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Objective In Australia, there is little evidence exploring why higher degrees by research (HDRs) are undertaken by surgeons. This study aims to describe the attitudes and experiences of surgical trainees and surgeons towards HDRs. Methods A 23-question cross-sectional survey of surgical trainees and consultant surgeons from three Australian public hospitals was undertaken between August and December 2022. Data were analysed according to stage of career and HDR status and assessed using chi-squared test, with P <0.05 considered significant. Results Out of 270 participants, 72 (27%) completed the survey including 30 (42%) trainees and 42 (58%) consultants. Overall, 43 (60%) participants had completed or were undertaking a HDR, which was similar between trainees (n =18) and consultants (N =25; P =0.968). A HDR was associated with more publications (P <0.5). Respondents with a HDR were more likely to have a salaried academic position (50%) than those without (15%). There was no significant difference in academic appointments based on HDR attainment (P =0.192). For surgical trainees, 93% rated the strengthening of resumes as the primary driver, compared with only 60% of consultants. For consultants, academic career aspirations and research interests were ranked the highest at 64% equally. Lack of time and competing nature of surgical training were equally ranked among all as the key barriers to completing a HDR. Conclusions These results provide insight into the academic pursuits of surgeons with an understanding of the role HDRs play, including the different drivers for Masters and Doctorates. This is important for supporting future surgeons who seek to pursue research.

Background: Whilst both mental illness comorbidity and the delivery of emergency surgery are commonplace in Australia, there is little evidence investigating any link between them. As such, this study examines the emergency surgical outcomes for patients with mental illness compared to other surgical patients within the Australian public surgical system., Methods: Retrospective cohort study involving adult emergency and elective surgical patients treated at three public hospitals in Sydney, Australia between 2018 and 2019. Patients were identified using ICD-10 diagnosis codes, and grouped by those with decompensated mental illness, chronic depression, or those without mental illness. Outcome measures included those within the emergency department (ED), along with in-hospital mortality and surgical outcomes., Results: Of 48 338 total patients, 31 890 (66.0%) had elective and 16 448 (34.0%) had emergency surgery. For patients with decompensated mental illness, only 228 (0.7%) had elective whilst 425 (2.6%) had emergency surgery. Their outcomes for this surgery type included being triaged significantly higher (Cat 1 or 2, 34% vs. 15%) and longer ED stays (8.3 vs. 6.6 h). They also had significantly more post-operative complications (26% vs. 8%) and total days in hospital (33.8 vs. 8.5 days). There was no significant difference for in-hospital mortality., Conclusion: Patients with mental illness are significantly more likely to have emergency surgery including presenting to the ED with more acute physical illness and to experience worse surgical outcomes compared to other surgical patients for every measure analyzed except mortality. There is considerable opportunity to further investigate how these differences might be improved., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Day-only emergency surgery for abscess drainage is poorly implemented in Australia. This study assessed the feasibility, outcomes, cost, and impact of an acute day-only surgery (ADOS) program., Method: A retrospective pre-post implementation study of patients requiring abscess drainage in theatre was performed. Following implementation of an ADOS program for abscess management, eligible patients were discharged from the emergency department and prioritized first on the following day's emergency list. Outcomes from the first 12 months of the ADOS era were compared with those of the preceding 6 months (pre-ADOS). Primary outcome was length of hospital stay (LOS). Secondary outcomes included 30-day complications, admission costs, and impact on overall emergency theatre workflow (measured by emergency appendicectomy metrics)., Results: Overall, 266 patients during the ADOS era (including 95 eligible for the ADOS pathway) were compared with 115 patients during the pre-ADOS era. Baseline characteristics were comparable. Median LOS was shorter during the ADOS era (21.9 h (IQR 11.8-43.3) vs. 30.1 h (IQR 24.7-48.8), P < 0.001). Median LOS was 10.2 h (IQR 8.9-13.1) for patients on the ADOS pathway. There were no significant differences in 30-day complications (9.3% vs. 9.5%), emergency department re-presentations (7.4% vs. 5.1%), or abscess recurrence (5.6% vs. 5.7%). Average cost per patient was lower during the ADOS era ($4155 vs. $4916, p = 0.005). ADOS did not appear to materially impact other emergency procedures., Conclusion: ADOS for abscess drainage is feasible, safe, and produces cost savings, while being implemented without significant additional resources., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: Historically, prioritizing abundant food production often resulted in overlooking nutrient quality and bioavailability, however, environmental concerns have now propelled sustainable nutrition and health efficacy to the forefront of global attention. In fact, increasing demand for protein is the major challenge facing the food system in the 21st century with an estimation that 70% more food is needed by 2050. This shift has spurred interest in plant-based proteins for their sustainability and health benefits, but most alternative sources of protein are poorly digestible. There are two approaches to solve digestibility: improve the digestibility of food proteins or improve the digestive capacity of consumers. Enhancing nutrient digestibility and bioavailability across diverse protein sources is crucial, with proteases presenting a promising avenue. Research, inspired by the proteases of human breast milk, has demonstrated that exogenous microbial proteases can activate within the human digestive tract and substantially increase the digestion of targeted proteins that are otherwise difficult to fully digest., Methods: Here, we introduce the use of an acid-active family of bacterial proteases (S53) to improve the digestibility and nutritional quality of a variety of protein sources, evaluated using the INFOGEST 2.0 protocol., Results: Results from in vitro digestibility indicate that the most effective protease in the S53 family substantially improves the digestibility of an array of animal and plant-derived proteins-soy, pea, chickpea, rice, casein, and whey. On average, this protease elevated protein digestibility by 115% during the gastric phase and by 15% in the intestinal phase, based on the degree of hydrolysis., Discussion: The widespread adoption of these proteases has the potential to enhance nutritional value and contribute to food security and sustainability. This approach would complement ongoing efforts to improve proteins in the food supply, increase the quality of more sustainable protein sources and aid in the nourishment of patients with clinically compromised, fragile intestines and individuals like older adults and high-performance athletes who have elevated protein needs., Competing Interests: WM, CJ, KM, and JH are employed by Digestiva, Inc. This study was funded in part by Mars Inc. and Digestiva, Inc. The funder, Mars Inc. was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication the funder, Digestiva, Inc. paid for the time and effort of researchers to collect data published herein. EF has ownership in Empowered Science, LLC. JG and JS are employees of University of California, Davis and scientific advisors to Digestiva, Inc. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Mak, Jones, McBride, Fritz, Hirsch, German and Siegel.)

