Leadership in 21st century military healthcare: what did clinical psychologists ever do for us?

Psychology is integral to the concepts and practice of leadership. Leadership models often have their roots in psychological paradigms, making it intrinsically easy for psychologists to grasp and apply them alongside clinical models. Psychologists' 'second-order' skills have been used to good effect in the changing landscape of military mental healthcare: modelling adaptive responses to change, understanding the non-conscious aspects of relationships in hierarchical organisations, working with systems, the ability to diagnose situational requirements and act accordingly, drawing on a range of psychological theories and leadership styles. The clinical psychologist as a professional who can help others 'reframe' a situation or experience is key to their leadership role within healthcare settings, 'enabling others to achieve shared purpose in the face of uncertainty'. The contribution that clinical psychology has made to leadership in Defence over the past 20 years will be illustrated by personal accounts from 'experts by experience'.

Influence of class IV laser therapy on the outcomes of tibial plateau leveling osteotomy in dogs.

OBJECTIVE: To determine the effects of low-level laser therapy (LLLT) on clinical outcomes in dogs with cranial cruciate ligament disease treated with tibial plateau leveling osteotomy (TPLO). STUDY DESIGN: Randomized, placebo-controlled clinical trial. Owners and surgeons (care providers and assessors) were masked. ANIMALS: Ninety-five dogs were admitted for TPLO and assigned to 1 of 2 groups, laser group (LG; n = 51) or placebo group (PG; n = 44). METHODS: Three treatments (laser or placebo) were administered within a 4-day perioperative period. A fourth treatment was recommended and was accepted in 28.4% of cases (LG, n = 14; PG, n = 13). Dogs in the LG group received laser at wavelengths 660 nm red (100 mW) and at 800, 905 and 970 nm infrared (maximum 15 W continuous wave, 20 W peak pulsed wave), administered simultaneously. Dogs in the PG group received placebo laser (660 nm, 4 mW). Other treatments were identical. Outcomes were measured by difference in clinical metrology instruments (Liverpool Osteoarthritis in Dogs and adjusted Canine Orthopedic Index [COI]), osteotomy healing on a radiographic scale, time to cessation of nonsteroidal anti-inflammatory drug administration, and wound healing by owner questionnaire. RESULTS: The only difference detected between groups consisted of a greater improvement in the gait section of the adjusted COI (ACOI) in the LG group (median [interquartile range; IQR] = 6 [4-7.5]) compared with the PG group (median [IQR] = 4 [2-6]; P < .05). CONCLUSION: The laser protocol used in this study was associated with a greater improvement in ACOI gait in dogs treated with TPLO but did not improve any other clinical metrology instrument scores or bone healing. CLINICAL SIGNIFICANCE: This study provides some evidence that LLLT may improve the gait of dogs recovering from a TPLO, as assessed by owners.

Lymphatic mapping of the breast: locating the sentinel lymph nodes.

When the concept of sentinel lymph node biopsy was described in patients with melanoma, researchers quickly started to use lymphatic mapping techniques in breast cancer patients in an attempt to locate the sentinel node in the axilla. We have been performing mammary lymphoscintigraphy in this role for 6 years and have now studied 159 patients. Like others, we have found that most breast cancers (93%) have lymphatic drainage that includes the axilla, and we have found an average of 1.4 axillary sentinel nodes in these patients. Surgical biopsy of the axillary sentinel nodes accurately staged the node field in 96% of patients. We have also found, however, that the pattern of lymphatic drainage from the cancer site is unpredictable; and in 49% of patients lymphatic drainage occurred across the center line of the breast to axillary or internal mammary sentinel nodes. In more than half of our patients (56%) lymphatic drainage occurred to lymph nodes outside the axilla including the internal mammary (45%), supraclavicular (13%), and interpectoral and intramammary interval nodes (12%). These nodes are also sentinel nodes, and their presence indicates that a sentinel node biopsy procedure that stages only the status of the axillary lymph nodes has the potential to understage about half the patients with breast cancer. High quality lymphoscintigraphy allows accurate mapping of peritumoral lymphatic drainage in most patients with breast cancer. It is possible that in the future accurate nodal staging in each individual will involve biopsy of all sentinel lymph nodes, regardless of their location.

The operative management of screen-detected breast cancers.

