Scientists Study Group.

The Australian Multi-centre study on CD34+ cell quantitation by flow cytometry documented, first, the extent of variation of CD34+ cell enumeration and, second, the influence of flow cytometric gating on CD34+ cell measurement. A PBSC harvest analyzed by 20 participating centers showed results ranging from 0.64% to 2.80%, with a median of 1.54% CD34+ cells. Of 20 centers, 9 obtained results within +/-10% of the median (the criteria for reproducibility suggested by the ISHAGE Guidelines). The flow cytometric gating strategy was identified as one of the major variables among the methods used. In stage 2, list mode data from two samples were analyzed by 24 Australian and overseas centers, including the authors of three published guidelines. Significantly different CD34+ results were obtained when different gating strategies were used (p < 0.006). When all the centers used the same gating strategy, the measurement of CD34+ cells fell within a narrow range, with 0-7% of results outside +/-10% of the median. However, when different gating strategies were used, the results were more widely scattered, with 17% of centers outside +/-10% of the median. This study demonstrated the potential impact of flow cytometric gating strategy on the reproducibility of CD34+ cell enumeration.