'Mrs L.'s case': a celebrated South Australian surgical case.

This paper concerns a dispute at the Adelaide Hospital in September 1896 between Professor Archibald Watson, Pathologist, Honorary Consulting Surgeon and sole remaining University teacher at the hospital, and Alexander Disney Leith Napier, who had arrived from England to fill the place of the honorary surgeons who had resigned from the hospital. Watson accused Napier of incompetence in his management of 'Mrs L.', who died after a femoral hernia operation. Mrs L had a form of internal hernia causing intestinal obstruction, whereas all the medical attendants, including Watson, originally thought an old femoral hernia was the cause of her illness. By fortuitous coincidence the operation on the femoral hernia could have cured the internal hernia if the band of omentum attached to the femoral hernia had been divided. Watson became aware of the band at the post-mortem and then asserted that the operation should have taken it into account. Napier complained to the Board of the Hospital, alleging that Watson had misrepresented the facts when he conducted the post-mortem on the patient and that he was disloyal to the hospital. The Board found the complaint proved and invited Watson to resign; he declined and was dismissed. Undaunted, Watson circulated a privately printed pamphlet (entitled 'Mrs L.'s case'), which re-stated the events of the case and graphically described his post-mortem findings. It was submitted to the Chairman of a Select Committee of the Legislative Council of South Australia established to review the running of the hospital. The Committee recommended the setting up of a Royal Commission but the Government let the matter lapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychosocial and physical activity changes after gastric restrictive procedures for morbid obesity.

Gastric restrictive procedures for morbid obesity are frequently performed to reduce problems arising from the physical limitations and social isolation of massive obesity. Numerous reports have described changes in weight after gastric restrictive operations, yet few studies have documented changes in the secondary effects of obesity. This report deals with changes in psychosocial status and physical activity occurring in 240 patients who remained in the study 3 years after surgery. These patients were members of a group of 310 patients who were entered into a prospective randomized trial to assess the relative benefits of three forms of gastric restrictive procedure. Prior to operation, and at yearly intervals after operation, the physical activities and psychosocial status of each patient was assessed by a standardized semi-structured interview. At the time of the three-year interview the median weight loss for these patients was 29.5 kg which represents 53% of excess weight lost. This weight loss was associated with a marked reduction in the amount of food eaten. There was a significant increase in the number of patients smoking more than 20 cigarettes a day and a mild increase in alcohol intake. There were significant improvements in the level of self-image and state of happiness. The social lives and sex lives of the majority of patients were improved and a significantly greater number of patients reported being in a stable emotional relationship at 3 years after operation than did so pre-operatively. There was a marked increase in the number of patients in full-time or part-time employment from 38% prior to surgery to 60% at 3 years after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric surgery for morbid obesity. The Adelaide Study.

The efficacy of three gastric restriction operations were compared in a prospective randomized study of 310 morbidly obese subjects. The median patient age was 34 years (range, 18 to 62 years). They were predominantly female (13:1) and had a median pre-operative weight that was 198% of their ideal weight (range, 160% to 318%). There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period. Compliance with follow-up at 3 years was 91%. When success was defined as a loss of more than 50% of excess weight or a current pregnancy, the success rates at 3 years were 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for Roux-en-Y gastric bypass (p less than 0.001). Although the gastric bypass operation took longer to perform, there were similar outcome patterns for the three groups during the postoperative period. We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity.

The pathology of experimental chronic fibrosing pancreatitis--light microscopic and ultrastructural observations.

The light microscopic and ultrastructural changes seen in a canine model of chronic fibrosing pancreatitis are described. The distribution of the experimental lesion is similar to that of human chronic obstructive pancreatitis. The canine lesion is also compared to that of human chronic calcifying pancreatitis. It is suggested that the common denominator in all these conditions is an increased pressure in the terminal intercalated ducts which produces pressure atrophy of the acinar cells in the periphery of the obstructed lobules.

The validity and reliability of a new examination of the clinical competence of medical students.

In a previous study we described a problem-based criterion-referenced test of the clinical competence of medical students which was felt to offer advantages over the traditional final-year examination. This paper reports the validity and reliability studies on which it is possible to judge the value of this new test when compared to the traditional approach. The results demonstrate a high level of content validity and provide evidence of the construct validity of the test. Efforts to obtain measures of concurrent and predictive validity were thwarted by a failure to attain reliable assessments of ward performance from resident and consultant staff. Satisfactory levels of internal consistency were established for the whole test. Marker reliability was satisfactory in all sections of the test except for those requiring examiners to rate practical clinical skills. This was so despite the use of simulated patients, behavioural check-lists and rater training. Possible solutions to this problem are discussed. It is concluded that this new approach overcomes many of the measurement problems inherent in the traditional final examination. It has been shown to be feasible to construct and administer in the medical school setting without the need for the allocation of additional resources.

A comparison of multiple-choice tests and free-response tests in examinations of clinical competence.