Introduction: Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities., Patients and Methods: A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes., Statistical Analysis Used: Mixed-effects linear regressions were used to determine changes in QoL trajectories., Results: Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS., Conclusions: RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS., (Copyright © 2023 Copyright: © 2023 Journal of Minimal Access Surgery.)

Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.

Objectives: To explore the association between preoperative mental health status and surgical outcomes following robotic-assisted radical prostatectomy (RARP)., Methods: This cohort study included consecutive patients undergoing RARP surgery for prostate cancer between October 2016 and May 2022 at a major public hospital in Sydney, Australia. The primary outcome was preoperative self-reported mental health status measured using the mental component score from the Short Form 36 survey. Other variables included patients' characteristics, surgical outcomes, postoperative quality of life, pain and decision regret. Data were analysed using linear regression analysis., Results: A total of 266 men underwent RARP during the studied period. Of these, 242 patients (91%) completed the preoperative survey and were analyzed. Poorer preoperative mental health had significant univariate associations with younger age (P = .025), reduced access to economic resources (P = .043), diagnosis of a mental illness (P = .033), poorer mental health at 6 weeks and 6 months postoperatively (both P <.001), greater pain (P = .001), and higher decision regret (P = .001) 6 weeks following surgery. In the multivariate analysis, poorer preoperative mental health status was associated with younger age (P = .028) and poorer mental health at 6 weeks (P <.001) and 6 months (P = .025) postoperatively., Conclusion: For patients undergoing RARP, poor preoperative mental health status was associated with younger age and poorer postoperative mental health. Future studies should investigate if targeted preoperative psychological interventions would improve postoperative mental health outcomes, specifically in younger men undergoing RARP., Competing Interests: Declaration of Competing Interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches., (© 2023. Crown.)

Background: Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting., Methods: A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1-5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes., Results: A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients., Conclusion: Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed., (© 2021. The Author(s).)

