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  • Gruen, Russell L.  (34)
  • Wiley Online Library  (34)
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  • 1
    In: Medical Journal of Australia, September 2013, Vol.199(5), pp.310-311
    Description: The dilemma that clinicians involved in the resuscitation of severely injured patients face with regards to the inclusion of tranexamic acid (TxA) in trauma management protocols is discussed. However, on the other hand, the need for more evidence to solve ongoing knowledge gaps has been emphasised, especially evidence of who benefits and whether anyone is harmed when TxA is administered to patients treated to modern civilian and military trauma standards.
    Keywords: Emergency Medicine
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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  • 2
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.819-826
    Description: This qualitative study identifies cultural factors that influence the effective implementation of evidence‐based medicine (EBM) in surgical practice among Australian surgeons. In‐depth interviews ( = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM; and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi‐structured interviews. Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often divorced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice; EBM training should occur early in the surgeons' careers; and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice. The study findings suggest that using pre‐existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context‐specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.
    Keywords: Ebm Training ; Epistemic Culture ; Implementation ; Hidden Curriculum ; Surgery
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 3
    In: Medical Journal of Australia, March 2014, Vol.200(5), pp.255-255
    Keywords: Emergency Medicine
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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  • 4
    In: Medical Journal of Australia, July 2002, Vol.177(2), pp.111-115
    Description: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). A cross‐sectional survey of GP–patient encounters. The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44–0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49–0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury‐related and non‐cancer‐related problems, follow‐up presentations, and more than one problem managed at an encounter. Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.
    Keywords: General Medicine ; General Medicine ; Surgical Procedures ; Operative
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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  • 5
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.678-683
    Description: Rural and remote surgical practice presents unique barriers to the uptake of the evidence‐based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. Descriptive survey of rural surgeons based in a tertiary care environment. The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM; (2) EBM evidence is somewhat useful but not very important to clinical decision making; and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons’ understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.
    Keywords: Attitudes And Training ; Evidence‐Based Medicine ; Rural ; Surgical Practice
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 6
    In: ANZ Journal of Surgery, March 2016, Vol.86(3), pp.167-172
    Description: Byline: Daniel T. Breen, Nuttaya Chavalertsakul, Eldho Paul, Russell L. Gruen, Jonathan Serpell Keywords: blood loss; elective; heparin; low-molecular-weight; surgical procedure; surgical; thromboembolism; warfarin Abstract Background Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin (LMWH) 'bridging' while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines. Purpose This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications. Methods A retrospective review of the Alfred Hospital General Surgical and 'Hospital at Home' databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated. Results The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day. Conclusion LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications. Article Note: D. T. Breen MBBS; N. Chavalertsakul MBBS; E. Paul MSc; R. L. Gruen MBBS, PhD, FRACS; J. Serpell MB, BS, MD, MEd, FRACS, FACS. This study is based on research presented at the 2012 RACS ASM.
    Keywords: Blood Loss ; Elective ; Heparin ; Low‐Molecular‐Weight ; Surgical Procedure ; Surgical ; Thromboembolism ; Warfarin
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 7
    In: ANZ Journal of Surgery, March 2010, Vol.80(3), pp.157-161
    Description: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.
    Keywords: Conservative Management ; Embolization ; Epidemiology Of Splenic Injuries ; Spenorrhaphy ; Splenectomy
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 8
    In: Medical Journal of Australia, September 2011, Vol.195(6), pp.340-344
    Description: To describe the frequency, characteristics, and outcomes of medicolegal disputes over informed consent. Retrospective review and analysis of negligence claims against doctors insured by Avant Mutual Group Limited and complaints lodged with the Office of the Health Services Commissioner of Victoria that alleged failures in the informed consent process and were adjudicated between 1 January 2002 and 31 December 2008. Case frequency (by medical specialty), type of allegation, type of treatment. A total of 481 cases alleged deficiencies in the informed consent process (218 of 1898 conciliated complaints [11.5%]; 263 of 7846 negligence claims [3.4%]). 57% of these cases were against surgeons. Plastic surgeons experienced dispute rates that were more than twice those of any other specialty or subspecialty group. 92% of cases (442/481) involved surgical procedures and 16% (77/481) involved cosmetic procedures. The primary allegation in 71% of cases was that the clinician failed to mention or properly explain risks of complications. Five treatment types — procedures on reproductive organs (12% of cases), procedures on facial features excluding eyes (12%), prescription medications (8%), eye surgery (7%) and breast surgery (7%) — accounted for 46% of all cases. The typical dispute over informed consent involves an operation, often cosmetic, and allegations that a particular complication was not properly disclosed. With Australian courts now looking to patient preferences in setting legal standards of care for risk disclosure, medicolegal disputes provide valuable insights for targeting both quality improvement efforts and risk management activities.
    Keywords: Ethics And Law ; Ethics And Law
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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  • 9
    In: Journal of General Internal Medicine, November 2006, Vol.21(11), pp.1150-1155
    Description: Information technology (IT) has been advocated as an important means to improve the practice of clinical medicine. To determine current prevalence of non‐electronic health record (EHR) IT use by a national sample of U.S. physicians, and to identify associated physician, practice, and patient panel characteristics. Survey conducted in early 2004 of 1,662 U.S. physicians engaged in direct patient care selected from 3 primary care specialties (family practice, internal medicine, pediatrics) and 3 nonprimary care specialties (anesthesiology, general surgery, cardiology). Self‐reported frequency of e‐mail communication with patients or other clinicians, online access to continuing medical education or professional journals, and use of any computerized decision support (CDS) during clinical care. Survey results were weighted by specialty and linked via practice zip codes to measures of area income and urbanization. Response rate was 52.5%. Respondents spent 49 (±19) (mean [±standard deviation]) hours per week in direct patient care and graduated from medical school 23 (±11) years earlier. “Frequent” use was highest for CDS (40.8%) and online professional journal access (39.0%), and lowest for e‐mail communication with patients (3.4%). Ten percent of physicians never used any of the 5 IT tools. In separate logistic regression analyses predicting usage of each of the 5 IT tools, the strongest associations with IT use were primary care practice (adjusted odds ratios [aORs] ranging from 1.34 to 2.26) and academic practice setting (aORs 2.17 to 5.41). Years since medical school graduation (aOR 0.85 to 0.87 for every 5 years after graduation) and solo/2‐person practice setting (aORs 0.21 to 0.55) were negatively associated with IT use. Practice location and patient panel characteristics were not independently associated with IT use. In early 2004, the majority of physicians did not regularly use basic, inexpensive, and widely available IT tools in clinical practice. Efforts to increase the use of IT in medicine should focus on practice‐level barriers to adoption.
    Keywords: Information Technology ; Physician Practice Patterns ; Primary Care ; Academic Medicine
    ISSN: 0884-8734
    E-ISSN: 1525-1497
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  • 10
    In: Medical Journal of Australia, January 2006, Vol.184(1), pp.4-5
    Description: The Australian government is in partnership with the Cochrane Collaboration's Effective Practice and Organization of Care (EPOC) Group and the National Institute of Clinical Studies (NICS) to improve professional practice and the delivery of effective health services. Its main goal is to assist evidence-based policy-making through systematic reviews of interventions designed to improve health care practice and delivery of effective health services relevant to Australia.
    Keywords: Health Services Administration ; Statistics ; Epidemiology And Research Design
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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