Learning Objectives: After studying this article, the participant should be able to: 1. Describe ... more Learning Objectives: After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. Summary: Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.
We optimized lipidomics methods to broadly detect endogenous lipids bound to cellular CD1a protei... more We optimized lipidomics methods to broadly detect endogenous lipids bound to cellular CD1a proteins. Whereas membrane phospholipids dominate in cells, CD1a preferentially captured sphingolipids, especially a C42, doubly unsaturated sphingomyelin (42:2 SM). The natural 42:2 SM but not the more common 34:1 SM blocked CD1a tetramer binding to T cells in all human subjects tested. Thus, cellular CD1a selectively captures a particular endogenous lipid that broadly blocks its binding to TCRs. Crystal structures show that the short cellular SMs stabilized a triad of surface residues to remain flush with CD1a, but the longer lipids forced the phosphocholine group to ride above the display platform to hinder TCR approach. Whereas nearly all models emphasize antigen-mediated T cell activation, we propose that the CD1a system has intrinsic autoreactivity and is negatively regulated by natural endogenous inhibitors selectively bound in its cleft. Further, the detailed chemical structures of nat...
Diabetic foot infections continue to be a major challenge for health care delivery systems. Follo... more Diabetic foot infections continue to be a major challenge for health care delivery systems. Following encouraging results from a pilot study using a novel purified reconstituted bilayer matrix (PRBM) to treat chronic diabetic foot ulcers (DFUs), we designed a prospective, multi‐centre randomised trial comparing outcomes of PRBM at 12 weeks compared with a standard of care (SOC) using a collagen alginate dressing. The primary endpoint was percentage of wounds closed after 12 weeks. Secondary outcomes included assessments of complications, healing time, quality of life, and cost to closure. Forty patients were included in an intent‐to‐treat (ITT) and per‐protocol (PP) analysis, with 39 completing the study protocol (n = 19 PRBM, n = 20 SOC). Wounds treated with PRBM were significantly more likely to close than wounds treated with SOC (ITT: 85% vs 30%, P = .0004, PP: 94% vs 30% P = .00008), healed significantly faster (mean 37 days vs 67 days for SOC, P = .002), and achieved a mean wou...
Plastic and Reconstructive Surgery - Global Open, 2021
the bilayer wound matrix from porcine tissue follows a three-step process; extraction, purificati... more the bilayer wound matrix from porcine tissue follows a three-step process; extraction, purification, and refinement of the material into a bilayer design featuring a compact upper layer and porous lower layer. The material is packaged dry, but its design allows for rapid fluid uptake. B: PRBM in hydrated condition.
Advanced wound scaffolds that integrate active substances to treat chronic wounds have gained sig... more Advanced wound scaffolds that integrate active substances to treat chronic wounds have gained significant recent attention. While wound scaffolds and advanced functionalities have previously been incorporated into one medical device, the wirelessly triggered release of active substances has remained the focus of many research endeavors. To combine multiple functions including light‐triggered activation, antiseptic, angiogenic, and moisturizing properties, a 3D printed hydrogel patch encapsulating vascular endothelial growth factor (VEGF) decorated with photoactive and antibacterial tetrapodal zinc oxide (t‐ZnO) microparticles is developed. To achieve the smart release of VEGF, t‐ZnO is modified by chemical treatment and activated through ultraviolet/visible light exposure. This process would also make the surface rough and improve protein adhesion. The elastic modulus and degradation behavior of the composite hydrogels, which must match the wound healing process, are adjusted by cha...
