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PubMed2004

The ABJS presidential lecture, June 2004: our orthopaedic heritage: the American Civil War.

War, considered to be one of the greatest causes of human suffering, often spurs some of the greatest advances in medical treatments. In the United States, the Civil War was a catalyst for the development of trauma management, including general wound management, amputation techniques, triage, and transportation of wounded soldiers. The War, by necessity, also accelerated surgical knowledge and treatment of gunshot wounds of the extremities more than any previous event. The War also served as the impetus for the specialization of surgical skills, hospital systems, and medical data collection. Orthopaedic surgery, at the time of the War, was not as yet a recognized specialty in the United States. However, the Civil War played an important role in the specialty's heritage and the creation of specialty orthopaedic and prosthetic hospitals. Although many discoveries in the area of orthopaedic surgery were not discovered until the 20th century, many basic orthopaedic procedures and techniques were developed during this war that continue to be used today, including Buck's traction, plaster splints, and open treatment of contaminated wounds. The first recorded attempts at open reduction-internal fixation techniques for gunshot fractures occurred during the War. Resection arthroplasties, shell and bone fragment extraction, and various types of amputation were improved because of the large numbers of casualties.

American Civil War↗
PubMed2004

15th Chapter of Surgeons Lecture: Surgeon of the new millennium--surgeon, scientist and scholar.

The surgeon of the new millennium has come a long way from his humble beginnings in the Middle Ages as the lowly barber-surgeon. The skills and techniques developed by outstanding surgeons like Astley Cooper of the 19th century have withstood the test of time and have been refined by subsequent generations of surgical masters. The scientific basis of modern surgery was put on a firm footing in the early 19th century through the discovery of anaesthesia and microorganisms as a cause of many diseases and surgical complications. The 20th century brought about rapid progress in medicine, information technology (IT) and the life sciences, and closed with a big bang with the completion of the sequencing of the human genome. For the surgeon of the 21st century to remain relevant, he must embrace the concept of the Total Surgeon. Not doing so will render him irrelevant in the course of time, for having good surgical technique alone is insufficient. He must also lead in scientific endeavours to push the frontiers of the life sciences in attempts to solve the insoluble, and be scholarly in thought, attitude and behaviour. In other words, he must be a Surgeon-Scientist-Scholar.

General Surgery↗
PubMed2004

1st college of physicians lecture: the role of internal medicine as a specialty in the era of subspecialisation.

This paper is divided into 4 parts. The first deals with the definition of specialties and traces its roots from the early 20th century in the United States of America with the formation and growth of Specialty Boards. The second is a reflection on the scene in Singapore from the 1960s to the present, describing the change from public healthcare institutions run by the civil service to the autonomous restructured public service hospitals towards the end of the 20th century. The third section deals with what the 4ps have expressed about changes necessary to the Singapore system in the 21st century. The 4ps are the politicians, the payers, the patients and the public. It is about value for money, better coordination and better communication. Finally, just what is Internal Medicine - its competencies and its practice. A review of the systems in Australia, New Zealand, and the USA is presented. The idea of the "hospitalist" is discussed. Concluding remarks deal with the viability of Internal Medicine because of low reimbursement, administrative burdens and brief patient visits.

Hospital Administration↗
PubMed2004

Ellen R. Grass Lecture: Motor evoked potential monitoring.

Because somatosensory evoked potentials (SSEPs) recorded from the brain are carried solely within the dorsal columns of the spinal cord, SSEP monitoring may fail to detect damage to the spinal cord motor pathways, and techniques for directly monitoring the motor pathways have been developed. Transcranial magnetic brain stimulation is useful for extraoperative evaluation of the motor system, but anesthetic effects on cortical synaptic activity limit its usefulness for intraoperative monitoring. Another proposed monitoring technique, rostral spinal cord stimulation with recording from peripheral nerves, predominantly reflects retrograde conduction within the dorsal columns; like SSEPs, this technique may fail to detect motor pathway damage. The true motor evoked potential (MEP) monitoring technique preferred by most institutions involves transcranial electrical brain stimulation. This stimulates the corticospinal tract axons directly, producing a D-wave in them. There may be additional corticospinal tract volleys, reflecting indirect activation of the pyramidal cells via synapses from cortical interneurons; these I-waves are largely suppressed by anesthesia. Temporal summation at the alpha motor neuron synapse is necessary to elicit myogenic MEPs (M-waves) under anesthesia; this is accomplished with brief trains of stimuli that produce multiple pyramidal tract volleys. High stimulus intensities are required to stimulate the brain through an intact skull; with proper precautions, this is acceptably safe. Myogenic MEPs are quite sensitive to anesthesia and show considerable run-to-run variability. Therefore, criteria for evaluating MEPs differ from those for SSEPs, and the anesthetic regimen and degree of neuromuscular blockade must be carefully controlled. SSEPs should be monitored concurrently with MEPs, because the dorsal columns may be affected without compromise of the motor tracts, and also because this provides redundancy, with two independent assessments of spinal cord function.

Brain↗
PubMedDate not supplied

The John F. Maher Recipient Lecture 2004: Rage in the peritoneum.

Several conditions in the peritoneal membrane of peritoneal dialysis (PD) patients promote the accumulation of advanced glycation end-products (AGEs), that is, the uremic state, exposure to high glucose concentrations, and exposure to glucose degradation products (GDPs). AGEs exert some of their biologic actions through binding with a cell surface receptor, termed RAGE. Interaction of AGEs with RAGE induces sustained cellular activation, including the production of the fibrogenic growth factor, transforming growth factor-beta (TGF-beta). TGF-beta is pivotal in the process of epithelial-to-mesenchymal transition, through which cells of epithelial origin acquire myofibroblastic characteristics. Myofibroblasts are involved in virtually all conditions of pathological fibrosis. Submesothelial fibrosis is an important feature in peritoneal biopsies of PD patients, especially of those with clinical problems. We therefore examined the role of RAGE in peritoneal fibrosis, in an animal model of uremia, of high glucose exposure, and of peritoneal dialysate exposure. All three models were characterized by accumulation of AGEs, upregulation of RAGE, and fibrosis. Antagonism of RAGE prevented the upregulation of TGF-beta and fibrosis in the peritoneal membrane. We further examined the underlying mechanism of peritoneal fibrosis in the uremic model. Prominent myofibroblast transdifferentiation of mesothelial cells was identified by co-localization of cytokeratin and alpha-smooth muscle actin in submesothelial and interstitial fibrotic tissue. Antagonism of RAGE prevented conversion of mesothelial cells to myofibroblasts in uremia. In conclusion, we hypothesize that accumulation of AGEs in the peritoneal membrane, as a consequence of the uremic environment, chronic exposure to high glucose, and exposure to GDPs, results in an increased expression of RAGE. The interaction of AGEs with RAGE induces peritoneal fibrosis by virtue of upregulation of TGF-beta and subsequent conversion of mesothelial cells into myofibroblasts.

Dialysis Solutions↗