Publication History View all

  • Journal of Plastic Reconstructive & Aesthetic Surgery 01/2014;
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    ABSTRACT: A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed whether endovascular treatment improved peri-operative outcomes when compared to an open approach to restore arterial perfusion in acute mesenteric occlusive disease. Four hundred and ninety seven papers were identified using the reported search; of which 4 represented the best evidence to answer the question and are discussed. The evidence on this subject is limited, comprising largely of non-randomised retrospective cohort studies. The evidence suggests that endovascular treatment is associated with reduced mortality and has better short-term peri-operative outcomes, as well as longer-term survival - however many endovascular cases require subsequent open surgery. There is also conflicting evidence to suggest endovascular therapy is associated with longer ICU stays. Aside from procedural complications, factors such as patient status, time delay to diagnosis and treatment may play a greater role in determining mortality rates. In summary, endovascular therapy appears to be a feasible treatment option with post-operative complications and inpatient mortality rates lower than those seen in open surgery.
    International Journal of Surgery (London, England) 10/2013;
  • Expert Opinion on Pharmacotherapy 09/2013;
  • Science 08/2013; 341(6149):959.
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    ABSTRACT: The current diagnostic criteria for traumatic brain injury (TBI) are heavily reliant on an accurate clinical history of events. Diagnosis of mild injury relies on one or more of the following: confusion or disorientation, loss of consciousness (LOC) for 30 min or less, post-ictus amnesia for less than 24 h and/or other transient neurological abnormalities and a Glasgow Coma Score (GCS). Given the nature of the condition it is obvious that significant clinical challenges remain to identify in the cases of mild TBI, and additionally to grade more severe forms so that appropriate treatment is received. The lack of clinically useful biomarkers in the serum of TBI patients is a significant barrier to improving their outlook. Discovery of such markers would aid the timely diagnosis of novel and recurrent disease in a minimally invasive manner. A PubMed search was performed to identify studies reporting serum biomarkers in traumatic brain injury. Details regarding the biomarkers analysed, specificity, indications for outcome and statistical significance were recorded. A total of 40 manuscripts reporting 11 biomarkers were identified in the literature. All but a few studies reported statistically significant differences in biomarker expression between groups. We conclude that serum biomarkers of TBI are an effective means for investigating the condition. However, the lack of novel markers identified in this mass of studies highlights the need to adopt new measure of biomarker identification.
    British Journal of Neurosurgery 07/2013;
  • The Lancet 05/2013;
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    ABSTRACT: AIMS: To develop electrocardiogram (ECG) tools to quantify the number of sources for atrial fibrillation (AF), i.e. spatially stable rotors and focal impulses, and whether they lie in right or left atrium. Intracardiac mapping has recently shown that paroxysmal and persistent AF is sustained by rotors or focal sources that are stable in location and thus targets for limited ablation [focal impulse and rotor modulation (FIRM)] to eliminate AF. Importantly, the numbers and locations of concurrent sources determine both the complexity of AF and the approach for ablation.METHODS AND RESULTS: In 36 AF patients (n = 29 persistent, 63 ± 9 years) in the CONventional ablation with or without Focal Impulse and Rotor Modulation (CONFIRM) trial, we developed phase lock (PL) to quantify spatial repeatability of ECG 'F-waves' between leads over time. Phase lock spectrally quantifies the angle θ between F-wave voltages in planes formed by ECG leads I, aVF, and V1 at successive points in time. We compared PL with ECG spectral dominant frequency (DF) and organizational index (OI) to characterize stable rotors and focal sources validated by intracardiac FIRM mapping. Focal impulse and rotor modulation ablation alone at ≤3 sources acutely terminated and rendered AF non-inducible or substantially slowed AF in 31 of 36 patients. Receiver operating characteristics of PL for this endpoint had area under the curve (AUC) = 0.72, and the optimum cut-point (PL = 0.09) had 74% sensitivity, 92% positive predictive value (PPV). Receiver operating characteristics areas for OI and DF were 0.50 and 0.58, respectively. Left (n = 28) or right (n = 3) atrial sources were localized by PL with AUC = 0.85, sensitivity 100%, PPV 30%, and negative predictive value 100%. Spectral DF provided AUC = 0.79. Notably, PL did not comigrate with diagnosis of paroxysmal or persistent AF (P = NS), unlike ECG DF.CONCLUSION: The novel metric of ECG PL identifies patients with fewer (≤3) or greater numbers of stable rotors/focal sources for AF, validated by intracardiac FIRM mapping, and localized them to right or left atria. These data open the possibility of using 12-lead ECG analyses to classify AF mechanistically and plan procedures for right- or left-sided FIRM ablation.
    Europace 02/2013;
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    ABSTRACT: INTRODUCTION: Necrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented. PRESENTATION OF CASE: A 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels. DISCUSSION: Pedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap). CONCLUSION: This case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.
    International journal of surgery case reports. 02/2013; 4(5):453-455.
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    ABSTRACT: The management of rheumatic conditions, including those occurring in children, has improved dramatically over the last decade following the introduction of biologic disease-modifying anti-rheumatic drugs (bDMARDS) into the therapeutic arsenal. The benefits have been realised in multiple aspects of disease including signs and symptoms, bone and cartilage destruction, disability and quality of life. Overall, bDMARDS have an acceptable safety profile in the short to medium term in adults and children, however, that following longer term use remains unclear. As these drugs target key signalling molecules and cells of the immune system, adverse events are not unanticipated. In this review we will discuss pulmonary complications of biologic therapies used in the management of rheumatic diseases in both children and adults.
    Paediatric Respiratory Reviews 02/2013;
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    ABSTRACT: Chondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery. A 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected. The outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis. This case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.
    International journal of surgery case reports. 01/2013; 4(8):669-674.
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