We audited our preoperative maintence fluid prescribing against the guideline. Methods: 20 patien... more We audited our preoperative maintence fluid prescribing against the guideline. Methods: 20 patients aged 18e65, operated on in February 2014 were randomly selected. Exclusion criteria: Complex fluid requirements/significant co-morbidities (renal impairment, shock, sepsis). Notes were examined documenting weights and fluids prescribed since being made NBM. The quantity of water & electrolytes prescribed was calculated. Weights were used to calculate the 'ideal' amount of each component according to the guideline and time frame. A fluid 'flashcard' was produced to guide the prescribing. We re-audited in August 2014 Results: Initial audit demonstrated on average (mean) patients were prescribed 19.7% of the recommended potassium & 11.5% of glucose however 519.2% of sodium, 459.3% chloride and 155.9% of water. The reaudit showed improvements with increases in potassium and glucose prescribed, 31.9% and 62.3% respectively and decreases in sodium 450.5% and Chloride 423.3%. Water 157%. Conclusion: This audit shows that further education is required. Our flashcard made improvements. Further dissemination & incorporation into a hospital protocol would be the ideal next step.
Introduction: Use of autologous fat grafting (AFG) for breast reconstructive surgery is gaining a... more Introduction: Use of autologous fat grafting (AFG) for breast reconstructive surgery is gaining acceptance, but concerns regarding its efficacy and safety remain. We present a protocol for a systematic review that aims to update the findings since our previous systematic review on a number of outcomes of AFG. Methods: The systematic review has been registered a priori (UIN: reviewregistry308). All study designs, including randomised controlled trials, cohort studies, case-controlled studies and case reports/series, reporting original data, on women undergoing AFG for breast reconstruction following mastectomy or breast conserving surgery, will be included. Six categorical outcomes will be assessed: oncological; clinical; aesthetic/functional; patient-reported; process; and radiological. The search strategy will be devised to investigate 'fat grafting and breast reconstruction'. Electronic databases will be searched, 01 April 2014 to 21 August 2017: PubMed, MEDLINE Ò , EMBASE, SCOPUS, CINAHL, PsychINFO, SciELO, The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature will be searched. Two trained, independent teams will screen all titles and abstracts, and relevant full texts, for eligibility. Data will be extracted under standardised extraction fields into a preformatted database. Ethics and dissemination: The systematic review will be published in a peer-reviewed journal and presented at national and international meetings within fields of plastic, reconstructive and aesthetic surgery, and surgical oncology. The work will be disseminated electronically and in print. Brief reports of the review and findings will be disseminated to interested parties through email and direct communication. The review aims to guide healthcare practice and policy.
Introduction: Strengthening the reporting of observational studies in epidemiology (STROBE) coine... more Introduction: Strengthening the reporting of observational studies in epidemiology (STROBE) coined in 2007, highlighted the importance of improving the quality of observational research by providing an item checklist in order to avoid inadequate reporting of research. However, currently there are no reporting guidelines specific to surgical cohort studies, which have an extremely important role within the surgical literature. The recent development of surgery specific guidelines has underscored how surgical and procedural interventions require additional detail for readers to have a complete, clear, transparent and reproducible understanding. The objective of this research is to conduct a Delphi consensus exercise to develop the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery). Methods and analysis: Current guidelines for case series (PROCESS), Cohort Studies (STROBE) and randomised controlled trials (CONSORT) will be analysed to compile items to form baseline material for developing cohort guidelines in the Delphi consensus exercise. The Delphi questionnaire will be administered via Google Forms and conducted using standard Delphi Methodology. Surgeons and individuals with significant experience of reviewing cohort studies as well as those with experience in developing reporting guidelines will be invited to participate. In the first round, existing items from PROCESS and STROBE will be put forward and participants will be invited to augment them or contribute further items for consideration. The provisional guidelines will then be updated in successive rounds using the ninepoint Likert scale as proposed by the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) working group. This process will be used to agree Standard definitions for the outcomes. Dissemination: The work will be published in a peer-reviewed journal and presented at national and international meetings. Findings will be disseminated to interested parties, and journals will be encouraged to endorse the reporting guidelines.