BACKGROUND: Mammographic screening for breast cancer not only reduces the overall mortality from breast cancer but allows greater opportunities for breast-conserving operations. The predicted degree of breast conservation is not being realized, but is increasing in centres that have published their results. METHODS: The operative management of breast cancers diagnosed by BreastScreen Central and Eastern Sydney Screening and Assessment Service were compared between two time periods: January 1988-December 1992 (group 1) and January 1993-December 1995 (group 2). The rate of breast conservation, and other data were compared between the two periods. An attempt was made with multivariate analysis to identify some of the factors that made mastectomy rather than conservation more likely. RESULTS: There were 723 cancers detected that were suitable for analysis (group 1, n = 273; group 2, n = 450). In group 1 the breast conservation rate was 42.9%; this increased significantly to 60.4% in group 2 (P < 0.001). The data were examined to determine if there was any other factor that had changed over the time periods which might account for the increased rate of breast conservation. The use of pre-operative diagnostic techniques such as fine needle aspirate cytology and core biopsy increased significantly. Multivariate analysis comparing the differences in patient age, diagnostic technique, tumour type, grade, size, location and lymph node status, both independently and compositely did not account for the increase in breast conservation in group 2. CONCLUSION: The increase in breast conservation is due to other factors such as the surgeons' approach and patient attitude. The use of pre-operative, minimally invasive tissue sampling techniques is increasing.

Femoral shaft fracture treatment in patients age 6 to 16 years.

Traction followed by spica casting, the one method used to treat femoral shaft fractures in children that was used in the past, has given way to a multiplicity of methods today. To evaluate the morbidity and costs of these various methods, 85 fractures in 81 patients age six to 16 years were evaluated. Early spica casting gave excellent results with low complications and low costs. All surgical treatments cost approximately the same: 3 times the cost of early spica casting and equivalent to traction followed by spica casting. Intramedullary flexible rods resulted in quicker healing and return to full weight bearing than did external fixation, which had the highest complication rate. One case of avascular necrosis in an 11-year-old girl treated with a reamed intramedullary rod suggests that this method is best reserved for children at or near skeletal maturity.

Purification, crystallization and preliminary X-ray analysis of human recombinant cytosolic serine hydroxymethyltransferase.

As an enzyme of the thymidylate synthase cycle, serine hydroxymethyltransferase (SHMT) has a key role in nucleotide biosynthesis. Elevated activities of SHMT have been correlated with the increased demand for nucleotide biosynthesis in tumors of human and rodent origin, making this enzyme a novel target for cancer chemotherapy. Here the purification and crystallization of recombinant human cytosolic SHMT are reported. Crystals belong to space group P6222 or P6422 with cell parameters a = b = 155.0, c = 235.5 A and diffract to at least 3.0 A resolution.

The crystal structure of human cytosolic serine hydroxymethyltransferase: a target for cancer chemotherapy.

BACKGROUND: Serine hydroxymethyltransferase (SHMT) is a ubiquitous enzyme found in all prokaryotes and eukaryotes. As an enzyme of the thymidylate synthase metabolic cycle, SHMT catalyses the retro-aldol cleavage of serine to glycine, with the resulting hydroxymethyl group being transferred to tetrahydrofolate to form 5, 10-methylene-tetrahydrofolate. The latter is the major source of one-carbon units in metabolism. Elevated SHMT activity has been shown to be coupled to the increased demand for DNA synthesis in rapidly proliferating cells, particularly tumour cells. Consequently, the central role of SHMT in nucleotide biosynthesis makes it an attractive target for cancer chemotherapy. RESULTS: We have solved the crystal structure of human cytosolic SHMT by multiple isomorphous replacement to 2.65 A resolution. The monomer has a fold typical for alpha class pyridoxal 5'-phosphate (PLP) dependent enzymes. The tetramer association is best described as a 'dimer of dimers' where residues from both subunits of one 'tight' dimer contribute to the active site. CONCLUSIONS: The crystal structure shows the evolutionary relationship between SHMT and other alpha class PLP-dependent enzymes, as the fold is highly conserved. Many of the results of site-directed mutagenesis studies can easily be rationalised or re-interpreted in light of the structure presented here. For example, His 151 is not the catalytic base, contrary to the findings of others. A mechanism for the cleavage of serine to glycine and formaldehyde is proposed.

Risk factors for infection with verocytotoxigenic Escherichia coli in cattle on Ontario dairy farms.

