Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism... more Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism. Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases. The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass. Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass. After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6). Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters. Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined. Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion. Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05). Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05). Myocardial ATP levels were markedly improved in the sulfide-treated group. Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass. These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.
INTRODUCTION The impact of preoperative glycated haemoglobin (HbA1c) in patients undergoing gastr... more INTRODUCTION The impact of preoperative glycated haemoglobin (HbA1c) in patients undergoing gastrointestinal and hepatobiliary surgery is unclear as data is limited. METHODS Patients undergoing gastrointestinal surgery attending pre-assessment screening (PAS) clinics from August to September 2016 at the Queen Elizabeth Hospital Birmingham (QEHB) were identifi ed. Outcome measure was postoperative complications as defi ned by the Clavien-Dindo classifi cation system. RESULTS In this study, 381 patients were included, of which 48% (181/381) had HbA1c measured. Of these, 27% (49/181) had a HbA1c ≥ 48 mmol/mol. Overall complications were 14% and major complication rates were 3% (11/381). In unadjusted models, patients with HbA1c ≥ 48 mmol/mol had signifi cantly higher rates of overall complications (odds ratio [OR] = 2.82, 95% confi dence interval [CI] = 1.22-6.49; p = 0.015). In adjusted models, only surgical grade was predictive of overall complications. In patients undergoing major s...
Aim: To elicit the incidence of visual field defects (VFDs) post temporal lobectomy and examine t... more Aim: To elicit the incidence of visual field defects (VFDs) post temporal lobectomy and examine the relationship between surgical resection size and VFD severity, relating this to Meyer's loop anatomy. Method: Records were obtained from 37 temporal lobectomy patients. Pre and post-operative visual field analyses were performed using automated static perimetry. Post-operative MRI data was used to measure resection extent. One way ANOVAs, Pearson correlation studies and linear regression models were utilised to analyse the relationship between resection size and VFD severity. Result: Of 37 cases, 31(84%) suffered immediate post-operative VFDs. 33 patients had long term follow up data, 20(61%) of which had permanent VFDs and 12(36%) had VFDs severe enough to preclude them from driving The severity of VFDs were not significantly different between ipsi and contralateral eyes(p¼0.195). Regression analyses show positive correlations between size of resection and VFD severity for the ipsilateral eye(r¼0.462, p¼0.008), contralateral eye(r¼0.448, p¼0.010) and binocular vision (r¼0.461, p¼0.008). However, the small R2 values (<0.3) and heteroscedasticity in residual plots indicate poor model predictability. Conclusion: Patients undergoing temporal lobectomy are at high risk of developing VFDs. However, our results highlight the significant intersubject variability in Meyer's loop anatomy, reinforcing the need for individualised post-surgical VFDs risk assessments
International journal of surgery (London, England), Mar 3, 2017
Traditionally few students have had the opportunity to contribute to high-quality clinical resear... more Traditionally few students have had the opportunity to contribute to high-quality clinical research. Over the last five years, collaborative networks have empowered students and trainees to participate in high-impact multicentre studies that have potential to change clinical practice and improve patient care. The UK Foundation Programme Application System (FPAS) should recognise the significant contributions of students participating in collaborative studies when ranking final year medical students applying for the Foundation Programme, encouraging a culture of positive engagement with audit and research. Postgraduate research collaboratives are regional and national networks of trainees who work together to run prospective multicentre research which identify and address areas of practice where there is a need for research for patient benefit [1]. For example, the National Sepsis Audit investigated the care of emergency general surgery patients, finding that whilst sepsis is a common presentation, adherence to severe sepsis guidelines is incomplete in the majority of patients [2]. Similarly, the National Appendicectomy Audit found wide variation in the care and outcomes of patients undergoing appendicectomy, challenging surgeons to evaluate their outcomes more closely [3]. Trainee collaboratives have also run randomised controlled trials, such as Reinforcement of Closure of Stoma Site, a trial testing a novel surgical intervention; prophylactic biological mesh to prevent incisional hernia following stoma closure [4]. Inspired by the well-established postgraduate trainee research collaborative model, Student Audit and Research in Surgery (STARSurg; www.starsurg.org) is a student-driven, national research network across the UK and Ireland. Founded in 2013, it aims to engage students in multicentre research studies early in their career, embedding clinical research as a fundamental part of their future evidence-based medical practice.
