Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptoma... more Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patient...
Krishan Madhan’s paper The epidemic of elderly patients with dialysis-requiring end-stage renal d... more Krishan Madhan’s paper The epidemic of elderly patients with dialysis-requiring end-stage renal disease in New Zealand, published in this edition of the New Zealand Medical Journal,1 raises important issues pertaining to planning and provision of renal replacement therapy (RRT) in New Zealand. (RRT includes home-delivered and institutional haemodialysis, peritoneal dialysis, and renal transplantation.) In common with all countries that provide comprehensive RRT programmes, New Zealand is experiencing substantial and sustained growth in demand for RRT, and a disproportionate increase in new patients accepted for RRT in the age group =65 years. It appears that there is no realistic prospect that this trend will reverse, and further expansion of this group is predicted. The complex interplay of pressures within our health system, generating expansion in RRT in the population aged =65 years, includes: § Ageing of the population in general, and ageing of the population sustained by dialysis specifically. § Explicit removal of age as a criterion for restriction of access to medical services.
To audit documentation of the process of informed consent in patients undergoing vascular surgica... more To audit documentation of the process of informed consent in patients undergoing vascular surgical and radiological procedures. A retrospective audit of randomly selected elective vascular radiological and surgical admissions was undertaken at Christchurch Hospital (Christchurch, New Zealand) to assess documented evidence of the consent process. Clinic letters, handwritten entries in patient notes, and consent forms were scrutinised and data collated on which medical practitioners took consent, what details of the consent process were documented, and what additional information was made available to patients. 100 sets of notes were reviewed (surgical n=51, radiological n=49). For patients undergoing vascular surgery, the consent form was signed by a consultant in 2 (4%) sets of notes compared to 46 (94%) for patients undergoing vascular radiological intervention (p<0.001). All radiology consent forms were signed on the day of the procedure whereas 43 (84%) of surgical consent for...
Aim To survey current opinion, regarding TNPWT, from New Zealand vascular surgeons. Method Regist... more Aim To survey current opinion, regarding TNPWT, from New Zealand vascular surgeons. Method Registered vascular surgeons currently practicing in New Zealand were identified from the Vascular Society of New Zealand (VSNZ) database. A questionnaire was emailed asking if they used TNP in their vascular surgical practice and whether or not they considered themselves ‘up to date ’ regarding published evidence for TNP. Surgeons were also asked how often and how successful they felt that TNP was in different clinical situations (arterial ulcers [after revascularisation]; venous ulcers; mixed arterial/venous ulcers; following debridement of the ‘diabetic (Db) foot’; lower limb (LL) surgical wound infections/dehiscences; and lymphocoeles/seromas/lymph fistulas not treated successfully with conservative management). One email reminder, followed by a hard copy reminder was sent to those who failed to respond to the first email. Results Of 38 vascular surgeons 34 responded (89.5%). Median respon...
Background Multiple observational studies have associated metformin prescription with reduced pro... more Background Multiple observational studies have associated metformin prescription with reduced progression of abdominal aortic aneurysm (AAA). The Metformin Aneurysm Trial (MAT) will test whether metformin reduces the risk of AAA rupture-related mortality or requirement for AAA surgery (AAA events) in people with asymptomatic aneurysms. Methods MAT is an international, multi-centre, prospective, parallel-group, randomised, placebo-controlled trial. Participants must have an asymptomatic AAA measuring at least 35 mm in maximum diameter, no diabetes, no contraindication to metformin and no current plans for surgical repair. The double-blind period is preceded by a 6-week, single-blind, active run-in phase in which all potential participants receive metformin. Only patients tolerating metformin by taking at least 80% of allocated medication will enter the trial and be randomised to 1500 mg of metformin XR or an identical placebo. The primary outcome is the proportion of AAA events defin...