Background: Despite relatively few COVID-19 cases within New South Wales, the uncertainty surrounding the pandemic has prevented a return to business as usual for the delivery of surgical services. This study aims to describe the evolving impact of COVID-19 on surgical activity and patient outcomes at a major public tertiary referral hospital., Methods: A retrospective cohort study involving adult surgical patients treated at a large public tertiary referral hospital in Sydney, Australia. Surgical activity, surgical outcomes and patient demographics were compared across two time periods, including the 'first wave' (February-May 2020 vs. February-May 2019) and the 'perseverance phase' (June-September 2020 vs. June-September 2019). Variables across both groups were compared using an independent t test or chi-squared test., Results: A -32% reduction in surgical separations was observed in the 'first wave', including -20% emergency and -37% elective. In the 'perseverance phase', there was a -19% reduction in surgical activity, including 0% emergency and -27% elective. The average length of stay, intensive care admissions, postoperative complications and in-hospital costs significantly increased in the 'first wave'. The proportion of public patients increased marginally (3%) in the 'first wave'., Conclusion: The impact of COVID-19 was most severely experienced in the initial months of the pandemic and observed in the number of patients treated. Although there was an initial effect on surgical outcomes, overall, the standard of care remained safe. The delivery of elective surgery remains a challenge and reflects the ongoing system-wide changes that are required to manage the COVID-19 pandemic., (© 2021 Royal Australasian College of Surgeons.)

Background: Laboratory simulation is increasingly important for teaching microsurgical skills. Training microsurgeons of different specialties within the same simulation laboratory increases efficiency of resource use. For maximal benefit, simulations should be available for trainees to practice specialty-specific, higher-order skills. Selection of appropriate simulations requires knowledge of the efficacy and validity of the numerous described laboratory models. Here we present a systematic review of validated training models that may serve as useful adjuncts to achieving competency in specialty elements of microsurgery, and appraise the evidence behind them., Methods: In setting up a multi-disciplinary microsurgery training course, we performed a systematic review according to preferred reporting items for systematic reviews and meta-analyses guidelines. EMBASE, MEDLINE, Cochrane and PubMed databases were searched for studies describing validated, microscope-based, specialty-specific simulations, and awarded a level of evidence and level of recommendation based on a modified Oxford Centre for Evidence-Based Medicine classification., Results: A total of 141 papers describing specialty-specific microsimulation models were identified, 49 of which included evidence of validation. Eleven were in the field of neurosurgery, 21 in otolaryngology/head and neck surgery, two in urology/gynaecology and 15 plastic and reconstructive surgery. These papers described synthetic models in 19 cases, cadaveric animals in 10 cases, live animals in 12 cases and human cadaveric material in 10 cases., Conclusion: Numerous specialty-specific models for use in the microscope laboratory are available, but the quality of evidence for them is poor. Provision of models that span numerous specialties may encourage use of a microscope lab whilst still enabling more specific skills training over a 'one-size-fits-all' approach., (© 2021 Royal Australasian College of Surgeons.)

Objective: To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay., Study Design: Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates., Data Sources: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library., Data Synthesis: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99)., Conclusions: Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients., Systematic Review Registration: PROSPERO, CRD42018080114 (prospective)., (© 2021 AMPCo Pty Ltd.)

Background: Cost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs., Methods: A retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs., Results: Of the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p < 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs., Conclusion: Delivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service., Competing Interests: Declaration of competing interest None., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Background: People with serious mental illness (SMI) have significantly worse surgical outcomes compared to the general population. There are many contributing factors to this complex issue, however consideration of the surgical experience from the patient's own perspective has never been undertaken. This lack of understanding prevents the provision of truly patient centred care and may limit the impact of potential improvement initiatives. Therefore this study aims to describe and better understand the surgical experience from the perspective of patients with SMI., Methods: Within this qualitative study, semi-structured, audio-recorded interviews were conducted between August 2019 - June 2020, with 10 consenting participants with SMI who had surgery in the previous 2 years. A thematic analysis approach was used to explore both the positive and negative aspects of the participant's surgical experience commencing from pre-operative consultation to hospital discharge and follow-up., Results: Four main themes and related subthemes emerged including i) the perceived lack of mental ill health recognition, ii) highly variable patient and clinician interactions, iii) the impact of healthcare services, and iv) strategies for improvement., Conclusion: Surgical patients with SMI want to be treated like everyone else whilst still having their mental ill health acknowledged and proactively managed despite this rarely occurring, which is valuable information for all surgical teams to consider and learn from. Participants were able to describe several readily implementable strategies to potentially improve their care and overall surgical experience, and as such highlight considerable opportunities for these to be tested and evaluated for this underserved patient group.