Aims: this study compared the patient and microbiological profile of prosthetic joint infection (... more Aims: this study compared the patient and microbiological profile of prosthetic joint infection (PJI) for patients treated with two-stage revision for knee arthroplasty with that of lower-limb endoprostheses for oncological resection. Patient and methods: a total of 118 patients were treated with two-stage revision surgery for infected knee arthroplasty and lower-limb endoprostheses between 1999 and 2019. A total of 74 patients had two-stage revision for PJI of knee arthroplasty, and 44 had two-stage revision of oncology knee endoprostheses. There were 68 men and 50 women. The mean ages of the arthroplasty and oncology cohorts were 70.2 years (range of 50-89) and 36.1 years (range of 12-78) respectively (p < 0.01). Patient host and extremity criteria were categorized according to the Musculoskeletal Infection Society (MSIS) host and extremity staging system. The patient microbiological culture, the incidence of polymicrobial infection, and multidrug resistance (MDR) were analysed and recorded. Results: polymicrobial infection was reported in 16 % (12 patients) of knee arthroplasty PJI cases and in 14.5 % (8 patients) of endoprostheses PJI cases (p = 0.783). There was a significantly higher incidence of MDR in endoprostheses PJI, isolated in 36.4 % of cultures, compared with knee arthroplasty PJI (17.2 %, p = 0.01). Gram-positive organisms were isolated in more than 80 % of cultures from both cohorts. Coagulase-negative Staphylococcus (CoNS) was the most common Gram-positive organism, and Escherichia coli was the most common Gram-negative organism in both groups. According to the MSIS staging system, the host and extremity grades of the oncology PJI cohort were significantly worse than those for the arthroplasty PJI cohort (p < 0.05). Conclusion: empirical antibiotic prophylaxis against PJI in orthopaedic oncology is based upon PJI in arthroplasty, despite oncology patients presenting with worse host and extremity staging. CoNS was the most common infective organism in both groups; however, pathogens showing MDR were significantly more prevalent in oncological PJI of the knee. Therefore, empirical broad-spectrum treatment is recommended in oncological patients following revision surgery.
Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the an... more Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort (p = 0.65). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.
Osteoid osteomas are mostly solitary. We report a case of metachronous osteoid osteoma of mid-dia... more Osteoid osteomas are mostly solitary. We report a case of metachronous osteoid osteoma of mid-diaphysis of fibula followed by distal humeral osteoid osteoma after a 7-year interval.
Background. Preoperative risk stratification and optimising care of patients undergoing elective ... more Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 ...
Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism... more Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism. Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases. The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass. Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass. After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6). Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters. Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined. Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion. Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05). Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05). Myocardial ATP levels were markedly improved in the sulfide-treated group. Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass. These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.
INTRODUCTION The impact of preoperative glycated haemoglobin (HbA1c) in patients undergoing gastr... more INTRODUCTION The impact of preoperative glycated haemoglobin (HbA1c) in patients undergoing gastrointestinal and hepatobiliary surgery is unclear as data is limited. METHODS Patients undergoing gastrointestinal surgery attending pre-assessment screening (PAS) clinics from August to September 2016 at the Queen Elizabeth Hospital Birmingham (QEHB) were identifi ed. Outcome measure was postoperative complications as defi ned by the Clavien-Dindo classifi cation system. RESULTS In this study, 381 patients were included, of which 48% (181/381) had HbA1c measured. Of these, 27% (49/181) had a HbA1c ≥ 48 mmol/mol. Overall complications were 14% and major complication rates were 3% (11/381). In unadjusted models, patients with HbA1c ≥ 48 mmol/mol had signifi cantly higher rates of overall complications (odds ratio [OR] = 2.82, 95% confi dence interval [CI] = 1.22-6.49; p = 0.015). In adjusted models, only surgical grade was predictive of overall complications. In patients undergoing major s...