AIM Patients with peripheral occlusive arterial disease (POAD) suffer significant morbidity and m... more AIM Patients with peripheral occlusive arterial disease (POAD) suffer significant morbidity and mortality from cardiovascular events that may be reduced by appropriate risk factor management. The aim of this study was to document the opinion of New Zealand vascular surgeons regarding risk factor management in patients with POAD. METHODS A questionnaire was emailed to 42 New Zealand vascular surgeons. Surgeons were asked if they checked risk factors in patients with POAD and who they thought should manage these risk factors. The survey was then re-emailed to non-responders after 3 weeks and subsequently posted to the remaining non-responders with a reply paid envelope after a further 3 weeks. RESULTS The overall response rate was 83% (35/42). Thirty-four of the 35 surgeons (97%) stated that they routinely asked smoking history, 69% monitored blood pressure, 74% checked cholesterol level, 57% checked blood glucose level, and none checked homocysteine level, although 43% consider hyper...
AIMS We present 5-year results of an abdominal aortic aneurysm surveillance programme at Christch... more AIMS We present 5-year results of an abdominal aortic aneurysm surveillance programme at Christchurch Hospital, based on the UK Small Aneurysm Trial. METHOD Patients with infrarenal abdominal aortic aneurysms between 30 and 55 mm were placed in an ultrasound-based surveillance programme with an intention to treat when their aneurysms reached the Vascular Service determined threshold, when the AAA became symptomatic, or when rapid AAA growth was demonstrated. Patients were divided into three groups: Group 1, those currently under or those who had completed surveillance (n=198); Group 2, those excluded from surveillance and therefore treatment due to unsuitability for open surgical or endoluminal exclusion who had not completed surveillance (n=18); and Group 3, those who declined surgery on completion of surveillance (n=5). We looked at the number of aneurysm-related deaths in these groups and examined any issues that arose during or upon completion of surveillance. RESULTS There were...
AIM To assess the documentation and modification of vascular risk factors in patients with interm... more AIM To assess the documentation and modification of vascular risk factors in patients with intermittent claudication enrolled in an exercise programme in Christchurch, New Zealand. PATIENTS/METHOD A retrospective review of case notes of patients who presented to the vascular outpatient department with intermittent claudication and were given "Green Prescriptions" for an exercise programme was performed. Referral letters, clinic letters, vascular nurse notes, and handwritten hospital notes were searched for evidence of documentation of risk factors for atherosclerosis. Modification of these risk factors was also noted. Positive attempts at risk factor modification included starting or asking the GP to start a medication or asking the GP to assist with smoking cessation. RESULTS Sixty patient notes were reviewed which included 81 referral letters (66 from GPs), 118 surgeon letters/clinic notes, and 43 vascular nurse assessments. Of the 60 patients referred, risk factor docum...
AIM To audit advice regarding the hereditary nature of aneurysm disease offered to patients under... more AIM To audit advice regarding the hereditary nature of aneurysm disease offered to patients undergoing elective AAA repair in a New Zealand teaching hospital (Christchurch Public Hospital). METHOD In a retrospective audit, the documentation of information and advice given to patients regarding the hereditary nature of AAA disease was reviewed. Patients undergoing non-emergency open or endovascular AAA repair in a tertiary referral centre were identified from a computerised database (patient management system). Typed clinic letters and in-patient notes were searched for evidence of advice given regarding the hereditary nature of AAAs and the need for surveillance of family members. RESULTS Of the 79 patients included in the study, 20 (25%) underwent endovascular AAA repair (EVAR) and 59 (75%) underwent open AAA repair. Only 19 of patient notes contained thorough documentation of the advice offered regarding family history of AAA. CONCLUSION This study has identified deficiencies in t...
AIMS This paper describes the rationale and methodology of a study assessing the reliability of t... more AIMS This paper describes the rationale and methodology of a study assessing the reliability of tools for clinical prioritisation (Clinical Priority Assessment Criteria [CPAC]) of patients for elective surgery in New Zealand. METHODS Surgeons from three specialties (general, vascular, and orthopaedic surgery) completed a computerised evaluation rating clinical vignettes across a range of diagnoses using several priority tools. The study design is described and an outline of the individual tool development and definitions is given. RESULTS Of the 124 surgeons that participated in this study, 48% (60) were general surgeons, 21% (26) were vascular surgeons and 31% (38) were orthopaedic surgeons. The response rates in the first phase of data collection were 67%, 79%, and 63% for general, vascular, and orthopaedic surgery respectively. Completion rates were high with 100%, 93%, and 98% of the same groupings of surgeons completing the first round evaluations. A further 77% to 89% of the p...
