Publications by authors named "Simon Richards"

29 Publications

  • Page 1 of 1

Transoesophageal echocardiography in cardiac arrest: A systematic review.

Resuscitation 2021 Aug 12. Epub 2021 Aug 12.

Teesside University, Middlesbrough, United Kingdom; Royal Victoria Infirmary, Newcastle upon Tyne, UK.

Aims: To identify, appraise and synthesize all available clinical evidence to evaluate the diagnostic role of transoesophageal echocardiography (TEE) during resuscitation of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) in the identification of reversible causes of cardiac arrest and cardiac contractility.

Methods: We conducted a systematic review following PRISMA guidelines. Medline, EMBASE, Web of Science Core Collection, Proquest Dissertations, Open Grey, CDSR, Cochrane Central, Cochrane Clinical Answers, and the clinicaltrials.gov registry were searched for eligible studies. Studies involving adult patients, with non-traumatic cardiac arrest in whom TEE was used for intra-arrest evaluation, were included. Case studies and case series, animal studies, reviews, guidelines and editorials were excluded. The QUADAS-2 tool was used for quality assessment of all studies.

Results: Eleven studies with a total of 358 patients were included. Four studies involved perioperative IHCA, three involved OHCA, and four were mixed population settings. Overall, the risk of bias in the selected studies was either high or unclear due to evidence or lack of information. In all 11 studies, TEE allowed the identification of reversible causes of arrest. We found significant heterogeneity in the criteria used to interpret findings, TEE protocol used, and timing of TEE.

Conclusion: Due to heterogeneity of studies, small sample size and inconsistent reference standard, the evidence for TEE in cardiac arrest resuscitation is of low certainty and is affected by a high risk of bias. Further studies are needed to better understand the true diagnostic accuracy of TEE in identifying reversible causes of arrest and cardiac contractility.
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http://dx.doi.org/10.1016/j.resuscitation.2021.08.001DOI Listing
August 2021

Delayed ileostomy closure increases the odds of Clostridium difficile infection.

Colorectal Dis 2021 Aug 5. Epub 2021 Aug 5.

Colorectal Surgical Unit, Department of Surgery, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia.

Aim: A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay.

Methods: A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables.

Results: Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03).

Conclusion: A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.
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http://dx.doi.org/10.1111/codi.15858DOI Listing
August 2021

Ixodes ricinus and Borrelia burgdorferi sensu lato in the Royal Parks of London, UK.

Exp Appl Acarol 2021 Jul 14;84(3):593-606. Epub 2021 Jun 14.

Medical Entomology & Zoonoses Ecology, Emergency Response Department Science & Technology, Public Health England, Porton Down, UK.

Assessing the risk of tick-borne disease in areas with high visitor numbers is important from a public health perspective. Evidence suggests that tick presence, density, infection prevalence and the density of infected ticks can vary between habitats within urban green space, suggesting that the risk of Lyme borreliosis transmission can also vary. This study assessed nymph density, Borrelia prevalence and the density of infected nymphs across a range of habitat types in nine parks in London which receive millions of visitors each year. Ixodes ricinus were found in only two of the nine locations sampled, and here they were found in all types of habitat surveyed. Established I. ricinus populations were identified in the two largest parks, both of which had resident free-roaming deer populations. Highest densities of nymphs (15.68 per 100 m) and infected nymphs (1.22 per 100 m) were associated with woodland and under canopy habitats in Richmond Park, but ticks infected with Borrelia were found across all habitat types surveyed. Nymphs infected with Borrelia (7.9%) were only reported from Richmond Park, where Borrelia burgdorferi sensu stricto and Borrelia afzelii were identified as the dominant genospecies. Areas with short grass appeared to be less suitable for ticks and maintaining short grass in high footfall areas could be a good strategy for reducing the risk of Lyme borreliosis transmission to humans in such settings. In areas where this would create conflict with existing practices which aim to improve and/or meet historic landscape, biodiversity and public access goals, promoting public health awareness of tick-borne disease risks could also be utilised.
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http://dx.doi.org/10.1007/s10493-021-00633-3DOI Listing
July 2021

Predicting pathological response to chemoradiotherapy for rectal cancer: a systematic review.