Objectives The use of robotic-assisted surgery (RAS) remains predominantly in the private sector. In the public sector, the effect of the implementation of RAS on theatre staff is unknown. The aim of this study was to examine the knowledge and attitudes of theatre staff before and after implementation of RAS in the public sector. Methods In all, 250 theatre staff, including nursing, medical and support staff, were invited to participate in the study. A survey investigating the benefits of RAS for patients and staff, concerns towards the workplace environment and facilitators towards the implementation of new technology was administered before (June 2016) and after (February 2019) the implementation of a comprehensive RAS program. Results The survey was completed by 164 (65.6%) staff before and 200 (80.0%) staff after the implementation of RAS. With time, most nursing (P=0.002) and medical staff (P=0.003) indicated that RAS may benefit patients by reducing intraoperative complications, whereas support staff remained uncertain about this benefit (P=0.594). Before the implementation, most medical staff indicated that RAS would benefit staff, although after they were unsure about this benefit. Overall, before RAS implementation, theatre staff were mostly concerned about workplace safety, but this concern was significantly reduced after RAS implementation (P<0.010). Conclusions With time, operating theatre staff considered their RAS program to be associated with enhanced benefits to patients, and their concerns regarding workplace safety were significantly reduced. Conversely, theatre staff were unsure about the benefits of RAS to themselves. It is important for organisations to consider the evolving impact of new technology on their staff and to refine ongoing education and training programs in line with these changes. What is known about the topic? The implementation of RAS is rapidly evolving in major hospitals. Therefore, it is important to investigate the knowledge, attitudes and experiences of operating theatre staff before and after the implementation of RAS, especially in the public sector. What does this paper add? This study found that with time theatre staff considered RAS to be beneficial to patients, and their initial concerns about the effect on workplace safety were significantly reduced. What are the implications for practitioners? It is important for organisations to consider the evolving impact of the implementation of new technology on operating theatre staff and to refine ongoing education and training programs as required.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor., Methods: This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed., Results: A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality., Conclusion: This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres., (© 2019 Royal Australasian College of Surgeons.)

Background: The use of robotic-assisted surgery (RAS) is becoming increasingly prevalent across a range of surgical specialties within public hospitals around Australia. As a result, it is critical that organisations consider workplace factors such as staff knowledge, attitudes and behaviours prior to the implementation of such new technology. This study aimed to describe the knowledge and attitudes of operating theatre staff from a large public tertiary referral hospital prior to the commencement of an RAS program., Methods: A cross-sectional survey of nursing, medical and support staff working in the operating theatre complex of a large public tertiary referral hospital was completed over a one-week period in June 2016. A 23-item questionnaire was utilised for data collection., Results: 164 (66%) theatre staff returned the surveys and were included in this study. The majority of medical staff reported being knowledgeable about RAS, whilst the majority of nursing and support staff did not. Overall the theatre staff were neutral about the potential benefits of RAS to patients. The majority of medical staff believed the implementation of RAS will increase the value of staff roles and job satisfaction, while nursing and support staff were uncertain about these benefits. All three staff groups were concerned about the impact of an RAS program on Workplace Health and Safety, and care and handling., Conclusion: Operating theatre staff presented different knowledge and attitudes prior to the introduction of RAS. Whilst theatre staff were more favourable towards RAS than negative, they largely reserved their judgement about the new system prior to their own experiences. Collectively, these findings should be taken into consideration for training and support strategies prior to the implementation of a RAS program., Competing Interests: The authors have declared that no competing interests exist.

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

Background: People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system., Methods: Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined., Results: Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%)., Conclusion: Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients., (© 2018 Royal Australasian College of Surgeons.)

