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PubMed1997

Inaugural lecture. Nursing and the counter culture for cancer.

The discourse surrounding cancer is that of warfare and of a militaristic endeavour aimed at helping those with the disease survive. The consequences of such a discourse have not previously been explored in detail; in particular the culture of the 'cancer clinic' has not been examined for how a battle mentality might effect the nature of care and treatment. This paper explores how the biomedical response to cancer and its treatment has established approaches which neglect the more day to day experiences of people living with the disease, and the suffering, disability and distress that it causes. A radical reconstruction of the culture surrounding cancer is called for, so that a new environment of care might be offered. This should be more participatory, collaborative and empowering of people with cancer and their families. It should also shift the dominant theme in cancer management from 'survival' to the here and now, and to the needs and problems people have. An argument is made for the contribution that nursing might make to such a reconstruction through developing new approaches to symptom and problem management, reorganising cancer services so that they are more supportive and patient focused, and through nursing research studies aimed at radically changing the process of research itself.

Attitude to Health↗
PubMed1998

Cancer nursing into the millennium: the Robert Tiffany Annual Lecture, Royal Marsden Hospital.

The nursing profession has shown tremendous adaptability throughout the ages. Cancer nurses have encountered many challenges and changes during this past century that have marked our increasingly rapid progress on the long road of development of cancer nursing. The movement from an illness-focused, hospital-based, physician-dominated health care model to preventive, community-defined and collaborative health care is providing exciting new opportunities for nurses. Advances in science and technology and a more informed consumer present unique challenges as well. Based on the trends and the tremendous breakthroughs occurring during this decade, this article explores visions and dreams of the preferred future of cancer nursing as we march into the next millennium.

Delivery of Health Care↗
PubMed1998

The Dorothy Russell Memorial Lecture. The molecular and cellular sequelae of experimental traumatic brain injury: pathogenetic mechanisms.

The mechanisms underlying secondary or delayed cell death following traumatic brain injury (TBI) are poorly understood. Recent evidence from experimental models of TBI suggest that diffuse and widespread neuronal damage and loss is progressive and prolonged for months to years after the initial insult in selectively vulnerable regions of the cortex, hippocampus, thalamus, striatum, and subcortical nuclei. The development of new neuropathological and molecular techniques has generated new insights into the cellular and molecular sequelae of brain trauma. This paper will review the literature suggesting that alterations in intracellular calcium with resulting changes in gene expression, activation of reactive oxygen species (ROS), activation of intracellular proteases (calpains), expression of neurotrophic factors, and activation of cell death genes (apoptosis) may play a role in mediating delayed cell death after trauma. Recent data suggesting that TBI should be considered as both an inflammatory and/or a neurodegenerative disease is also presented. Further research concerning the complex molecular and neuropathological cascades following brain trauma should be conducted, as novel therapeutic strategies continue to be developed.

Animals↗
PubMed1999

Repair of the damaged brain. The Alfred Meyer Memorial Lecture 1998.

Over the last decade, neural transplantation has progressed from being an experimental technique for studying regeneration and plasticity in the brain to clinical trials of reconstructive surgery in human neurodegenerative disease. Whereas clear evidence is only available at present for the viability of this technique in Parkinson's disease, applications to several other diseases, including Huntington's disease, multiple sclerosis, spinal cord injury, and chronic pain are currently under active consideration. It is clear that the techniques of transplantation can be functionally viable under certain well-defined biological circumstances, but significant problems remain in the availability of suitable donor tissues and defining the optimal conditions for reliable survival of the implanted cells. If we are to obtain improved reliability of the present techniques or identify suitable alternatives, we need a better understanding of the conditions for the survival and integration of grafts into the host brain, and the mechanisms by which they influence host function. In this review I consider the nature of the structural reconstruction required to achieve repair in animal models of Parkinson's and Huntington's diseases, contrasting the replacement of deficient neurochemicals within the striatum in the former case, and the need for reconstruction of input and output connections of the striatal circuitry in the latter.

Animals↗
PubMed2000

Quality use of medicines: where does pharmacology 'end'? Invited ASCEPT Lecture. Australasian Society of Clinic and Experimental Pharmacologists and Toxicologists.