BackgroundCategorising research by level of evidence (LOE) is an important evidence-based medicin... more BackgroundCategorising research by level of evidence (LOE) is an important evidence-based medicine initiative. Our objective was to assess the change in LOEs in plastic surgery from 2003 to 2013 and compared this with five other surgical specialties.MethodsA search for all research articles published in the top three general plastic surgery journals (ranked by impact factor) was conducted for 2003 and 2013. Articles were then labelled as LOE 1–5 and compared to other specialties.ResultsMean LOE for plastic surgery improved by 4.1 % from 3.86 (95 % confidence interval 3.81–3.91) to 3.70 (95 % confidence interval 3.64–3.74) from 2003 to 2013 respectively. All six surgical specialties improved their mean LOE (range 3.7 to 10.9 %). By mean LOE, plastic surgery continues to rank five out of six.ConclusionsPlastic surgery is tending towards higher levels of evidence at a slow pace. The specialty must continue to drive towards higher levels of evidence.Level of Evidence: Not ratable.
American women and 1.5 million women worldwide are diagnosed with breast cancer. 1,2 After mastec... more American women and 1.5 million women worldwide are diagnosed with breast cancer. 1,2 After mastectomy, patients are given the option of undergoing reconstruction of their breasts with flaps or implants. Unfortunately, over 60 percent of American women elect to not undergo reconstruction. 3 They do not welcome invasive flap surgery and prefer to avoid prosthetic materials. Based on tissue-engineering principles, we developed a minimally invasive, patientfriendly alternative for women to regenerate their lost breast in situ without additional scars or incisions. 4
Background and aims: Poor recruitment and retention are common challenges to the successful deliv... more Background and aims: Poor recruitment and retention are common challenges to the successful delivery of surgical trials, possibly alleviated by greater patient and public involvement (PPI). We aim to develop a
Journal of Plastic Reconstructive and Aesthetic Surgery, Apr 1, 2013
Our objective was to assess the methodological quality of randomized controlled trials (RCTs) in ... more Our objective was to assess the methodological quality of randomized controlled trials (RCTs) in Plastic Surgery. An information specialist searched MEDLINE for the period of 1 January 2009 to 30 June 2011 for the MESH heading "Surgery, Plastic" with limitations for English language, human studies and randomized controlled trials. Results were manually searched for RCTs involving surgical techniques. The papers were then scored with the authors' seven point extended version of the Linde Internal Validity Scale (ELIVS). Secondary scoring was then performed and discrepancies resolved by consensus. 57 papers met the inclusion criteria. The median ELIVS score was 3.0 with a range of 1.0-6.5. Compliance was poorest with use of intention to treat analysis (4%), blinding of patients (23%) and the handling and reporting of patient withdrawals (25%). There was no statistically significant correlation between journal ELIVS score and 2010 impact factor or number of authors (Spearman rho 0.10 and 0.27 respectively). Multicentre trials had a higher average ELIVS score than single centre ones (3.6 vs 2.7) although this did not reach significance. There was no correlation between the volume of RCTs performed in a particular country and methodological quality. The methodological quality of RCTs in Plastic Surgery needs improvement.
Shock focusing in water is a phenomenon that can occur during the impact of a shock wave generate... more Shock focusing in water is a phenomenon that can occur during the impact of a shock wave generated by an underwater explosion onto any type of convergent marine structures. To predict the dynamic material response of the marine structure, it is important to understand the shock wave dynamics during the focusing event. In this paper, both experimental investigations and numerical studies of twodimensional shock focusing in water are presented. Here, a convergent geometry given by a logarithmic spiral curve is used to focus the shock waves. In the experiments, the interaction between three types of materials and the shock wave in water is explored by using high-speed photography. Distinct features of such flows are unveiled. Three scenarios have been considered in simulations: a rigid structure where only the water-filled region is taken into account, a fluid-structure interaction problem in which the surrounding material responses are included, and an axisymmetric simulation to determine the threedimensional effects.