BACKGROUND Varicose veins are a significant health problem which attract much medicolegal attenti... more BACKGROUND Varicose veins are a significant health problem which attract much medicolegal attention. Recent publications have suggested "best practice" regarding assessment of patients with varicose veins. A retrospective audit was performed comparing clinical practice in a New Zealand teaching hospital with suggested standards. METHODS Clinic letters from 80 patients awaiting varicose vein surgery were reviewed. Data were collated regarding presenting problem, relevant medical history, clinical findings on examination, further investigations, and outcome. RESULTS Presenting complaint was noted for 99% of patients but actual symptoms were only recorded for 41%. The degree of disability caused by varicose veins was documented for 33% and patient concerns in 4%. Half of the patients presented with leg ulcers but ankle-brachial indices (ABPIs) were only recorded in 26% of clinic letters. Duplex scanning was recommended prior to surgery for 69% of patients and hand held Dopple...
Atherosclerotic plaques are complex tissues containing many different cell types. Macrophages con... more Atherosclerotic plaques are complex tissues containing many different cell types. Macrophages contribute to inflammation, formation of the necrotic core, and plaque rupture. We examined whether macrophages in plaque can be activated and compared this to monolayer cells. The volume of calcium in the plaque was compared to the level of macrophage activation measured by total neopterin output. Carotid plaque samples were cut into 3 mm sections and cultured for up to 96 h. Live sections were stimulated with interferon-γ, phytohaemagglutinin or phorbol 12-myristate 13-acetate. Macrophage activation and oxidative stress were monitored by total neopterin (oxidized and non-oxidized 7,8-dihydroneopterin) and neopterin levels every 24 h for up to 4 d. The calcium content of two plaques was investigated by spectral imaging. Direct stimulation of macrophages in plaque sections with interferon-γ caused a sustained increase in neopterin (p = .037) and total neopterin (p = .003). The addition of p...
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2017
Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihoo... more Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihood of increased mortality. The aim of this study was to investigate how SES and ethnicity impacted patient survival after abdominal aortic aneurysm (AAA) repair. Consecutive patients undergoing open and endovascular AAA repair during a 14.5 year period were identified. Ethnicity was defined as recorded on health records and SES (a score of 10, where 1 is least deprived and 10 being most deprived) and was linked to census data. Operative outcomes were reported at 30 days and a medium-term survival analysis used the Cox model to report adjusted hazard ratios (HR). A total of 6239 patients with a median age of 75 years and 78.7% males were included. The majority (5,654) were identified as New Zealand (NZ) Europeans, with 421 identified as NZ Maori, 97 identified as belonging to a Pacific ethnic group, and 67 identified as an Asian ethnic group. The median survival follow-up period was 5 year...
Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptoma... more Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patient...
Journal of medical imaging and radiation oncology, Jan 21, 2016
Computed tomography colonography (CTC) for the detection of colorectal disease is gaining popular... more Computed tomography colonography (CTC) for the detection of colorectal disease is gaining popularity as an alternative to colonoscopy. This has been associated with an increase in incidental extra-colonic findings such as abdominal aortic aneurysms. However, due to the patient selection process of obtaining a CTC, it was hypothesised that this patient cohort might represent a high-risk group. The primary aim of this study was to determine the impact that CTC had on small aneurysm referrals. Owing to the potential selection bias, the secondary aim was to compare baseline characteristics referred by CTC to the cohort referred by other radiological modalities. Consecutive patients attending the small aneurysm clinic at a single tertiary centre were included. Baseline patient comorbidities were collected and recorded on a prospective database. The characteristics of patients who had a CTC-detected aneurysm were compared to patients referred by other radiological modalities. There were 5...