Expert Rev Anticancer Ther 2021 May 14;21(5):489-500. Epub 2021 Jan 14.

Department of Surgery, University of Otago, Christchurch, New Zealand.

: Pathological complete response (pCR) rates of approximately 20% following neoadjuvant long-course chemoradiotherapy for rectal cancer have given rise to non-operative or watch-and-wait (W&W) management. To improve outcomes there has been significant research into predictors of response. The goal is to optimize selection for W&W, avoid chemoradiotherapy in those who won't benefit and improve treatment to maximize the clinical complete response (cCR) rate and the number of patients who can be considered for W&W.: A systematic review of articles published 2008-2018 and indexed in PubMed, Embase or Medline was performed to identify predictors of pathological response (including pCR and recognized tumor regression grades) to fluoropyrimidine-based chemoradiotherapy in patients who underwent total mesorectal excision for rectal cancer. Evidence for clinical, biomarker and radiological predictors is discussed as well as potential future directions.: Our current ability to predict the response to chemoradiotherapy for rectal cancer is very limited. cCR of 40% has been achieved with total neoadjuvant therapy. If neoadjuvant treatment for rectal cancer continues to improve it is possible that the treatment for rectal cancer may eventually parallel that of anal squamous cell carcinoma, with surgery reserved for the minority of patients who don't respond to chemoradiotherapy.
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http://dx.doi.org/10.1080/14737140.2021.1868992DOI Listing
May 2021

Pre-operative frailty is predictive of adverse post-operative outcomes in colorectal cancer patients.

ANZ J Surg 2021 03 25;91(3):379-386. Epub 2020 Sep 25.

Department of Colorectal Surgery, University of Otago, Christchurch, New Zealand.

Background: An increasing number of elderly patients are presenting for elective surgery. Pre-operative risk assessment in this population is inexact due to the complex interplay between age, comorbidity and functional status. Frailty assessment may provide a surrogate measure of a patient's physiological reserve and aid operative decision-making. The aim of this study is to determine the association between pre-operative frailty, as assessed using the Edmonton Frail Scale, and post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery.

Methods: A prospective analysis of 86 patients over the age of 65 undergoing elective colorectal cancer surgery at a tertiary centre between October 2017 and October 2018 was performed. Frailty assessment was conducted pre-operatively using the Edmonton Frail Scale. Primary outcomes included length of stay and post-operative complication rates. Multivariable logistic regression analyses were used to determine the influence of frailty on post-operative outcomes including mortality, prolonged hospital admission, complication rates and quality of life.

Results: Of 86 patients, 12 (14.0%) were identified as frail. Frailty was associated with a significantly increased median length of stay (20 days versus 6 days, incidence rate ratio 2.83, P < 0.01) and a significantly increased risk of major post-operative complications (50.0% versus 6.7%, odds ratio 13.8, P < 0.01). Frailty was not associated with a significant reduction in quality of life scores at 30 and 90 days post-operatively.

Conclusion: Frailty is associated with adverse post-operative outcomes in elderly patients undergoing elective colorectal cancer surgery. Frailty assessment is an important component of pre-operative risk assessment and may identify targets for pre-operative optimisation.
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http://dx.doi.org/10.1111/ans.16319DOI Listing
March 2021

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

Lancet 2020 08;396(10248):390-401

Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK.

Background: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less.

Methods: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing.

Findings: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group).

Interpretation: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite.

Funding: National Institute for Health Research Health Technology Assessment Programme.
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http://dx.doi.org/10.1016/S0140-6736(20)30931-4DOI Listing
August 2020

The association between low pre-operative step count and adverse post-operative outcomes in older patients undergoing colorectal cancer surgery.

Perioper Med (Lond) 2020 2;9:20. Epub 2020 Jul 2.