Risk factors for prevalent infection with verocytotoxigenic Escherichia coli (VTEC) were studied in a random sample of 886 cows and 592 calves under 3 months of age on 80 randomly selected dairy farms in southern Ontario. Fecal-culture supernatants from each animal were screened for verocytotoxicity using a Vero cell assay (VCA) and for verocytotoxin (VT) genes by a polymerase chain reaction (PCR) procedure. Up to 20 F. colt isolates from positive samples were tested for VT production using VCA and PCR. VTEC isolates were serotyped. Farm managers were interviewed using a standardized questionnaire to obtain information on farm- and individual animal-level management practices and characteristics. There was a significant (P < 0.001) positive association between age of calves and their VTEC infection status, and calves were significantly more likely to be infected than cows. The proportion of calves infected on the farm was positively associated with both the use of regular pails for feeding calves (as opposed to nipple bottles or nipple pails) and bringing new animals into the herd in the previous year.

Persistence of Escherichia coli O157:H7 in dairy cattle and the dairy farm environment.

The persistence of Escherichia coli O157:H7 in cattle and the farm environment was investigated on eight Ontario dairy farms positive for E. coli O157:H7 in a longitudinal study commenced one year previously. Faecal samples from cows, calves, humans, cats, rodents, wild birds, a composite fly sample and numerous composite and individual environmental samples were cultured and tested for verotoxin-producing E. coli (VTEC). VTEC isolates were serotyped and E. coli O157:H7 isolates were phage typed. E. coli O157:H7 phage type 34 was isolated from one calf on each of two farms. The same phage type had been isolated on one of these farms 12 months earlier. Most E. coli O157:H7-positive animals and farms became culture-negative within 2 and 3 months, respectively. E. coli O157:H7 was not isolated from any environmental samples, although evidence of VTEC was found in composite samples from calf feeders (19.1%), calf barn surfaces (18%), cow feeders (14.9%), flies (12.5%), cow barn surfaces (11.3%), and individual milk filters (12.5%). VTEC belonging to 21 non-O157 serotypes were isolated from 24 cows (8.2%), 21 calves (18.3%), 2 cow feeder samples (3.0%), and 1 calf feeder sample (4.8%). Shedding of E. coli O157:H7 by infected dairy cattle appears to be transient and persistence of E. coli O157:H7 was not demonstrated from the farm environment sites tested.

Risk analysis and international trade principles applied to the importation into Canada of caprine embryos from South Africa.

Between November 1994 and February 1995 over nine thousand Boer goat embryos were imported into Canada from the Republic of South Africa. This substantial international movement of animal genetics via embryos was achieved through the application of the risk analysis principles prescribed in Section 1.4. of the International Animal Health Code of the Office International des Epizooties (OIE). Integral to the development of the health certification procedures was the application of the fundamental principles of non-discrimination, harmonisation, equivalence and transparency defined in the World Trade Organisation Agreement on Sanitary and Phytosanitary measures. Risk mitigation interventions were founded upon full consideration of the potential for disease transmission by animal embryos as espoused by the International Embryo Transfer Society and the relevant standards contained in Appendix 4.2.3.3. of the OIE International Animal Health Code. All the embryos imported into Canada were implanted into synchronised recipients on arrival. Twenty months later there has been no evidence of disease in either the recipient animals or the resulting animals born in Canada.

Comparison of Vero cell assay and PCR as indicators of the presence of verocytotoxigenic Escherichia coli in bovine and human fecal samples.

Comparisons were made between Vero cell assay (VCA) and PCR as indicators for the detection of verocytotoxigenic Escherichia coli (VTEC; also known as Shiga-like toxin-producing E. coli) and as predictors of VTEC isolation from bovine and human fecal samples. Fecal samples were collected as part of a survey on the prevalence of VTEC on dairy farms in southern Ontario (J. B. Wilson et al., J. Infect. Dis., 174:1021-1027, 1996). A total of 2,655 samples were examined by VCA and PCR, 2,153 originating from cattle and 502 originating from humans. Overall, 36.2% of the samples were positive in the VCA and 38.7% were positive by PCR. Of the VCA-positive samples screened, 41.6% yielded a VTEC isolate. For both human and bovine samples, a significant positive association between PCR result and VCA titer (P = 0.0001) was found. In addition, there was a significant positive association between the PCR result and VTEC isolation from VCA-positive samples for cattle (odds ratio = 9.1, P < 0.0001). For bovine samples positive in the VCA, VCA titer was significantly associated with the probability of obtaining a VTEC isolate. Agreement between VCA and PCR was good for both bovine and human samples (kappa = 0.69 and 0.64, respectively). The sensitivity and specificity of the PCR with respect to the VCA for bovine samples were 82.0 and 86.5%, respectively, and those for human samples were 59.3 and 98.1%, respectively. Although correlation between VCA and PCR results was not absolute, when used in conjunction, these tests complemented one another as predictors of VTEC isolation.