1. Pharmacology can be defined very narrowly (e.g. as solely a laboratory based specialty) or more broadly to include issues surrounding rational drug use in the community. 2. While the hypothetio-deductive approach is more clearly in evidence in laboratory and clinical pharmacological experimentation, it is no less important in the comparatively less-well charted area of drug use in the community. 3. Just as laboratory pharmacology has built new partnerships with molecular biology and genetics, the exploration of community drug use brings pharmacologists into partnership with other disciplines (epidemiology, economics, behavioural science) and other sectors (consumers, government, health professionals and industry). 4. Implementing Australia's Quality Use of Medicines Policy (1992) has led to vigorous exploration of issues and problems in medicinal drug use in the community and much scientific study of causes and potential interventions to improve the situation. 5. The Australian National Prescribing Service (1998) is attempting to bring an evidence-based approach to the many facets of prescribing and drug use, by prescribers and consumers alike. 6. Innovation commonly occurs at the interface between the boundaries of traditional disciplines.

Australia↗
PubMed2002

Changing role of endoscopy in the new millennium. Bushell Lecture, Asia-Pacific Digestive Week 2001.

Endoscopy has confronted many challenges, including serology tests for Helicobacter pylori, virtual colonoscopy and magnetic resonance cholangiopancreatography. These new modalities might eventually replace endoscopy in diagnosing digestive tract diseases. New advancements such as capsule endoscopy, infrared spectroscopy, optical coherent tomography, and various therapeutic procedures have opened new horizons in the field. Endoscopists should keep their mind open and be prepared for the changing role of endoscopy in the new millennium.

Digestive System Diseases↗
PubMed2000

Fred Hollows lecture: digital screening for eye disease.

The purpose of this study was to explore progress, in the adaptation to community screening for blinding eye disease, of digital imaging devices and technology for storage and transmission. Available imaging systems were compared to gold standard clinical photography in terms of sensitivity and specificity for diagnosis of common blinding eye conditions. Since the use of expensive non-portable imaging devices is likely to be limited for widespread community screening purposes, a portable fundus camera (Nidek, Chiyoda-ku, Japan) and a prototype monocular digital indirect ophthalmoscope constructed at the Lions Eye Institute (LEI) were selected for comparative trials for the screening of optic disc cupping, glaucoma and clinical signs of diabetic retinopathy. Fifty-one eyes of 27 consecutive patients being assessed at the LEI clinic for glaucoma were dilated and photographed with a Zeiss retinal camera, and digital images were taken with the portable Nidek NM100 fundus camera (Carl Zeiss, Oberkochen, Germany) or with a prototype digital monocular indirect ophthalmoscope. Vertical cup: disc ratios (VCDR) were measured on the disc photographs by one ophthalmologist while three other clinicians were presented with compressed digital images in random order to estimate VCDR. Field trials were also carried out to demonstrate the practicality of compression, local storage and then transmission by mobile telephone ISDN lines and satellite, of optic discs and fundus images of patients with diabetes in either rural Western Australia or Surabaya, Indonesia. Kappa values of correlations of measurement of agreement between measured and estimated VCDR were 0.87, 0.45 and 0.84, respectively, for the three observers, corresponding to a specificity of 79-97% and a sensitivity of 70-95%. The portable Nidek fundus camera was also assessed for specificity and sensitivity in the diagnosis of diabetic retinopathy in comparison to standard Zeiss fundus camera photographs. Of 49 eyes in 25 consecutive patients attending the LEI clinic for assessment of diabetic retinopathy, three ophthalmologists assessed photographs and images in random order. When used for screening diabetic retinopathy, the digital images of the Nidek camera were graded as adequate quality in only 56% of eyes compared to 93% of the photographs. The kappa value of agreement in analysis of diabetic retinopathy was only 0.30. The prototype digital monocular indirect ophthalmoscope compared favourably with the Nidek camera. At 1:5 compression, images of size 36 kB transmitted from Surabaya to Perth took 29 s on the mobile telephone, while uncompressed images took 170 s. Images compressed 1:5 were transmitted in 60 s using the satellite telephone, while the uncompressed images took 240 s. Satellite transmission was more expensive but the lines were more stable than telephone connections from Indonesia. Digital imaging is becoming a powerful tool for ophthalmology in clinical records, teaching and research, and interoffice diagnostic opinions. It also has enormous potential for community screening for blinding eye diseases, such as glaucoma and diabetic retinopathy. Inexpensive portable imaging devices that are easy to use, and on which local health workers might be trained, must be developed and validated in terms of sensitivity and specificity of performance. The technology of image capture, image compression, transmission, data base storage and analysis is rapidly evolving and becoming less expensive.