Christchurch Public Hospital, University of Otago, Christchurch, New Zealand.

Background: Multiple tools exist estimating perioperative risk. With an ageing surgical demographic, frailty is becoming an increasingly important concept in perioperative medicine due to its association with adverse post-operative outcomes. Reduced physical activity is a hallmark of frailty, and we postulate that a low pre-operative step count may be an objective measure of frailty. This study aimed to determine the association between low pre-operative step count and post-operative outcomes in patients undergoing elective colorectal cancer surgery.

Methods: A prospective analysis of 85 older patients undergoing major elective colorectal surgery was performed at a tertiary centre between October 2017 and October 2018. Patients aged 65 years and over who met inclusion criteria were provided with an activity tracker to wear for 14 days prior to planned surgery. Their median daily step count was measured and a cut-off of < 2500 steps/day was used to define a reduced step count. Primary outcomes included length of stay and 30-day post-operative complication rate. Multivariable logistic regression analyses were used to analyze the influence of low pre-operative step count and other preoperative variables, on post-operative outcomes including mortality, prolonged hospital admission, and complication rates.

Results: Of 85 patients, 17 (20%) were identified as having a low pre-operative step count. A low pre-operative step count was associated with a significantly increased length of stay (14 vs. 6 days, IRR 2.09, 95% CI 1.55-2.83, ≤ 0.01) and rate of major post-operative complications (29.4% vs. 8.8%, OR 3.34, 95% CI 1.03-14.3, = 0.04). It was also associated with significantly increased rates of discharge to care facilities ( < 0.01) and requiring support on discharge ( = 0.03).

Conclusion: Low pre-operative step count (< 2500 steps/day) is predictive of an increased risk of post-operative morbidity in patients undergoing elective colorectal surgery. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of using a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an important avenue for future study.

Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12618000045213).
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http://dx.doi.org/10.1186/s13741-020-00150-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330986PMC
July 2020

Sarcopenia, as Assessed by Psoas Cross-Sectional Area, Is Predictive of Adverse Postoperative Outcomes in Patients Undergoing Colorectal Cancer Surgery.

Dis Colon Rectum 2020 06;63(6):807-815

Department of Surgery, University of Otago, Christchurch, New Zealand.

Background: Frailty and sarcopenia are important concepts in surgical practice because of their association with adverse postoperative outcomes. Radiologically assessed psoas muscle mass has been proposed as a surrogate for sarcopenia and may be predictive of poor postoperative outcomes.

Objective: This study aimed to determine the association between sarcopenia, as assessed by psoas cross-sectional area, and postoperative outcomes in patients undergoing colorectal cancer surgery.

Design: This was a retrospective review of patient records from 2014 to 2016.

Settings: This study was conducted at a single tertiary center.

Patients: Patients undergoing elective resection of colorectal cancer were included.

Main Outcome Measures: Sarcopenia was assessed using the total psoas index, calculated by measuring the cross-sectional area of the psoas muscle at the third lumbar vertebra and normalized for patient height. Preoperative and intraoperative variables, including the presence of preoperative sarcopenia, were evaluated as potential risk factors for adverse postoperative outcomes.

Results: Of 350 patients, 115 (32.9%) were identified as sarcopenic. Sarcopenia was associated with a significantly increased length of stay (13 days vs 7 days; OR, 1.31; 95% CI, 1.23-1.42; p < 0.01) and 1-year mortality (13.9% vs 0.9%; OR, 16.2; 95% CI, 4.34-83.4; p < 0.01). Sarcopenia was also associated with a significant increased risk of any complication (85.2% vs 34.5%; OR, 15.4; 95% CI, 8.39-29.7; p < 0.01) and of major complications (30.4% vs 8.9%; OR, 15.1; 95% CI, 7.16-33.2; p < 0.01).

Limitations: This study was limited by its retrospective design and by being conducted in a single institution. Although reduced muscle mass is suggestive of sarcopenia, it does not assess a patient's physical function or other components of the frailty phenotype.

