Summary of the 57th British Association of Paediatric Surgeons congress in Aberdeen, July 22-24, 2010

This is a summary of the 57th annual meeting of the British Association of Paediatric Surgeons held in Aberdeen, Scotland, 22nd to 24th of July, 2010.     

Clinical forensic medicine in the present day trauma-care system--an overview

Criminal violence and its associated trauma comprise a critical health problem throughout the world. Clinical forensic medicine represents a new discipline of medical practice that is evolving in direct response to the sequelae of criminal and interpersonal violence. The application of the principles and standards of the forensic specialist has been increasingly recognized as playing a crucial role in trauma care; the results of the extremes of human behaviour-abused children, individuals suffering from blatant neglect and maltreatment, or self-inflicted injury, and victims of road-traffic accidents, firearm injuries and other assaults. These cases must be reported to a legal agency for investigation and follow-up. As trends in crime and violence change, new antiviolence legislation is likely to be implemented; consequently, new personnel resources are required to ensure that these legislative mandates effectively meet the needs of society.     

Challenges confronting female surgical leaders: overcoming the barriers

BACKGROUND: The number of women reaching top ranks in academic surgery is remarkably low. The purpose of this study was to identify: 1) barriers to becoming a female surgical leader; 2) key attributes that enable advancement and success; and 3) current leadership challenges faced as senior leaders. METHODS: Semi-structured interviews of ten female surgical leaders queried the following dimensions: attributes for success, lessons learned, mistakes, key career steps, the role of mentoring, gender advantages/disadvantages, and challenges. RESULTS: Perseverance (60%) and drive (50%) were identified as critical success factors, as were good communication skills, a passion for scholarship, a stable home life and a positive outlook. Eighty percent identified discrimination or gender prejudice as a major obstacle in their careers. While 90% percent had mentors, 50% acknowledged that they had not been effectively mentored. Career advice included: develop broad career goals (50%); select a conducive environment (30%); find a mentor (60%); take personal responsibility (40%); organize time and achieve balance (40%); network (30%); create a niche (30%); pursue research (30%); publish (50%); speak in public (30%); and enjoy the process (30%). Being in a minority, being highly visible and being collaborative were identified as advantages. Obtaining buy-in and achieving consensus was the greatest leadership challenge reported. CONCLUSIONS: Female academic surgeons face challenges to career advancement. While these barriers are real, they can be overcome by resolve, commitment, and developing strong communication skills. These elements should be taken into consideration in designing career development programs for junior female surgical faculty.     

The origins of surgery. 2: From barbers to surgeons*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

The origins of surgery: 1. From prehistory to Renaissance*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

Civiale,stones and statistics: the dawn of evidence‐based medicine

The statistical research on bladder stones conducted by Paris urologist Jean Civiale in the early 19th century provided historical roots for evidence‐based medicine. Translations of original documents by Civiale describing his work on treating bladder stones, and the discussion by members of the Paris Academy of Sciences that commented on his results in 1835, were reviewed. By collecting statistical data on a wide scale throughout Europe, Civiale argued that his new transurethral procedure, called lithotripsy, was superior to the more widely used but highly morbid technique, lithotomy. The Paris Academy of Sciences commented on his research and chose the occasion to debate whether or not numerical reasoning and statistics had any place in medical and surgical practice. Civiale’s insights and methods espoused similar concepts and ideas driving today’s new paradigm of evidence‐based medicine.     

Concepts in regenerative medicine: Past,present, and future in articular cartilage treatment

Regenerative medicine is emerging with great interest and hope from patients, industry, academia, and medical professionals. Cartilage regeneration, restoration, or repair is one of the prime targets that remains largely unsolved, and many believe that regenerative medicine can possibly deliver solutions that can be widely used to address the current gap(s) in treatment. In the United States, Europe, Australia, and India the regulation of regenerative based treatments has become a big debate. Although the rules and regulations remain unclear, clinicians that are interested should carry-on with the best available guidelines to ensure safety and compliance during delivery in clinical practice to avoid regulatory infraction. Many have made significant investment of time, resources, and facilities in recent years to provide new regenerative treatment options and advance medical care for patients. Instead of reinventing the wheel, it would be more efficient to adopt currently accepted standards and nomenclature borrowed from transplantation science, and cord blood storage industries. The purposes of this article are to provide some historical background to the field of regenerative medicine as it applies to cartilage, and how this field has developed. This will be followed by a separate discussion on regulatory oversight and input and how it has influenced access to care. Furthermore, we discuss current clinical techniques and progress, and ways to deliver these treatments to patients safely, effectively, and in a cost sensitive manner, concluding with an overview of some of the promising regenerative techniques specific to cartilage.     