Vero cytotoxigenic Escherichia coli infection in dairy farm families.

Fecal samples from 335 dairy farm residents and 1458 cattle on 80 farms were tested for Vero cytotoxin (VT)-producing Escherichia coli (VTEC). Residents were also tested for antibodies to VT1 and O157 lipopolysaccharide (LPS). Residents and cattle on farms with VTEC-positive persons or E. coli O157:H7-positive cattle were retested. Twenty-one persons (6.3%) on 16 farms (20.8%) and 46% of cattle on 100% of the farms had VTEC in fecal samples. Human VTEC isolates included E. coli O157:H7 and 8 other serotypes, 4 of which were present in cattle on the same farms. More persons had antibodies to VT1 (41%) than to O157 LPS (12.5%). Seropositivity to O157 LPS was associated with isolation of E. coli O157:H7 on the farm (P = .022). Human VTEC infection was negatively associated with age (P < .05) and was not associated with clinical illness. Many dairy farm residents experience subclinical immunizing VTEC infections at a young age, which frequently involve non-O157 VTEC found in cattle.

Neutralizing antibodies to Escherichia coli Vero cytotoxin 1 and antibodies to O157 lipopolysaccharide in healthy farm family members and urban residents.

An enzyme-linked immunosorbent assay (ELISA) to detect antibodies to Escherichia coli O157 lipopolysaccharide (LPS) was developed with sera from 63 children with confirmed recent E. coli O157 infection and from 256 age-stratified urban controls. The median ELISA values for control and case sera were 0.05 (interquartile range, 0 to 0.20; mean +/- standard deviation [SD], 0.15 +/- 0.22) and 1.41 (interquartile range, 1.11 to 1.59; mean +/- SD, 1.41 +/- 0.53), respectively (P < 0.001). With a breakpoint of 0.59 (mean ELISA value of the control sera + 2 SDs), the assay had a sensitivity, specificity, and positive and negative predictive values of 95, 94, 80, and 98%, respectively, for recent E. coli O157 infection. The O157 LPS assay and Vero cytotoxin (VT) 1-neutralizing-antibody (NAb) assay were used to compare the relative frequencies of O157 LPS antibodies and VT1-NAbs in an age-stratified urban population from Toronto, Ontario, Canada, and in 216 healthy family members from dairy farm in southern Ontario. The frequency of O157 LPS antibodies was about threefold higher in dairy farm residents (12.5%) than in urban residents (4.7%) (P < 0.01). Similarly, the frequency of VT1-NAbs was about sixfold higher in dairy farm residents (42.0%) than in urban residents (7.7%) (P < 0.001). These findings are consistent with a greater level of exposure of dairy farm residents to VT-producing E. coli (VTEC) strains. The high rate of seropositivity to VT1 in farm residents probably reflects the booster effect of repeated VTEC exposures and argues against a sustained generalized immunosuppressive effect of VT1. Seroepidemiological studies may help in assessing the level of exposure of different populations to VTEC strains.

Silicone breast implants: implications for society and surgeons.

In the last two years, scientific studies have confirmed that there is no significant increase in risk of subsequent breast cancer, connective-tissue disease or symptoms in women with silicone gel-filled breast implants. Despite this evidence, a moratorium (in place since 1992) on the use of these prostheses in the United States has been maintained by the pressure of overwhelming litigation. At the same time, Australian authorities also announced a moratorium, restricting the availability of silicone breast implants. Huge damages awarded by United States courts forced Dow Corning, manufacturer of a large percentage of breast prostheses, to file for Chapter 11 bankruptcy in May 1995. This effectively terminated the major source of implantable silicone for medical use. The withdrawal of implantable silicone and other implantable prosthetic material will be a significant loss for surgeons and society. This paper will highlight the consequences if reasoned scientific data are not relied on by Australian courts to assess claims for damages relating to medical devices.