Conclusion: Radiological sarcopenia is an important predictive risk factor for adverse postoperative outcomes in surgical patients. Computed tomography scans, which are routinely performed as part of staging, provide an opportunity to assess for sarcopenia preoperatively. See Video Abstract at http://links.lww.com/DCR/B201. LA SARCOPENIA, EVALUADA POR EL ÁREA TRANSVERSAL DE PSOAS, PREDICE RESULTADOS POSTOPERATORIOS ADVERSOS EN PACIENTES SOMETIDOS A CIRUGÍA DE CÁNCER COLORECTAL: La fragilidad y la sarcopenia son conceptos importantes en la práctica quirúrgica debido a su asociación con los resultados postoperatorios adversos. La masa muscular del psoas evaluada radiológicamente se ha propuesto como un sustituto de la sarcopenia y puede predecir resultados postoperatorios deficientes.Determinar la asociación entre la sarcopenia, según lo evaluado por el área transversal del psoas, y los resultados postoperatorios en pacientes sometidos a cirugía de cáncer colorrectal.Esta fue una revisión retrospectiva de los registros de pacientes de 2014 a 2016.Este estudio se llevo a cabo en un solo centro terciario.Se incluyeron pacientes sometidos a resección electiva de cáncer colorrectal.La sarcopenia se evaluó utilizando el índice de psoas total (TPI), calculado midiendo el área de la sección transversal del músculo psoas en la tercera vértebra lumbar y normalizado para la altura del paciente.Se evaluaron las variables preoperatorias e intraoperatorias, incluida la presencia de sarcopenia preoperatoria, como posibles factores de riesgo de resultados postoperatorios adversos.De 350 pacientes, 115 (32,9%) fueron identificados como sarcopénicos. La sarcopenia se asoció con un aumento significativo de la duración de la estancia (13 días frente a 7 días, OR 1.31, IC 95% 1.23-1.42, p < 0.01) y de la mortalidad al año (13.9% vs 0.9%, OR 16.2, IC 95% 4.34-83.4, p < 0.01). La sarcopenia también se asoció con un aumento significativo del riesgo de cualquier complicación (85.2% vs 34.5%, OR 15.4, IC 95% 8.39-29.7, p < 0.01) y de complicaciones mayores (30.4% vs 8.9%, OR 15.1 IC 95% 7.16-33,2, p < 0,01).Este estudio estuvo limitado por su diseño retrospectivo y por el hecho de que se realizó en una sola institución. Aunque la reducción de la masa muscular es un indicio de sarcopenia, no evalúa la función física del paciente ni otros componentes del fenotipo de fragilidad.La sarcopenia radiológica es un importante factor de riesgo predictivo para resultados postoperatorios adversos en pacientes quirúrgicos. Las tomografías computarizadas, que se realizan rutinariamente como parte de la estadificación, brindan la oportunidad de evaluar la sarcopenia antes de la operación. Consulte Video Resumen en http://links.lww.com/DCR/B201. (Traducción-Dr. Gonzalo Hagerman).
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http://dx.doi.org/10.1097/DCR.0000000000001633DOI Listing
June 2020

Primary umbilical endometriosis.

N Z Med J 2019 08 16;132(1500):95-99. Epub 2019 Aug 16.

Pathology Registrar, Christchurch Hospital, Christchurch.

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August 2019

Prevalence of frailty in a tertiary hospital: A point prevalence observational study.

PLoS One 2019 1;14(7):e0219083. Epub 2019 Jul 1.

Department of Surgery, University of Otago, Christchurch, New Zealand.

Introduction: Frailty is an important concept in modern healthcare due to its association with adverse outcomes. Its prevalence varies in the literature and there is a paucity of literature looking at the prevalence of frailty in an inpatient setting. Its significance lies on its impact on resource utilisation and costs.

Aim: To determine the prevalence of frailty in the adult population in a tertiary New Zealand hospital.

Methods: Eligible patients aged 18 years and over were invited to participate, and frailty assessment was performed using the Reported Edmonton Frail Scale. A score of 8 or more was considered frail. Factors associated with frailty were assessed.