This paper reports a study which compared the performance of different groups of students and doctors on identical and equivalent tests set in an objective-type format and in a free-response format. The tests were designed to ensure that the content was relevant to clinical practice at the hospital intern level. In all test situations candidates' scores were significantly higher in the objective tests than in the free-response tests. This difference was greater for the more junior and less competent students than for the more competent doctors. The cueing effect of the options was thought to be the main factor responsible for the difference in performance. The results of a questionnaire survey demonstrated that students were aware of the deficiencies in multiple-choice tests. A large majority of the students believed that the free-response tests gave a more accurate assessment of their clinical ability. It was found that in these tests, aimed at measuring aspects of clinical competence, multiple-choice questions appeared to overestimate the candidate's ability to an extent that made them less suitable than free-response questions for this purpose. It was also found that free-response tests, of the type used in this study, provide a suitable alternative to multiple-choice tests for use in the written section of clinical examinations. It was concluded that the written component of the final examination in the medical course should have a preponderance of free-response items over multiple-choice items.

A problem-based criterion-referenced examination of clinical competence.

A model has been developed for a problem-based criterion-referenced test of clinical competence. The model, designed to increase the reliability and validity of traditional final year examinations for medical students, aims to provide a profile of student performance over a range of defined competence categories. The level of competence has been referenced to that expected of an intern. Both the content of the examination and the selection of test methods are based on patient problem blueprints which identify key areas that require testing. The content and test methods were incorporated, as appropriate, into either th;e written section or the practical section of the examination. The approach was found to be feasible and acceptable to staff and students.

Determination of enteropeptidase activity in human duodenal aspirates.

A sensitive procedure is described for the determination in duodenal aspirates of enteropeptidase activity based on the activation of trypsinogen and the estimation of trypsin formed with benzoyl-arginine-p-nitroanilide. Using the recovery approach where a known amount of purified human enteropeptidase is diluted in duodenal fluid and the recoverable activity determined, this method was shown to give a sensitive and reliable estimate of the enteropeptidase activity in duodenal fluid although it was shown that the enzyme was subject to a 10% activation by components in the duodenal fluid. The reported 5-fold stimulation of enteropeptidase activity by bile salts could not be demonstrated.

Identification of a mucosal form of enteropeptidase in triton X-100 extracts of porcine duodenal mucosa.

Porcine enteropeptidase (EC 3.4.21.9) purified from acetone powders of fresh duodenal fluid shows a molecular weight, as determined on Ultragel AcA-34, of 190000. Enteropeptidase has been solubilised from pig intestinal mucosa using 1% (v/v) Triton X-100. When Triton X-100 extracts of freeze-dried mucosa after partial fractionation on DEAE-cellulose were chromatographed on Sephadex G-200, the bulk of the activity eluted in the void volume rather than with an expected Ve/V0 ratio of about 1.24 corresponding to a molecular weight of around 200000. Gel filtration of aqueous mucosal extracts obtained in the absence of Triton X-100 showed two regions of enzymic activity in approximately equal proportions, one in the void volume, and the other with the expected Ve/V0 ratio of 1.24, whereas the Triton X-100 extracts of the residue from the above extract showed the presence of only the macromolecular species of enteropeptidase. This species was excluded from Sepharose 4B. It was confirmed that aminopeptidase was also extracted by Triton X-100 in a molecular form which was excluded from Sepharose 4B. The results suggest that Triton X-100 extracts enteropeptidase with a membrane component attached and in agreement with this it was found that proteolysis rapidly converted the macromolecular form to a stable smaller molecular species corresponding in size to that found in solution in the duodenal fluid. There was full recovery of the enzymic activity following this conversion. Papain and trypsin brought about an almost complete conversion to the smaller form of enteropeptidase whereas chymotrypsin, pancreatin and an intestinal peptidase preparation were only partially effective. It is concluded that membrane bound enzymes such as enteropeptidase and aminopeptidase are bound to the intestinal brush border membrane in a similar manner and are not actively secreted into the lumen but rather are largely released or solubilised by the combined action of the bile and pancreatic secretions.

The effect of calcium ions on the hydrolysis of benzoylarginine ethyl ester by porcine enteropeptidase.

Calcium ions are shown to have a marked pH-dependent effect on the kinetics of benzoyllarginine ethyl ester hydrolysis by porcine enteropeptidase (EC 3.4.21.9). Below pH 6.0, calcium ions stimulate benzoylarginine ethyl ester hydrolysis but inhibit this activity above pH 6.0. This effect is mainly on the Km for benzoylarginine ethyl ester. At pH 5.3, 2mM calcium ions reduce the Km for benzoylarginine ethyl ester from 0.31 mM to 0.26 mM while at pH 6.5 the Km increases four-fold from 0.035 mM to 0.12 mM in the presence of calcium ions. Enteropeptidase activity is not inhibited by ethylenediaminetetra-acetate indicating that calcium ions are a non-essential cofactor for benzoylarginine ethyl ester hydrolysis.