Learning Objectives: After studying this article, the participant should be able to: 1. Describe ... more Learning Objectives: After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. Summary: Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.
We optimized lipidomics methods to broadly detect endogenous lipids bound to cellular CD1a protei... more We optimized lipidomics methods to broadly detect endogenous lipids bound to cellular CD1a proteins. Whereas membrane phospholipids dominate in cells, CD1a preferentially captured sphingolipids, especially a C42, doubly unsaturated sphingomyelin (42:2 SM). The natural 42:2 SM but not the more common 34:1 SM blocked CD1a tetramer binding to T cells in all human subjects tested. Thus, cellular CD1a selectively captures a particular endogenous lipid that broadly blocks its binding to TCRs. Crystal structures show that the short cellular SMs stabilized a triad of surface residues to remain flush with CD1a, but the longer lipids forced the phosphocholine group to ride above the display platform to hinder TCR approach. Whereas nearly all models emphasize antigen-mediated T cell activation, we propose that the CD1a system has intrinsic autoreactivity and is negatively regulated by natural endogenous inhibitors selectively bound in its cleft. Further, the detailed chemical structures of nat...
Diabetic foot infections continue to be a major challenge for health care delivery systems. Follo... more Diabetic foot infections continue to be a major challenge for health care delivery systems. Following encouraging results from a pilot study using a novel purified reconstituted bilayer matrix (PRBM) to treat chronic diabetic foot ulcers (DFUs), we designed a prospective, multi‐centre randomised trial comparing outcomes of PRBM at 12 weeks compared with a standard of care (SOC) using a collagen alginate dressing. The primary endpoint was percentage of wounds closed after 12 weeks. Secondary outcomes included assessments of complications, healing time, quality of life, and cost to closure. Forty patients were included in an intent‐to‐treat (ITT) and per‐protocol (PP) analysis, with 39 completing the study protocol (n = 19 PRBM, n = 20 SOC). Wounds treated with PRBM were significantly more likely to close than wounds treated with SOC (ITT: 85% vs 30%, P = .0004, PP: 94% vs 30% P = .00008), healed significantly faster (mean 37 days vs 67 days for SOC, P = .002), and achieved a mean wou...
Plastic and Reconstructive Surgery - Global Open, 2021
the bilayer wound matrix from porcine tissue follows a three-step process; extraction, purificati... more the bilayer wound matrix from porcine tissue follows a three-step process; extraction, purification, and refinement of the material into a bilayer design featuring a compact upper layer and porous lower layer. The material is packaged dry, but its design allows for rapid fluid uptake. B: PRBM in hydrated condition.
Advanced wound scaffolds that integrate active substances to treat chronic wounds have gained sig... more Advanced wound scaffolds that integrate active substances to treat chronic wounds have gained significant recent attention. While wound scaffolds and advanced functionalities have previously been incorporated into one medical device, the wirelessly triggered release of active substances has remained the focus of many research endeavors. To combine multiple functions including light‐triggered activation, antiseptic, angiogenic, and moisturizing properties, a 3D printed hydrogel patch encapsulating vascular endothelial growth factor (VEGF) decorated with photoactive and antibacterial tetrapodal zinc oxide (t‐ZnO) microparticles is developed. To achieve the smart release of VEGF, t‐ZnO is modified by chemical treatment and activated through ultraviolet/visible light exposure. This process would also make the surface rough and improve protein adhesion. The elastic modulus and degradation behavior of the composite hydrogels, which must match the wound healing process, are adjusted by cha...