Results: Of 640 occupied inpatient beds, 420 patients were assessed. 220 patients were excluded, of which 89 were absent from their bed-space, 73 declined and 41 were critically unwell. The overall prevalence of frailty across assessed patients was 48.8%. The prevalence of frailty increased significantly with age; patients aged 85 and over were significantly more likely to be frail compared to those aged under 65 (OR 6.25, 95% CI 3.17-12.7). Maori patients were significantly more likely to be frail (OR 4.0, 95% CI 1.45-11.9). When compared to those patients admitted to a medical specialty, patients admitted to surgical specialty were less likely to be frail (OR 0.52 95% CI 0.31-0.86) and those admitted for rehabilitation were more likely to be frail (OR 1.86 95% CI 1.03-3.41). Frail patients were more likely to come from a rest home (OR 2.81, 95% CI 1.38-6.14) or hospital level care (OR 9.62, 95% CI 2.68-61.6).

Conclusion: Frailty is highly prevalent in the hospital setting with 48.8% of all inpatients classified as frail. This high number of frail patients has significant resource implications and an increased understanding of the burden of frailty in this population may aid targeting of interventions towards this vulnerable population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219083PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602419PMC
March 2020

Unplanned readmissions in frail individuals.

N Z Med J 2018 10 26;131(1484):7-9. Epub 2018 Oct 26.

General Surgery Consultant, Department of General Surgery, Christchurch Public Hospital, Christchurch.

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October 2018

Frailty in surgical patients.

Int J Colorectal Dis 2018 Dec 14;33(12):1657-1666. Epub 2018 Sep 14.

University of Otago, Christchurch, New Zealand.

Objective: To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.

Background: Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.

Methods: Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.

Results: Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.

Conclusion: Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.
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http://dx.doi.org/10.1007/s00384-018-3163-yDOI Listing
December 2018

Acute appendicitis in an incarcerated femoral hernia.

N Z Med J 2018 06 8;131(1476):85-87. Epub 2018 Jun 8.

General Surgical Registrar, Christchurch Hospital, Christchurch.

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June 2018

Enteric duplication cyst as a cause for small bowel obstruction in adulthood.

N Z Med J 2018 05 4;131(1474):74-76. Epub 2018 May 4.

General Surgery Consultant, Department of General Surgery, Christchurch Public Hospital, Christchurch.

We report a case of a patient presenting with small bowel obstruction secondary to an enteric ileal duplication cyst. Although common in infancy, they are rarely seen in adults. Radiologically they may be difficult to distinguish from a Meckel diverticulum and often the diagnosis is made retrospectively. Optimal management of the asymptomatic adult is unclear.
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May 2018

Outcomes of endoscopic retrograde cholangiopancreatography: a series from a provincial New Zealand hospital.

ANZ J Surg 2018 Mar 6;88(3):207-211. Epub 2016 Sep 6.

Department of General Surgery, Taranaki Base Hospital, New Plymouth, New Zealand.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential tool in the management of pancreaticobiliary pathology. It is technically demanding and has the potential to cause significant morbidity and mortality. Several trials have identified small centres and lower hospital volume as risk factors for lower success rates and higher complication rates. Taranaki Base Hospital (TBH) is a provincial hospital with a catchment of 100 000, providing its population with an on-site ERCP service. Transporting patients to the nearest tertiary centre would incur significant costs to both the patient and district health board.

Aims: To determine the outcomes of performing ERCP at TBH and compare these with published figures. To determine if it is a safe and effective option for patients in this region.

Methods: An ambi-directional study of all ERCP procedures at TBH between January 2011 and December 2015 was conducted. Patient demographics, procedure indication and procedural details were captured via ProVation MD and endoscopist's notes. Complications were identified through patient's notes and recorded if occurring within 30 days of the procedure. All complications were graded mild, moderate or severe based on a grading system described by Cotton et al.