Key Message: A simple and versatile ternary vector system that utilizes improved accessory plasmids for rapid maize transformation is described. This system facilitates high-throughput vector construction and plant transformation. The super binary plasmid pSB1 is a mainstay of maize transformation. However, the large size of the base vector makes it challenging to clone, the process of co-integration is cumbersome and inefficient, and some Agrobacterium strains are known to give rise to spontaneous mutants resistant to tetracycline. These limitations present substantial barriers to high throughput vector construction. Here we describe a smaller, simpler and versatile ternary vector system for maize transformation that utilizes improved accessory plasmids requiring no co-integration step. In addition, the newly described accessory plasmids have restored virulence genes found to be defective in pSB1, as well as added virulence genes. Testing of different configurations of the accessory plasmids in combination with T-DNA binary vector as ternary vectors nearly doubles both the raw transformation frequency and the number of transformation events of usable quality in difficult-to-transform maize inbreds. The newly described ternary vectors enabled the development of a rapid maize transformation method for elite inbreds. This vector system facilitated screening different origins of replication on the accessory plasmid and T-DNA vector, and four combinations were identified that have high (86-103%) raw transformation frequency in an elite maize inbred.

Background: To undertake a comprehensive needs assessment to determine the baseline of surgical research activity at a tertiary referral hospital in Sydney, Australia., Method: The comprehensive needs assessment comprised three components: a retrospective audit of the hospital ethics committee records to identify surgical research activity; a survey of all 17 surgical departments about the availability of 10 potential research resources and a survey of surgical staff to ascertain perceptions of research culture at the organizational, team and individual levels., Results: Of all research studies submitted to the hospital ethics committee in a 2-year period, only 9% were identified as surgical studies. Among the 17 surgical departments, there was wide variation in activity with only four defined as being 'research active'. On average, 52% of potential resources for surgical research were found to be in place within surgical departments. Only five departments were considered to be adequately research resourced (≥75% potential resources in place). Surgical research culture was rated 'moderate' at the organizational and team level, and 'low' at the individual level. Medical staff rated research capacity significantly higher at the team and individual levels compared to nursing staff., Conclusion: Collectively, the baseline results indicate there is considerable opportunity to enhance surgical research at the hospital level and to use this information to guide new and innovative approaches in the future., (© 2016 Royal Australasian College of Surgeons.)

Study Design: A systematic review of all sexual health outcome measures reporting psychometric properties for a spinal cord injury (SCI) population., Objectives: To evaluate the psychometric evidence for sexual health outcome measures used in a SCI population in order to (1) determine the clinical relevance of current tools and (2) suggest recommendations for future tool development., Setting: Vancouver, British Columbia, Canada., Methods: Electronic databases were searched for articles reporting psychometric properties of sexual health outcome measures used in a SCI population. The search was limited to papers published between January 1986 and January 2006. Hand-searching the references of papers obtained from the electronic search identified additional articles., Results: Four outcome measures met the search criteria: Emotional Quality of the Relationship Scale (EQR), Sexual Activity and Satisfaction Scale (SAS), Sexual Attitude and Information Questionnaire (SAIQ) and Sexual Interest and Satisfaction Scale (SIS). While the clinical utility of these tools may be compromised by their limited scope and advancing age, they may still prove useful for guiding SCI research and clinical practice., Conclusion: There is no clinically agreed upon SCI measurement tool for sexual health outcomes. To adequately assess the complex issue of sexual health, it is recommended that future sexual health outcome measures include both quantitative and qualitative data as well as address several key issues.

Background/objective: To determine the incidence of symptomatic autonomic dysreflexia (AD) and asymptomatic autonomic dysreflexia (silent AD) in men with spinal cord injury (SCI) undergoing sperm retrieval procedures., Design: Descriptive study., Methods: Thirteen men underwent cardiovascular monitoring during vibrostimulation (or self-stimulation) to the point of ejaculation. Cardiovascular results were compared with objective and subjective signs of AD to determine the incidence of symptomatic and silent AD. Past history and knowledge of AD were correlated to participants' experience of AD in the clinical setting., Outcome Measures: Change in diastolic and systolic blood pressure is the primary outcome data that will be compared to AD history and data from each participant's questionnaire., Results: Twelve of the 13 men experienced a rise in blood pressure consistent with AD (defined as an increase in blood pressure > 20 mmHg). Men with incomplete tetraplegia were able to identify symptoms associated with AD, and those with complete tetraplegia did not experience symptoms. Eleven of the 13 men knew that sexual activity could cause AD; however, only 2 of the 13 men acknowledged a history of AD with sexual activity and/or ejaculation., Conclusions: Symptomatic and silent AD occur frequently during sperm retrieval in men with SCI above T6. Knowledge and past history of AD are not accurate indicators of who will experience AD with sexual activity and/or ejaculation.