Aim: To elicit the incidence of visual field defects (VFDs) post temporal lobectomy and examine t... more Aim: To elicit the incidence of visual field defects (VFDs) post temporal lobectomy and examine the relationship between surgical resection size and VFD severity, relating this to Meyer's loop anatomy. Method: Records were obtained from 37 temporal lobectomy patients. Pre and post-operative visual field analyses were performed using automated static perimetry. Post-operative MRI data was used to measure resection extent. One way ANOVAs, Pearson correlation studies and linear regression models were utilised to analyse the relationship between resection size and VFD severity. Result: Of 37 cases, 31(84%) suffered immediate post-operative VFDs. 33 patients had long term follow up data, 20(61%) of which had permanent VFDs and 12(36%) had VFDs severe enough to preclude them from driving The severity of VFDs were not significantly different between ipsi and contralateral eyes(p¼0.195). Regression analyses show positive correlations between size of resection and VFD severity for the ipsilateral eye(r¼0.462, p¼0.008), contralateral eye(r¼0.448, p¼0.010) and binocular vision (r¼0.461, p¼0.008). However, the small R2 values (<0.3) and heteroscedasticity in residual plots indicate poor model predictability. Conclusion: Patients undergoing temporal lobectomy are at high risk of developing VFDs. However, our results highlight the significant intersubject variability in Meyer's loop anatomy, reinforcing the need for individualised post-surgical VFDs risk assessments
International journal of surgery (London, England), Mar 3, 2017
Traditionally few students have had the opportunity to contribute to high-quality clinical resear... more Traditionally few students have had the opportunity to contribute to high-quality clinical research. Over the last five years, collaborative networks have empowered students and trainees to participate in high-impact multicentre studies that have potential to change clinical practice and improve patient care. The UK Foundation Programme Application System (FPAS) should recognise the significant contributions of students participating in collaborative studies when ranking final year medical students applying for the Foundation Programme, encouraging a culture of positive engagement with audit and research. Postgraduate research collaboratives are regional and national networks of trainees who work together to run prospective multicentre research which identify and address areas of practice where there is a need for research for patient benefit [1]. For example, the National Sepsis Audit investigated the care of emergency general surgery patients, finding that whilst sepsis is a common presentation, adherence to severe sepsis guidelines is incomplete in the majority of patients [2]. Similarly, the National Appendicectomy Audit found wide variation in the care and outcomes of patients undergoing appendicectomy, challenging surgeons to evaluate their outcomes more closely [3]. Trainee collaboratives have also run randomised controlled trials, such as Reinforcement of Closure of Stoma Site, a trial testing a novel surgical intervention; prophylactic biological mesh to prevent incisional hernia following stoma closure [4]. Inspired by the well-established postgraduate trainee research collaborative model, Student Audit and Research in Surgery (STARSurg; www.starsurg.org) is a student-driven, national research network across the UK and Ireland. Founded in 2013, it aims to engage students in multicentre research studies early in their career, embedding clinical research as a fundamental part of their future evidence-based medical practice.
Aims: this study compared the patient and microbiological profile of prosthetic joint infection (... more Aims: this study compared the patient and microbiological profile of prosthetic joint infection (PJI) for patients treated with two-stage revision for knee arthroplasty with that of lower-limb endoprostheses for oncological resection. Patient and methods: a total of 118 patients were treated with two-stage revision surgery for infected knee arthroplasty and lower-limb endoprostheses between 1999 and 2019. A total of 74 patients had two-stage revision for PJI of knee arthroplasty, and 44 had two-stage revision of oncology knee endoprostheses. There were 68 men and 50 women. The mean ages of the arthroplasty and oncology cohorts were 70.2 years (range of 50-89) and 36.1 years (range of 12-78) respectively (p < 0.01). Patient host and extremity criteria were categorized according to the Musculoskeletal Infection Society (MSIS) host and extremity staging system. The patient microbiological culture, the incidence of polymicrobial infection, and multidrug resistance (MDR) were analysed and recorded. Results: polymicrobial infection was reported in 16 % (12 patients) of knee arthroplasty PJI cases and in 14.5 % (8 patients) of endoprostheses PJI cases (p = 0.783). There was a significantly higher incidence of MDR in endoprostheses PJI, isolated in 36.4 % of cultures, compared with knee arthroplasty PJI (17.2 %, p = 0.01). Gram-positive organisms were isolated in more than 80 % of cultures from both cohorts. Coagulase-negative Staphylococcus (CoNS) was the most common Gram-positive organism, and Escherichia coli was the most common Gram-negative organism in both groups. According to the MSIS staging system, the host and extremity grades of the oncology PJI cohort were significantly worse than those for the arthroplasty PJI cohort (p < 0.05). Conclusion: empirical antibiotic prophylaxis against PJI in orthopaedic oncology is based upon PJI in arthroplasty, despite oncology patients presenting with worse host and extremity staging. CoNS was the most common infective organism in both groups; however, pathogens showing MDR were significantly more prevalent in oncological PJI of the knee. Therefore, empirical broad-spectrum treatment is recommended in oncological patients following revision surgery.
Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the an... more Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort (p = 0.65). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.
Osteoid osteomas are mostly solitary. We report a case of metachronous osteoid osteoma of mid-dia... more Osteoid osteomas are mostly solitary. We report a case of metachronous osteoid osteoma of mid-diaphysis of fibula followed by distal humeral osteoid osteoma after a 7-year interval.
Background. Preoperative risk stratification and optimising care of patients undergoing elective ... more Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 ...
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