Results: A total of 445 procedures were performed. Bile duct cannulation rate was 92.3% and therapeutic success rate was 89.9%. Complications occurred in 8.99% of patients and ERCP-specific mortality was 0.22%. Haemorrhage occurred in 1.35% of patients, pancreatitis in 5.2% and perforation in 0.45%. Success and complication rates are similar to other published studies.

Conclusion: ERCP can be safely and successfully performed in a provincial centre.
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http://dx.doi.org/10.1111/ans.13734DOI Listing
March 2018

Adult idiopathic hypertrophic pyloric stenosis.

N Z Med J 2016 Jul 1;129(1437):77-9. Epub 2016 Jul 1.

Department of General Surgery, Taranaki Base Hospital, David Street, New Plymouth, New Zealand.

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July 2016

Delirium in critically ill military patients following trauma: A cohort analysis.

J Intensive Care Soc 2016 Feb 1;17(1):12-18. Epub 2015 Oct 1.

Anaesthetics and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, UK.

Critically ill military trauma patients have been found to have a high incidence of psychological morbidity following their Intensive Care Unit (ICU) experience, including recall of significant auditory and visual hallucinations. It follows that this may be attributable to delirium, which has not been previously described in a young, previously fit population following trauma. The case-notes of 85 male patients (mean age 26 years), admitted to a single UK ICU following military trauma, were retrospectively assessed for delirium using DSM-IV criteria. Of the 993 ICU days assessed, 13.4% were delirium-positive, with just over half of patients (51.8%) experiencing at least one day of delirium. On delirium-positive days, 69.2% received a documented intervention, with the majority of interventions (66.4%) being pharmacological, commonly with a sedative or anti-psychotic. Presence of delirium was significantly associated with severity of injury, assessed by Injury Severity Score (OR 1.037, 95% CI 1.003-1.072,  = 0.031). Duration of ICU stay was significantly increased, from 4 to 8 days ( < 0.005), as was the duration of mechanical ventilation (for the 84.7% of patients who were ventilated) from 7 to 13 days ( < 0.005). Delirium is common in military trauma patients, despite their young age and premorbid fitness. A review of longer-term psychological outcomes should be considered.
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http://dx.doi.org/10.1177/1751143715605850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606384PMC
February 2016

A systematic review of ultrasound-guided and non-ultrasound-guided therapeutic injections to treat Morton's neuroma.

J Am Podiatr Med Assoc 2014 Jul;104(4):337-48

Background: Morton's neuroma is a frequently painful condition of the forefoot, causing patients to seek medical care to alleviate symptoms. A plethora of therapeutic options is available, some of which include injection therapies. Researchers have investigated injection therapy for Morton's neuroma, and latterly the evidence base has been augmented with methods that use diagnostic ultrasound as a vehicle to deliver the injectate under image guidance for additional accuracy. To date, there seems to be no consensus that ultrasound-guided injections provide better therapeutic outcomes than nonguided injections for the treatment of Morton's neuroma.

Methods: A systematic review was chosen because this method can undertake such a process. The review process identified 13 key papers using predetermined inclusion and exclusion criteria, which then underwent methodological quality assessment using a pretested Quality Index. A narrative synthesis of the review findings is presented in light of the heterogeneity of the data from the extraction process.

Results: This systematic review provides an argument that ultrasound guidance can produce better short- and long-term pain relief for corticosteroid injections, can reduce the need for additional procedures in a series of sclerosing alcohol injections, can reduce the surgical referral rate, and can add efficacy to a single injection.

Conclusions: Ultrasound guidance should be considered for injection therapy in the management of Morton's neuroma.
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http://dx.doi.org/10.7547/0003-0538-104.4.337DOI Listing
July 2014

A Systematic Review of Ultrasound-Guided and Non Ultrasound-Guided Therapeutic Injections to treat Morton's neuroma.

J Am Podiatr Med Assoc 2014 Jun 24. Epub 2014 Jun 24.

a South Tyneside Foundation Trust, Biomechanics Department.