The main determinants of survival following abdominal aortic aneurysm (AAA) repair are pre-existi... more The main determinants of survival following abdominal aortic aneurysm (AAA) repair are pre-existing risk factors rather than the method of repair chosen. The main aim of this meta-analysis was to assess the effect of modifiable risk factors on late survival following AAA repair. Electronic databases were searched to identify all relevant articles reporting the influence of modifiable risk factors on long-term survival (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 1 year) following elective open aneurysm repair and endovascular aneurysm repair. Twenty-four studies comprised of 53,118 patients published between 1989 and 2015 were included in the analysis. The use of statin, aspirin, beta-blockers and a higher hemoglobin level were all significant predictors of improved survival following repair with a hazard ratio (HR) 95% confidence interval (CI) of 0.75 (0.70-0.80), 0.81 (0.73-0.89), 0.75 (0.61-0.93) and 0.84 (0.74-0.96), respectively. Smoking history and uncorrected coronary disease were associated with a worse long-term survival, HRs (95%CI) were 1.27 (1.07-1.51) and 2.59 (1.14-5.88), respectively. Addressing cardiovascular risk factors in patients pre-operatively improves long-term survival following AAA repair. Global strategies to improve risk factor modifications in these patients are warranted to optimize long-term outcomes.
In New Zealand (NZ), there are two major sources of operative data for abdominal aortic aneurysm ... more In New Zealand (NZ), there are two major sources of operative data for abdominal aortic aneurysm (AAA) repair: the Australasian Vascular Audit (AVA) and the National Minimum Data Set (NMDS). Since the introduction of the AVA in NZ, there has not been any attempt at the validation of outcome data. The aims of this study were to report the outcomes of AAA repair and validate the AAA data captured by AVA using the NMDS. AAA procedures performed in NZ from January 2010 to December 2014 were extracted from the AVA and NMDS. Patients identified from the AVA had their survival status matched to the NMDS. Only primary AAA procedures were included for the analysis, with re-interventions and graft infections excluded. Demographical, risk factors and outcome data were used for validation. The number of patients undergoing primary AAA procedure from AVA and NMDS was 1713 and 2078, respectively. The AVA inpatient mortality for elective and rupture AAA was 1.6 and 32.2%, respectively. The NMDS 30...
Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptoma... more Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patient...
Krishan Madhan’s paper The epidemic of elderly patients with dialysis-requiring end-stage renal d... more Krishan Madhan’s paper The epidemic of elderly patients with dialysis-requiring end-stage renal disease in New Zealand, published in this edition of the New Zealand Medical Journal,1 raises important issues pertaining to planning and provision of renal replacement therapy (RRT) in New Zealand. (RRT includes home-delivered and institutional haemodialysis, peritoneal dialysis, and renal transplantation.) In common with all countries that provide comprehensive RRT programmes, New Zealand is experiencing substantial and sustained growth in demand for RRT, and a disproportionate increase in new patients accepted for RRT in the age group =65 years. It appears that there is no realistic prospect that this trend will reverse, and further expansion of this group is predicted. The complex interplay of pressures within our health system, generating expansion in RRT in the population aged =65 years, includes: § Ageing of the population in general, and ageing of the population sustained by dialysis specifically. § Explicit removal of age as a criterion for restriction of access to medical services.
To audit documentation of the process of informed consent in patients undergoing vascular surgica... more To audit documentation of the process of informed consent in patients undergoing vascular surgical and radiological procedures. A retrospective audit of randomly selected elective vascular radiological and surgical admissions was undertaken at Christchurch Hospital (Christchurch, New Zealand) to assess documented evidence of the consent process. Clinic letters, handwritten entries in patient notes, and consent forms were scrutinised and data collated on which medical practitioners took consent, what details of the consent process were documented, and what additional information was made available to patients. 100 sets of notes were reviewed (surgical n=51, radiological n=49). For patients undergoing vascular surgery, the consent form was signed by a consultant in 2 (4%) sets of notes compared to 46 (94%) for patients undergoing vascular radiological intervention (p<0.001). All radiology consent forms were signed on the day of the procedure whereas 43 (84%) of surgical consent for...