The effects and prospects of the integration of traditional Chinese medicine and Western medicine on andrology in China

Andrology has a long history in traditional Chinese medicine (TCM) discussions concerning andropathies, and documentation of relevant therapeutic methods abound in the ancient literature on TCM. Integrated treatment combining TCM and Western medicine has seen both broad and in-depth development, with formidable status in the field of modern andrology in China. This article attempts to demonstrate the unique advantage of integrated treatment in the therapy of andropathies through a review of the ancient literature on andrology in the field of TCM and on the integrative treatment of prostatic diseases, sexual dysfunction, male infertility and late-onset hypogonadism. There is a need for the advancement of a medical theory that integrates TCM and Western medicine practices to create a new therapeutic system with standardized therapeutic and evaluative protocols for diseases involving male sexual health.     

The language of evidence based medicine: Answers to common questions?

Evidence based medicine (EBM) is an expanding field that combines clinical intuition with the best available evidence in clinical decision making. The shift to evidence based rationale encourages educating future physicians to formulate appropriate research questions and develop critical appraisal skills that are needed to practice EBM.This article identifies areas where clinicians may struggle with epidemiological terminology when critically appraising the literature. A review of the relevant terminology encountered in studies that focus on therapy, harm, diagnosis and prognosis can be beneficial to the clinician and are explained within this article.     

Notable names in the history of surgery: 1. Percivall Pott (1714–1788) *

Surgery today owes much to the services of early practitioners who made their advances as a result of wide clinical experience and compassion. This two‐part series explores the careers of Percivall Pott and William Arbuthnot Lane. Percivall Pott was born in 1714 in east London. Pott was apprenticed to Nourse of St. Bartholomew's Hospital at 15 years of age. After gaining licence to practise in 1736, Pott remained as surgeon to the hospital from 1745 till his retirement aged 73. After falling from his horse in 1756, Pott sustained a fracture of his leg, confining him to bed. During this time, he wrote on his own fracture, as well as hernia and head injuries. Several diseases are named after him, viz. Pott's fracture, Pott's puffy tumour, and Pott's disease of the spine. He was the first to describe cancer of the scrotum in chimney sweepers, as the earliest occupational cancer.      

J Martin Littlejohn (1865–1947) and James Buchan Littlejohn (1868–1947): Two distinct directions – Osteopathy and the birth of osteopathic medicine

J Martin Littlejohn (JML) bestrides osteopathic history especially in Chicago, Illinois, USA and in Europe. This article re-addresses much that has been written. His brother, James Buchan Littlejohn has never been acknowledged as an equal partner in formulating coherent principles, meanwhile James developed a lucid direction for US osteopathy against vitriolic osteopathic pressure. Although James's distinct vision has never been recognised, he laid out a blue print for osteopathy to evolve into osteopathic medicine. His path was protecting major surgery as an integral subject within the core curriculum of Kirksville and Chicago and later, introduction of materia medica into the Chicago course as a prelude to opting for prescribing drugs. An irretrievable falling out between the two brothers meant that J Martin Littlejohn never stated James's valuable contribution in his writings. This paper reasserts the dangers of hagiographical approach in placing osteopathic pioneers on a pedestal, divorced from a social historical context. Much of their cherished ideas were those attributed to or co-authored by others, unmentioned persons like James Buchan Littlejohn. Both brothers represent distinct paths for the profession's development: James's in the vanguard of those advocating its place within mainstream medicine and academia; JML's located within Protestant non-conformism, a metaphysical component and complementary medicine. Importantly, their Littlejohn College ideals envisaged broader causative factors than the spinal lesion to dysfunction which were rejected outright by the profession. Whereas James's reputation was enhanced and JML's declined, under considerable duress from external institutions neither brother could sustain their working or personal relationship.     