Abstract BACKGROUND:Morton's neuroma is a frequently painful condition of the forefoot, causing sufferers to seek medical care to alleviate symptoms. A plethora of therapeutic options are available, some of which include injection therapies. Researchers have investigated injection therapy for Morton's neuroma, and latterly the evidence base has been augmented with methodologies which utilise diagnostic ultrasound (US) as a vehicle to deliver the injectate under image guidance for additional accuracy. There appears to date to be no consensus that US-guided injections provide better therapeutic outcomes than non US-guided (blind) injections for treatment of Morton's neuroma. METHODS:A systematic review was chosen, as this methodology can undertake such a process. The review process identified 13 key papers using pre-determined inclusion and exclusion criteria, which then underwent methodological quality assessment using a pre-tested Quality Index. A narrative synthesis of the review findings was presented in light of the heterogeneity of the data from the extraction process. RESULTS:This systematic review provides an argument that ultrasound-guidance can produce better short- and long-term pain relief for corticosteroid injections, can reduce the need for additional procedures in a series of sclerosing alcohol injections, can reduce the surgical referral rate, and adds efficacy to a single injection.

Conclusions: Ultrasound guidance should be considered for injection therapy in the management of Morton's neuroma.
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http://dx.doi.org/10.7547/12-124.1DOI Listing
June 2014

Discovery of a potent, dual serotonin and norepinephrine reuptake inhibitor.

ACS Med Chem Lett 2013 Jun 7;4(6):560-4. Epub 2013 May 7.

Lilly Research Laboratories, Eli Lilly and Company , Lilly Corporate Center, Indianapolis, Indiana 46285, United States.

The objective of the described research effort was to identify a novel serotonin and norepinephrine reuptake inhibitor (SNRI) with improved norepinephrine transporter activity and acceptable metabolic stability and exhibiting minimal drug-drug interaction. We describe herein the discovery of a series of 3-substituted pyrrolidines, exemplified by compound 1. Compound 1 is a selective SNRI in vitro and in vivo, has favorable ADME properties, and retains inhibitory activity in the formalin model of pain behavior. Compound 1 thus represents a potential new probe to explore utility of SNRIs in central nervous system disorders, including chronic pain conditions.
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http://dx.doi.org/10.1021/ml400049pDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4027471PMC
June 2013

Distal humerus cortical strains following total elbow arthroplasty.

Proc Inst Mech Eng H 2013 Feb;227(2):120-8

Department of Engineering, Cardiff University, Epsom, UK.

The aseptic loosening of total elbow replacements is a serious complication resulting in significant patient morbidity. It is thought to occur secondary to stress shielding of the distal humeral cortex by the stiff stem of the implant. Some total elbow prostheses incorporate an anterior flange intended to improve implant stability and peri-articular load transfer in an attempt to reduce this effect However, few studies have directly assessed the changes in cortical strains following total elbow arthroplasty or the biomechanical advantage of the anterior flange design. A regular and a long flange Coonrad-Morrey total elbow prosthesis were implanted into six Sawbone synthetic humeri. The constructs were subjected to physiological loads in axial compression (500 N), antero-posterior bending (50 N) and antero-posterior compression with condylar supports (300 N). Digital image correlation was used to measure the distal antero-lateral cortical strains and the results compared with those of whole Sawbones that had been tested in the same way. Significant stress shielding was demonstrated over the distal humeral cortex following prosthesis implantation during axial compression. In contrast, cortical strains increased following prosthesis implantation during antero-posterior compression with condylar supports. The increase in cortical strains following total elbow arthroplasty may help to maintain the integrity of the anterior cortex offering additional stability for implants with an anterior flange. These results are important for the development of future total elbow prosthesis designs and indicate that simulating the action of the forearm muscles is essential when evaluating changes in strain about the distal humerus in vitro.
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http://dx.doi.org/10.1177/0954411912463321DOI Listing
February 2013

Benign palmar schwannoma - a rare case in a handball player.

BMJ Case Rep 2012 Jun 14;2012. Epub 2012 Jun 14.

Orthopaedics Department, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK.