Aim To survey current opinion, regarding TNPWT, from New Zealand vascular surgeons. Method Regist... more Aim To survey current opinion, regarding TNPWT, from New Zealand vascular surgeons. Method Registered vascular surgeons currently practicing in New Zealand were identified from the Vascular Society of New Zealand (VSNZ) database. A questionnaire was emailed asking if they used TNP in their vascular surgical practice and whether or not they considered themselves ‘up to date ’ regarding published evidence for TNP. Surgeons were also asked how often and how successful they felt that TNP was in different clinical situations (arterial ulcers [after revascularisation]; venous ulcers; mixed arterial/venous ulcers; following debridement of the ‘diabetic (Db) foot’; lower limb (LL) surgical wound infections/dehiscences; and lymphocoeles/seromas/lymph fistulas not treated successfully with conservative management). One email reminder, followed by a hard copy reminder was sent to those who failed to respond to the first email. Results Of 38 vascular surgeons 34 responded (89.5%). Median respon...
Background Multiple observational studies have associated metformin prescription with reduced pro... more Background Multiple observational studies have associated metformin prescription with reduced progression of abdominal aortic aneurysm (AAA). The Metformin Aneurysm Trial (MAT) will test whether metformin reduces the risk of AAA rupture-related mortality or requirement for AAA surgery (AAA events) in people with asymptomatic aneurysms. Methods MAT is an international, multi-centre, prospective, parallel-group, randomised, placebo-controlled trial. Participants must have an asymptomatic AAA measuring at least 35 mm in maximum diameter, no diabetes, no contraindication to metformin and no current plans for surgical repair. The double-blind period is preceded by a 6-week, single-blind, active run-in phase in which all potential participants receive metformin. Only patients tolerating metformin by taking at least 80% of allocated medication will enter the trial and be randomised to 1500 mg of metformin XR or an identical placebo. The primary outcome is the proportion of AAA events defin...
AIM Patients with peripheral occlusive arterial disease (POAD) suffer significant morbidity and m... more AIM Patients with peripheral occlusive arterial disease (POAD) suffer significant morbidity and mortality from cardiovascular events that may be reduced by appropriate risk factor management. The aim of this study was to document the opinion of New Zealand vascular surgeons regarding risk factor management in patients with POAD. METHODS A questionnaire was emailed to 42 New Zealand vascular surgeons. Surgeons were asked if they checked risk factors in patients with POAD and who they thought should manage these risk factors. The survey was then re-emailed to non-responders after 3 weeks and subsequently posted to the remaining non-responders with a reply paid envelope after a further 3 weeks. RESULTS The overall response rate was 83% (35/42). Thirty-four of the 35 surgeons (97%) stated that they routinely asked smoking history, 69% monitored blood pressure, 74% checked cholesterol level, 57% checked blood glucose level, and none checked homocysteine level, although 43% consider hyper...
AIMS We present 5-year results of an abdominal aortic aneurysm surveillance programme at Christch... more AIMS We present 5-year results of an abdominal aortic aneurysm surveillance programme at Christchurch Hospital, based on the UK Small Aneurysm Trial. METHOD Patients with infrarenal abdominal aortic aneurysms between 30 and 55 mm were placed in an ultrasound-based surveillance programme with an intention to treat when their aneurysms reached the Vascular Service determined threshold, when the AAA became symptomatic, or when rapid AAA growth was demonstrated. Patients were divided into three groups: Group 1, those currently under or those who had completed surveillance (n=198); Group 2, those excluded from surveillance and therefore treatment due to unsuitability for open surgical or endoluminal exclusion who had not completed surveillance (n=18); and Group 3, those who declined surgery on completion of surveillance (n=5). We looked at the number of aneurysm-related deaths in these groups and examined any issues that arose during or upon completion of surveillance. RESULTS There were...
AIM To assess the documentation and modification of vascular risk factors in patients with interm... more AIM To assess the documentation and modification of vascular risk factors in patients with intermittent claudication enrolled in an exercise programme in Christchurch, New Zealand. PATIENTS/METHOD A retrospective review of case notes of patients who presented to the vascular outpatient department with intermittent claudication and were given "Green Prescriptions" for an exercise programme was performed. Referral letters, clinic letters, vascular nurse notes, and handwritten hospital notes were searched for evidence of documentation of risk factors for atherosclerosis. Modification of these risk factors was also noted. Positive attempts at risk factor modification included starting or asking the GP to start a medication or asking the GP to assist with smoking cessation. RESULTS Sixty patient notes were reviewed which included 81 referral letters (66 from GPs), 118 surgeon letters/clinic notes, and 43 vascular nurse assessments. Of the 60 patients referred, risk factor docum...