Diabetic Retinopathy↗
PubMed2002

Fred Hollows lecture. Eye care for the community.

Eye disease is a huge and largely unrecognized problem in our community, especially in the elderly. The Visual Impairment Project, an intensive epidemiological study conducted by the Centre for Eye Research Australia (CERA) from 1991 to 1999, determined the prevalence, causes and risk factors for eye disease in Australia, and helped identify a series of specific, often simple, steps and strategies to significantly reduce its impact. A distillation of CERA"s findings has highlighted the growing problem of eye disease in our community. In addition, CERA has joined with other interested bodies to form Vision 2020: the Right to Sight Australia. This partnership was established in response to the Global Initiative to Eliminate Avoidable Blindness by the year 2020 - Vision 2020: the Right to Sight. This Global Initiative was established by the World Health Organization and the International Agency for the Prevention of Blindness. Vision 2020 Australia aims to be the peak body for all those involved in vision care in its broadest sense in Australia, and to put vision on the national agenda.

Aged↗
PubMedDate not supplied

Herbert Moran Memorial Lecture. World War I: the genesis of craniomaxillofacial surgery?

Herbert Moran enlisted in the Royal Army Medical Corps early in World War I. His autobiography captures the impact of contemporary experience of wartime gunshot wounds, seen in vast numbers and with little understanding of the requirements of wartime surgery. Wounds of the face and brain were numerous, especially in trench fighting. In France, Germany, Britain and elsewhere, surgeons and dentists collaborated to repair mutilated faces and special centres were set up to facilitate this. The innovative New Zealand surgeon Harold Gillies developed his famous reconstructive techniques in the Queen's Hospital at Sidcup, with the help of dental surgeons, anaesthetists and medical artists. The treatment of brain wounds was controversial. Many surgeons, especially on the German side, advocated minimal primary operative surgery and delayed closure. Others advocated early exploration and immediate closure; among the first to do so was the Austro-Hungarian otologist Robert Bárány. In 1918, the pioneer American neurosurgeon Harvey Cushing published well-documented proof of the desirability of definitive operative management done as soon as possible. Few World War I surgeons developed their knowledge of plastic surgery, neurosurgery and oral surgery in post-war practice. An exception was Henry Newland, who went on to pioneer the development of these specialties in Australasia. After World War II, the French plastic surgeon Paul Tessier created the multidisciplinary subspecialty of craniomaxillofacial surgery, with the help of his neurosurgical colleague Gérard Guiot, and applied this approach to the correction of facial deformities. It has become evident that the new subspecialty requires appropriate training programs.

Brain Injuries↗
PubMed2003

Foundation lecture. Fracture care of friend and foe during World War I.

BACKGROUND: In the early years of trench warfare, compound lower limb fractures caused by gunshot missiles prompted the -questioning of traditional splintage techniques and established evacuation methods. These prejudiced recovery and delayed surgery, often by many days, causing a high mortality rate especially for open femoral fractures. Importantly, battle weaponry was modified by differences in climate and terrain in Mesopotamia, Gallipoli, the Alps and the Northern European plain, to manifest differences in wound pathology. In Flanders, the static situation limited simple bullet wounds and launched a high percentage of jagged shell -fragment injuries complicated by tissue destruction, in-driven clothing and metal contaminated with mud, lethal bacteria and spores. From no-mans-land, soldiers with arm fractures scrambled back unaided, with tibial fractures they might hobble between two comrades, but with femoral fractures they were helpless unless stretcher bearers arrived. Often they did not, or only after a lull in fighting, by which time death from blood loss or exposure supervened. Even on a stretcher, poor fracture immobilization and long arduous carries added to shock and mortality. Remedies to these deficiencies and observations by Australasian, Austrian, British, Canadian, French, German, South African and American surgeons are noted. CONCLUSIONS: Trained to treat bullet wounds in open terrain, many military medical organizations were slow to adjust to the novel challenges associated with trench warfare. However, from 1917 well-trained stretcher bearers, efficient application of the Thomas splint, better control of haemorrhage and more rapid evacuation with motorized ambulances reduced deaths, amputation rates and long-term disability significantly.

Europe↗