Placental reproduction is widespread across vertebrate taxa, but little is known about its life-history correlates and putative adaptive value. We studied variation in life-history traits in two populations of the placental poeciliid fish Poeciliopsis prolifica to determine whether differences in post-fertilization maternal provisioning to embryos have a genetic basis and how food availability affects reproduction. Life histories were characterized for wild-caught females and for second-generation lab-born females raised under two levels of food availability. We found that the two populations did not differ significantly in the wild for any life-history traits except for the lipid dry weight in females and in embryos at an advanced stage of development. When environmental effects were experimentally controlled, however, populations exhibited significant differences in several traits, including the degree of maternal provisioning to embryos. Food availability significantly affected female size at first parturition, brood size and offspring dry weight at birth. Altogether, these results demonstrate that population differences in maternal provisioning and other life-history traits have a genetic basis and show a plastic response to food availability. We infer that phenotypic plasticity may mask population differences in the field. In addition, when comparing life-history patterns in these two populations with known patterns in placental and non-placental poeciliids, our results support the hypotheses that placentation is an adaptive reproductive strategy under high-resource conditions but that it may represent a cost under low-food conditions. Finally, our results highlight that age at maturity and reproductive allotment may be key life-history traits accompanying placental evolution.

The focus of this article is to describe and outline a method of nursing care intervention that will assist nurses in addressing the sexual health concerns of their clients with spinal cord impairment (SCI). A "road map" is described that serves as a guide to recognize and respond to clients' sexual health concerns. A sexual assessment framework is explored to help nurses identify common concerns shared by persons with SCI. Each area will be defined, and the impact of SCI will be discussed. The PLISSIT Model is presented as a way for planning nursing interventions to address sexual health concerns. Strategies are identified for talking with clients about changes to sexuality and sexual function following SCI.

The Bacillus thuringiensis (Bt) crystal toxins are safe biological insecticides, but have short persistance and are poorly effective against pests that feed inside plant tissues. Production of effective levels of these proteins in plants has required resynthesis of the genes encoding them. We report that amplification of an unmodified crylA(c) coding sequence in chloroplasts up to approximately 10,000 copies per cell resulted in the accumulation of an unprecedented 3-5% of the soluble protein in tobacco leaves as protoxin. The plants were extremely toxic to larvae of Heliothis virescens, Helicoverpa zea, and Spodoptera exigua. Since the plastid transgenes are not transmitted by pollen, this report has implications for containment of Bt genes in crop plants. Furthermore, accumulation of insecticidal protein at a high level will facilitate improvement in the management of Bt resistant insect populations.

Phage T7 RNA polymerase has been used extensively in Escherichia coli for high-level expression of selected genes placed under the control of the phage T7 gene 10 promoter. We have constructed an analogous system for use in plastids of higher plants. A T7 RNA polymerase chimeric gene containing a cauliflower mosaic virus 35S promoter and a tobacco ribulose-bisphosphate carboxylase/oxygenase small-subunit chloroplast transit-peptide sequence was introduced into tobacco by nuclear transformation. Stable plastid transformation of tobacco expressing the T7 RNA polymerase activity with a T7 promoter/beta-glucuronidase (GUS) reporter gene construct resulted in expression of GUS mRNA and enzyme activity in all tissues examined. Expression of GUS activity was extremely high in mature leaves, moderate in young leaves and petals, and low in stems, roots, and developing seeds. Plastid transformation of wild-type tobacco with the same chimeric GUS gene resulted in undetectable levels of GUS mRNA and enzyme activity. Genetic crosses demonstrated that a silent T7/GUS reporter gene could be activated in the F1 generation by transmission of an active nuclear T7 RNA polymerase gene from the male parent.