AIM To audit advice regarding the hereditary nature of aneurysm disease offered to patients under... more AIM To audit advice regarding the hereditary nature of aneurysm disease offered to patients undergoing elective AAA repair in a New Zealand teaching hospital (Christchurch Public Hospital). METHOD In a retrospective audit, the documentation of information and advice given to patients regarding the hereditary nature of AAA disease was reviewed. Patients undergoing non-emergency open or endovascular AAA repair in a tertiary referral centre were identified from a computerised database (patient management system). Typed clinic letters and in-patient notes were searched for evidence of advice given regarding the hereditary nature of AAAs and the need for surveillance of family members. RESULTS Of the 79 patients included in the study, 20 (25%) underwent endovascular AAA repair (EVAR) and 59 (75%) underwent open AAA repair. Only 19 of patient notes contained thorough documentation of the advice offered regarding family history of AAA. CONCLUSION This study has identified deficiencies in t...
AIMS This paper describes the rationale and methodology of a study assessing the reliability of t... more AIMS This paper describes the rationale and methodology of a study assessing the reliability of tools for clinical prioritisation (Clinical Priority Assessment Criteria [CPAC]) of patients for elective surgery in New Zealand. METHODS Surgeons from three specialties (general, vascular, and orthopaedic surgery) completed a computerised evaluation rating clinical vignettes across a range of diagnoses using several priority tools. The study design is described and an outline of the individual tool development and definitions is given. RESULTS Of the 124 surgeons that participated in this study, 48% (60) were general surgeons, 21% (26) were vascular surgeons and 31% (38) were orthopaedic surgeons. The response rates in the first phase of data collection were 67%, 79%, and 63% for general, vascular, and orthopaedic surgery respectively. Completion rates were high with 100%, 93%, and 98% of the same groupings of surgeons completing the first round evaluations. A further 77% to 89% of the p...
BACKGROUND Varicose veins are a significant health problem which attract much medicolegal attenti... more BACKGROUND Varicose veins are a significant health problem which attract much medicolegal attention. Recent publications have suggested "best practice" regarding assessment of patients with varicose veins. A retrospective audit was performed comparing clinical practice in a New Zealand teaching hospital with suggested standards. METHODS Clinic letters from 80 patients awaiting varicose vein surgery were reviewed. Data were collated regarding presenting problem, relevant medical history, clinical findings on examination, further investigations, and outcome. RESULTS Presenting complaint was noted for 99% of patients but actual symptoms were only recorded for 41%. The degree of disability caused by varicose veins was documented for 33% and patient concerns in 4%. Half of the patients presented with leg ulcers but ankle-brachial indices (ABPIs) were only recorded in 26% of clinic letters. Duplex scanning was recommended prior to surgery for 69% of patients and hand held Dopple...
Atherosclerotic plaques are complex tissues containing many different cell types. Macrophages con... more Atherosclerotic plaques are complex tissues containing many different cell types. Macrophages contribute to inflammation, formation of the necrotic core, and plaque rupture. We examined whether macrophages in plaque can be activated and compared this to monolayer cells. The volume of calcium in the plaque was compared to the level of macrophage activation measured by total neopterin output. Carotid plaque samples were cut into 3 mm sections and cultured for up to 96 h. Live sections were stimulated with interferon-γ, phytohaemagglutinin or phorbol 12-myristate 13-acetate. Macrophage activation and oxidative stress were monitored by total neopterin (oxidized and non-oxidized 7,8-dihydroneopterin) and neopterin levels every 24 h for up to 4 d. The calcium content of two plaques was investigated by spectral imaging. Direct stimulation of macrophages in plaque sections with interferon-γ caused a sustained increase in neopterin (p = .037) and total neopterin (p = .003). The addition of p...