We audited our preoperative maintence fluid prescribing against the guideline. Methods: 20 patien... more We audited our preoperative maintence fluid prescribing against the guideline. Methods: 20 patients aged 18e65, operated on in February 2014 were randomly selected. Exclusion criteria: Complex fluid requirements/significant co-morbidities (renal impairment, shock, sepsis). Notes were examined documenting weights and fluids prescribed since being made NBM. The quantity of water & electrolytes prescribed was calculated. Weights were used to calculate the 'ideal' amount of each component according to the guideline and time frame. A fluid 'flashcard' was produced to guide the prescribing. We re-audited in August 2014 Results: Initial audit demonstrated on average (mean) patients were prescribed 19.7% of the recommended potassium & 11.5% of glucose however 519.2% of sodium, 459.3% chloride and 155.9% of water. The reaudit showed improvements with increases in potassium and glucose prescribed, 31.9% and 62.3% respectively and decreases in sodium 450.5% and Chloride 423.3%. Water 157%. Conclusion: This audit shows that further education is required. Our flashcard made improvements. Further dissemination & incorporation into a hospital protocol would be the ideal next step.
Introduction: Use of autologous fat grafting (AFG) for breast reconstructive surgery is gaining a... more Introduction: Use of autologous fat grafting (AFG) for breast reconstructive surgery is gaining acceptance, but concerns regarding its efficacy and safety remain. We present a protocol for a systematic review that aims to update the findings since our previous systematic review on a number of outcomes of AFG. Methods: The systematic review has been registered a priori (UIN: reviewregistry308). All study designs, including randomised controlled trials, cohort studies, case-controlled studies and case reports/series, reporting original data, on women undergoing AFG for breast reconstruction following mastectomy or breast conserving surgery, will be included. Six categorical outcomes will be assessed: oncological; clinical; aesthetic/functional; patient-reported; process; and radiological. The search strategy will be devised to investigate 'fat grafting and breast reconstruction'. Electronic databases will be searched, 01 April 2014 to 21 August 2017: PubMed, MEDLINE Ò , EMBASE, SCOPUS, CINAHL, PsychINFO, SciELO, The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature will be searched. Two trained, independent teams will screen all titles and abstracts, and relevant full texts, for eligibility. Data will be extracted under standardised extraction fields into a preformatted database. Ethics and dissemination: The systematic review will be published in a peer-reviewed journal and presented at national and international meetings within fields of plastic, reconstructive and aesthetic surgery, and surgical oncology. The work will be disseminated electronically and in print. Brief reports of the review and findings will be disseminated to interested parties through email and direct communication. The review aims to guide healthcare practice and policy.
Introduction: Strengthening the reporting of observational studies in epidemiology (STROBE) coine... more Introduction: Strengthening the reporting of observational studies in epidemiology (STROBE) coined in 2007, highlighted the importance of improving the quality of observational research by providing an item checklist in order to avoid inadequate reporting of research. However, currently there are no reporting guidelines specific to surgical cohort studies, which have an extremely important role within the surgical literature. The recent development of surgery specific guidelines has underscored how surgical and procedural interventions require additional detail for readers to have a complete, clear, transparent and reproducible understanding. The objective of this research is to conduct a Delphi consensus exercise to develop the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery). Methods and analysis: Current guidelines for case series (PROCESS), Cohort Studies (STROBE) and randomised controlled trials (CONSORT) will be analysed to compile items to form baseline material for developing cohort guidelines in the Delphi consensus exercise. The Delphi questionnaire will be administered via Google Forms and conducted using standard Delphi Methodology. Surgeons and individuals with significant experience of reviewing cohort studies as well as those with experience in developing reporting guidelines will be invited to participate. In the first round, existing items from PROCESS and STROBE will be put forward and participants will be invited to augment them or contribute further items for consideration. The provisional guidelines will then be updated in successive rounds using the ninepoint Likert scale as proposed by the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) working group. This process will be used to agree Standard definitions for the outcomes. Dissemination: The work will be published in a peer-reviewed journal and presented at national and international meetings. Findings will be disseminated to interested parties, and journals will be encouraged to endorse the reporting guidelines.