A Bacillus thuringiensis (B.t.) cryIIIA delta-endotoxin gene was designed for optimal expression in plants. The modified cry gene has the codon usage pattern of an average dicot gene and does not contain AT-rich nucleotide sequences typical of native B.t. cry genes. We assembled the 1.8 kb cryIIIA gene in nine blocks of three oligonucleotide pairs. For two DNA blocks, the polymerase chain reaction was used to enrich for correctly ligated pairs. We compared modified cryIIIA gene with native gene expression by electroporation of dicot (carrot) and monocot (corn) protoplasts. CryIIIA-specific RNA and protein was detected in carrot and corn protoplasts only after electroporation with the rebuilt gene. Transgenic potato lines were generated containing the redesigned cryIIIA gene under the transcriptional control of a chimeric CaMV 35S/mannopine synthetase (Mac) promoter. Out of 63 transgenic potato lines, 58 controlled first-instar Colorado potato beetle (CPB) larvae in bioassays. Egg masses which produced ca. 250,000 CPB larvae were placed on replicate clones of 56 transgenic potatoes. No CPB larvae developed past the second instar on any of these plants. Plants expressing high levels of delta-endotoxin were identified by their toxicity to more resistant third-instar larvae. We show there was good correlation between insect control and the levels of delta-endotoxin RNA and protein.

Tomato fruits contain a metallocarboxypeptidase inhibitor (MCPI) the sequence of which has already been determined. Here we report the isolation of a tomato cDNA clone that encodes the mature MCPI protein as well as an N-terminal signal peptide for entry into the secretory system and an eight amino acid carboxyterminal extension. MCPI RNA is present at very high levels in anthesis stage ovaries and decreases quite rapidly during fruit development. MCPI protein accumulation reflects the pattern of MCPI RNA accumulation in fruit, consistent with a transcriptional control of MCPI gene activity. In leaves, the levels of MCPI RNA and protein are very low. Wounding of the leaves causes a dramatic (100-fold) increase in steady-state level of MCPI RNA without a concomitant increase in MCPI protein level suggesting a control at the post-transcriptional or translational level of gene expression. Genomic DNA blot hybridization data indicate that MCPI in tomato may be encoded by a single gene.

Improved plant transformation vectors were constructed which utilize the pRiHRI origin of replication for highly stable maintenance in Agrobacterium tumefaciens, the ColE1 origin of replication for high copy maintenance in Escherichia coli, and a gentamycin resistance gene as a strong selectable marker for bacteria. Concise T-DNA elements were engineered with border sequences from the TL-DNA of pTiA6, the Tn5 neomycin phosphotransferase gene (npt II) expressed from either CaMV 35S or mannopine synthase (mas) promoters, and the lac Z' gene segment from pUC18 as a source of unique restriction sites as well as an insertional inactivation marker for cloned DNA. The order of T-DNA components in all vectors is left border, plant marker cassette, lac Z', and right border, respectively. The prototype vector, pCGN1547, was shown to be very stable in A. tumefaciens strain LBA4404 and to act as an efficient donor of T-DNA in tomato transformation experiments. Use of the other vectors is also described.

The virE operon of the Agrobacterium tumefaciens Ti plasmid pTiA6 encodes at least one trans-acting protein involved in the expression of virulence. Two open reading frames designated virE1 and virE2 code for polypeptides of 7 and 60 kilodaltons (kDa), respectively, that can be visualized after expression in Escherichia coli minicells. To determine which virE sequences are required for virulence, a strain deleted for the entire locus [strain KE1(pTiA6 delta E)] was constructed and tested for the ability to be complemented by subclones with and without site-directed mutations in the virE operon. One subclone containing only virE1 and virE2 as well as upstream promoter sequences was sufficient to restore full virulence on the host plant Kalanchoe daigremontiana. However, some other virulence locus representing a host range determinant appeared to be deleted from strain KE1(pTiA6 delta E), since virE1 and virE2 were not sufficient to fully restore virulence on wounded tomato plants. virE operon constructs with specific lesions in either virE1 or virE2 were impaired for complementation of pTiA6 delta E. Several mutations specific for the promoter-proximal virE1 locus appeared to have a polar effect on expression of the virE2-encoded 60-kDa protein. However, virE2::lacZ fusion constructs suggest that this effect is not at the level of transcription or translation. Collectively, these data indicate that both the 7- and the 60-kDa polypeptides are virulence determinants for the Ti plasmid pTiA6 and suggest that the 60-kDa protein may be less stable in the absence of the 7-kDa protein.