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2017
Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihoo... more Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihood of increased mortality. The aim of this study was to investigate how SES and ethnicity impacted patient survival after abdominal aortic aneurysm (AAA) repair. Consecutive patients undergoing open and endovascular AAA repair during a 14.5 year period were identified. Ethnicity was defined as recorded on health records and SES (a score of 10, where 1 is least deprived and 10 being most deprived) and was linked to census data. Operative outcomes were reported at 30 days and a medium-term survival analysis used the Cox model to report adjusted hazard ratios (HR). A total of 6239 patients with a median age of 75 years and 78.7% males were included. The majority (5,654) were identified as New Zealand (NZ) Europeans, with 421 identified as NZ Maori, 97 identified as belonging to a Pacific ethnic group, and 67 identified as an Asian ethnic group. The median survival follow-up period was 5 year...
Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptoma... more Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patient...
Journal of medical imaging and radiation oncology, Jan 21, 2016
Computed tomography colonography (CTC) for the detection of colorectal disease is gaining popular... more Computed tomography colonography (CTC) for the detection of colorectal disease is gaining popularity as an alternative to colonoscopy. This has been associated with an increase in incidental extra-colonic findings such as abdominal aortic aneurysms. However, due to the patient selection process of obtaining a CTC, it was hypothesised that this patient cohort might represent a high-risk group. The primary aim of this study was to determine the impact that CTC had on small aneurysm referrals. Owing to the potential selection bias, the secondary aim was to compare baseline characteristics referred by CTC to the cohort referred by other radiological modalities. Consecutive patients attending the small aneurysm clinic at a single tertiary centre were included. Baseline patient comorbidities were collected and recorded on a prospective database. The characteristics of patients who had a CTC-detected aneurysm were compared to patients referred by other radiological modalities. There were 5...
The main determinants of survival following abdominal aortic aneurysm (AAA) repair are pre-existi... more The main determinants of survival following abdominal aortic aneurysm (AAA) repair are pre-existing risk factors rather than the method of repair chosen. The main aim of this meta-analysis was to assess the effect of modifiable risk factors on late survival following AAA repair. Electronic databases were searched to identify all relevant articles reporting the influence of modifiable risk factors on long-term survival (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 1 year) following elective open aneurysm repair and endovascular aneurysm repair. Twenty-four studies comprised of 53,118 patients published between 1989 and 2015 were included in the analysis. The use of statin, aspirin, beta-blockers and a higher hemoglobin level were all significant predictors of improved survival following repair with a hazard ratio (HR) 95% confidence interval (CI) of 0.75 (0.70-0.80), 0.81 (0.73-0.89), 0.75 (0.61-0.93) and 0.84 (0.74-0.96), respectively. Smoking history and uncorrected coronary disease were associated with a worse long-term survival, HRs (95%CI) were 1.27 (1.07-1.51) and 2.59 (1.14-5.88), respectively. Addressing cardiovascular risk factors in patients pre-operatively improves long-term survival following AAA repair. Global strategies to improve risk factor modifications in these patients are warranted to optimize long-term outcomes.
In New Zealand (NZ), there are two major sources of operative data for abdominal aortic aneurysm ... more In New Zealand (NZ), there are two major sources of operative data for abdominal aortic aneurysm (AAA) repair: the Australasian Vascular Audit (AVA) and the National Minimum Data Set (NMDS). Since the introduction of the AVA in NZ, there has not been any attempt at the validation of outcome data. The aims of this study were to report the outcomes of AAA repair and validate the AAA data captured by AVA using the NMDS. AAA procedures performed in NZ from January 2010 to December 2014 were extracted from the AVA and NMDS. Patients identified from the AVA had their survival status matched to the NMDS. Only primary AAA procedures were included for the analysis, with re-interventions and graft infections excluded. Demographical, risk factors and outcome data were used for validation. The number of patients undergoing primary AAA procedure from AVA and NMDS was 1713 and 2078, respectively. The AVA inpatient mortality for elective and rupture AAA was 1.6 and 32.2%, respectively. The NMDS 30...
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Papers by Justin Roake