BackgroundCategorising research by level of evidence (LOE) is an important evidence-based medicin... more BackgroundCategorising research by level of evidence (LOE) is an important evidence-based medicine initiative. Our objective was to assess the change in LOEs in plastic surgery from 2003 to 2013 and compared this with five other surgical specialties.MethodsA search for all research articles published in the top three general plastic surgery journals (ranked by impact factor) was conducted for 2003 and 2013. Articles were then labelled as LOE 1–5 and compared to other specialties.ResultsMean LOE for plastic surgery improved by 4.1 % from 3.86 (95 % confidence interval 3.81–3.91) to 3.70 (95 % confidence interval 3.64–3.74) from 2003 to 2013 respectively. All six surgical specialties improved their mean LOE (range 3.7 to 10.9 %). By mean LOE, plastic surgery continues to rank five out of six.ConclusionsPlastic surgery is tending towards higher levels of evidence at a slow pace. The specialty must continue to drive towards higher levels of evidence.Level of Evidence: Not ratable.
American women and 1.5 million women worldwide are diagnosed with breast cancer. 1,2 After mastec... more American women and 1.5 million women worldwide are diagnosed with breast cancer. 1,2 After mastectomy, patients are given the option of undergoing reconstruction of their breasts with flaps or implants. Unfortunately, over 60 percent of American women elect to not undergo reconstruction. 3 They do not welcome invasive flap surgery and prefer to avoid prosthetic materials. Based on tissue-engineering principles, we developed a minimally invasive, patientfriendly alternative for women to regenerate their lost breast in situ without additional scars or incisions. 4
Background and aims: Poor recruitment and retention are common challenges to the successful deliv... more Background and aims: Poor recruitment and retention are common challenges to the successful delivery of surgical trials, possibly alleviated by greater patient and public involvement (PPI). We aim to develop a
Journal of Plastic Reconstructive and Aesthetic Surgery, Apr 1, 2013
Our objective was to assess the methodological quality of randomized controlled trials (RCTs) in ... more Our objective was to assess the methodological quality of randomized controlled trials (RCTs) in Plastic Surgery. An information specialist searched MEDLINE for the period of 1 January 2009 to 30 June 2011 for the MESH heading "Surgery, Plastic" with limitations for English language, human studies and randomized controlled trials. Results were manually searched for RCTs involving surgical techniques. The papers were then scored with the authors' seven point extended version of the Linde Internal Validity Scale (ELIVS). Secondary scoring was then performed and discrepancies resolved by consensus. 57 papers met the inclusion criteria. The median ELIVS score was 3.0 with a range of 1.0-6.5. Compliance was poorest with use of intention to treat analysis (4%), blinding of patients (23%) and the handling and reporting of patient withdrawals (25%). There was no statistically significant correlation between journal ELIVS score and 2010 impact factor or number of authors (Spearman rho 0.10 and 0.27 respectively). Multicentre trials had a higher average ELIVS score than single centre ones (3.6 vs 2.7) although this did not reach significance. There was no correlation between the volume of RCTs performed in a particular country and methodological quality. The methodological quality of RCTs in Plastic Surgery needs improvement.
Shock focusing in water is a phenomenon that can occur during the impact of a shock wave generate... more Shock focusing in water is a phenomenon that can occur during the impact of a shock wave generated by an underwater explosion onto any type of convergent marine structures. To predict the dynamic material response of the marine structure, it is important to understand the shock wave dynamics during the focusing event. In this paper, both experimental investigations and numerical studies of twodimensional shock focusing in water are presented. Here, a convergent geometry given by a logarithmic spiral curve is used to focus the shock waves. In the experiments, the interaction between three types of materials and the shock wave in water is explored by using high-speed photography. Distinct features of such flows are unveiled. Three scenarios have been considered in simulations: a rigid structure where only the water-filled region is taken into account, a fluid-structure interaction problem in which the surrounding material responses are included, and an axisymmetric simulation to determine the threedimensional effects.
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Papers by Dennis Orgill