Enrichment of soil samples for organisms able to utilize the herbicide bromoxynil (3,5-dibromo-4-hydroxybenzonitrile) as a nitrogen source yielded bacterial isolates capable of rapidly metabolizing this compound. One isolate, identified as Klebsiella pneumoniae subsp. ozaenae, could completely convert 0.05% bromoxynil to 3,5-dibromo-4-hydroxybenzoic acid and use the liberated ammonia as a sole nitrogen source. Assays of cell extracts of this organism for the ability to produce ammonia from bromoxynil revealed the presence of a nitrilase (EC 3.5.51) activity. The enzyme could not utilize 3,5-dibromo-4-hydroxybenzamide as a substrate, and no 3,5-dibromo-4-hydroxybenzamide could be detected as a product of bromoxynil transformation. Comparison of related aromatic nitriles as substrates demonstrated that the Klebsiella enzyme is highly specific for bromoxynil.

The herbicide bromoxynil (3,5-dibromo-4-hydroxybenzonitrile) is a photosynthetic (photosystem II) inhibitor in plants. A gene, bxn, encoding a specific nitrilase that converts bromoxynil to its primary metabolite 3,5-dibromo-4-hydroxybenzoic acid, was cloned from the natural soil bacterium Klebsiella ozaenae. For expression in plants, the bxn gene was placed under control of a light-regulated tissue-specific promoter, the ribulose bisphosphate carboxylase small subunit. Transfer of this chimeric gene and expression of a bromoxynil-specific nitrilase in leaves of transgenic tobacco plants conferred resistance to high levels of a commercial formulation of bromoxynil. The results presented indicate a successful approach to obtain herbicide resistance by introducing a novel catabolic detoxification gene in plants.

A Klebsiella ozaenae nitrilase which converts the herbicide bromoxynil (3,5-dibromo-4-hydroxybenzonitrile) to 3,5-dibromo-4-hydroxybenzoic acid has been expressed at 5-10% of the total protein in Escherichia coli from a cloned K. ozaenae DNA segment and purified 10.3-fold to homogeneity. The purified polypeptide is molecular weight 37,000 in size, but the active form of the enzyme is composed of two identical subunits. The purified enzyme exhibits a pH optimum of 9.2 and a temperature optimum of 35 degrees C. The purified enzyme is also quite sensitive to thiol-specific reagents. The nitrilase is highly specific for bromoxynil as substrate with a Km of 0.31 mM and Vmax of 15 mumol of NH3 released/min/mg protein. Analysis of bromoxynil-related substrates indicates the enzyme exhibits preference for compounds containing two meta-positioned halogen atoms. Nucleotide sequence analysis of a 1,212-base pair PstI-HincII DNA segment containing the locus (bxn) encoding the bromoxynil-specific nitrilase reveals a single open reading frame encoding a polypeptide 349 amino acids in length. The predicted sequence of the purified enzyme was derived from the nucleotide sequence of the bxn gene.

An enzyme (nitrilase) that converts the herbicide bromoxynil (3,5-dibromo-4-hydroxybenzonitrile) to its metabolite 3,5-dibromo-4-hydroxybenzoic acid was shown to be plasmid encoded in the natural soil isolate Klebsiella ozaenae. The bromoxynil-specific nitrilase was expressed in Escherichia coli by direct transfer and stable maintenance in E. coli of a naturally occurring 82-kilobase K. ozaenae plasmid. Irreversible loss of the ability to metabolize bromoxynil both in E. coli and K. ozaenae was associated with the conversion of the 82-kilobase plasmid to a 68-kilobase species. In E. coli this conversion was the result of a host recA+-dependent recombinational event. A gene, designated bxn, encoding the bromoxynil-specific nitrilase was constitutively expressed in K. ozaenae and E. coli and subcloned on a 2.6-kilobase PstI DNA segment. The polarity and the location of the gene were determined by assaying hybrid constructs of the bromoxynil-specific nitrilase gene fused with the heterologous lac promoter.

The Agrobacterium tumefaciens Ti plasmid contains at least six transcriptional units (designated vir loci) which are essential for efficient crown gall tumorigenesis. Mutations in one of these loci, virE, result in a sharply attenuated virulence phenotype. In the present communication, we have analyzed the virE operon at the molecular level. This locus contains open reading frames coding for two hydrophilic proteins having molecular weights of approximately 7,000 daltons and 60,500 daltons. Using a maxicell strain of E. coli, we have visualized two proteins encoded by virE which correspond in size to these open reading frames. Analysis of codon usage of virE and seven other vir loci indicates that, in contrast to E. coli, all possible codons for a given amino acid are utilized at approximately the same frequency.