The changing role of pathologists from morphologists to molecular pathologists in the era of precision medicine

Pathology is the study of human illness. Throughout centuries of scientific discoveries, pathologic examination of tissue samples has been the gold standard for diagnosis and pathologists have been involved in the elucidation of aetiology, assessment of the biology, clinicopathologic correlation and prediction of prognosis. The advances in science and technology and focused interest in breast cancer research have provided ample opportunities for pathologists to participate in better understanding of the basic fundamental cascade of events leading to tumorigenesis in breast cancer. They also partnered with their clinical colleagues and scientists to find more effective therapeutic options. This change has been possible with recognition of the fact that morphology alone may not be sufficient to tell the entire story of clinical behaviour of all breast cancer patients. In addition, the realization of heterogeneity of breast cancer and the differences in the expression of various biomarkers and the observed differences in response to therapy have resulted in extensive efforts to better define the characters of each breast cancer subtype. It is now generally agreed that breast cancer is not a single disease and not all patients with breast cancer can benefit from the same therapy. These changes have brought new challenges for pathologists. Pathologist are now required to not only provide diagnosis, but also study the precise molecular characterization of each individual breast cancer case and play a significant role in the treatment planning of breast cancer patients. This remarkable change in the role of the pathologist require his/her involvement in the modern taxonomy of this disease and to rise to the challenge of genomic medicine and molecular diagnostics, which are the fastest growing areas of medicine. Emphasis should also been placed to create a new morphomolecular pathology and train our young pathologist to expand beyond morphology and to embrace the power of molecular diagnostics, in order to be able to effectively practise in the era of precision medicine.     

From amputation to limb salvage reconstruction: evolution and role of the endoprosthesis in musculoskeletal oncology

In 1943, Austin Moore developed the first endoprosthesis fashioned from Vitallium, providing the first alternative to traditional amputation as primary treatment of bone tumors. The success of the Vitallium endoprosthesis has since then led to the development of new materials and designs further advancing limb salvage and reconstructive surgery. Combined with the advent of chemotherapy use and imaging advances, conservative treatment of musculoskeletal tumors has expanded greatly. As the implantable options increased with the development of the Lewis expandable adjustable prosthesis and the noninvasive Phenix Growing prosthesis, receiving the diagnosis of a bone tumor no longer equates to automatic limb loss. Our review details the history and development of endoprostheses throughout orthopedic oncology in the treatment of musculoskeletal tumors.     

Infrared measurement of carbon dioxide in the human breath: "breathe-through" devices from Tyndall to the present day

The ability to measure carbon dioxide (CO(2)) in the breath of a patient or capnometry, is one of the fundamental technological advances of modern medicine. I will chronicle the evolution and commercialization of mainstream capnometry based upon infrared measurement of CO(2) in the breath using information from the historical record and personal interviews with many of the developers.     

The discovery of lymphatic system in the seventeenth century. Part I: the early history

The early history of lymphatic anatomy from Hippocrates (ca. 460–377 B.C.) to Eustachius (1510–1574). The presence of lymphatic vessels and lymph nodes was reported by ancient anatomists without any accurate knowledge of their true functions. Lymph nodes were described as spongy structures, spread over the whole body for the support of vulnerable body parts. Digestion was explained as being the resorption of clear chyle from digested food by the open endings of chyle vessels. The first insights into the place of lymphatic components within nutrition emanated from the medical school of Alexandria (fourth century B.C.) where vivisection was a common practice. Herophilus and Erasistratus described mesenteric veins full of clear liquid, air or milk. For Galen of Pergamum, (104–210) mesenteric lymph nodes also had a nutritional function. He described three different types of mesenteric vessels, namely, the arterial vessels, for the transport of spirituous blood to the intestines; the venous side branches of the portal vein, for the transport of nutritive blood from the liver to the intestines; and small vessels, from the intestines to the mesenteric lymph nodes (serous lymph vessels?). According to Galen, chyle was transported via the above-mentioned mesenteric venous vessels from the intestines to the portal vein and liver, where it was transformed into nutritive blood. This doctrine would be obliterated in the seventeenth century by the discovery of systemic circulation and of the drainage of chyle through a thoracic duct to the subclavian veins.