Peripheral nerve sheath tumours (PNSTs) of the hand are rare. Schwannomas, also known as neurilemmomas, are the commonest benign PNSTs. They arise from a proliferation of Schwann cells. Aetiology is unclear. In this report, the authors present the case of a lifelong Rugby Fives (a handball variant) player who developed a symptomatic benign schwannoma at the impact point on his palm. To our knowledge, there are no documented cases of upper limb schwannomas which may be related to repetitive trauma from sport.
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http://dx.doi.org/10.1136/bcr.01.2012.5532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387442PMC
June 2012

Does a single application of PRP alter the expression of IGF-I in the early phase of tendon healing?

J Foot Ankle Surg 2011 May-Jun;50(3):276-82. Epub 2011 Mar 25.

Trauma Fellow, Poole NHS Hospital, Poole, United Kingdom.

The purpose of this study was to determine whether or not a single application of platelet-rich plasma (PRP) in a ruptured tendon alters the expression of IGF-I in the early phase of healing in an animal wound model. We performed an Achilles tendon rupture model on 48 New Zealand white rabbits, by transecting the tendon transversely and then injecting 0.5 mL of PRP into the tendon mass on one side, and injecting saline on the contralateral, control side. Twenty-four animals received PRP (PRP group), and 24 animals served as untreated controls (control group). Six animals (12 limbs) were killed from each group at 1, 2, 3, and 4 weeks postoperatively. After the animals were killed, 6 paraffin sections were made from each Achilles tendon, 3 of which were stained with hematoxylin and eosin and subjected to microscopic examination, and 3 of which were immunostained with an anti-IGF-I primary antibody. Density of brown diaminobenzidine (DAB) staining was evaluated to quantitatively analyze the results. IGF-I was expressed intracellularly in various cell types throughout the entire healing phase. The growth factor was localized in the epitenon and the endotenon, with an overexpression in the epitenon in the PRP group by the fourth week in comparison with the controls. Furthermore, the tendons treated with PRP healed more rapidly. Based on these findings, PRP could be useful to surgeons treating ruptured tendon.
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http://dx.doi.org/10.1053/j.jfas.2011.02.010DOI Listing
January 2012

Iliopsoas tendonitis a complication after total hip arthroplasty.

J Arthroplasty 2007 Feb;22(2):166-70

Sydney Hip and Knee Surgeons, New South Wales, Australia.

The causes of pain after total hip arthroplasty are multiple. We present a series of 15 patients (16 cases) who presented with pain related to the iliopsoas tendon. All patients had previously undergone cementless hip arthroplasty and presented with similar symptoms and clinical signs. Surgery was carried out after failure of conservative measures. Release of the iliopsoas tendon from the lesser trochanter gave good symptomatic relief in all except one patient who required reposition of acetabular prosthesis, with the average Harris Hip Score improving from 58 (range, 44-70) to 91 (range, 78-95) postoperatively. This relatively uncommon condition should be considered in the differential diagnosis of all patients who present with groin pain after total hip arthroplasty. Surgical release of the iliopsoas tendon can give excellent results in these patients.
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http://dx.doi.org/10.1016/j.arth.2006.05.034DOI Listing
February 2007

The role of the liver in lipid metabolism during cold acclimation in non-hibernator rodents.

Comp Biochem Physiol B Biochem Mol Biol 2006 Jul 6;144(3):372-81. Epub 2006 Apr 6.

Department of Physiology, Division of Medical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.

Cold exposure increases the demand for energy substrates. Cold acclimation of rats led to a 3-fold increase in fatty acid (FA) beta-oxidation (P<0.01) for ex vivo livers perfused at 37 degrees C. This increase was preserved following perfusion at 25 degrees C (P<0.001). In vitro measurement of absolute rates of hepatic beta-oxidation revealed no significant difference following cold acclimation, implying changes in fatty acid flux through beta-oxidation rather than increased oxidation capacity. Total FA uptake was increased one-third following perfusion at 25 degrees C (P<0.001) and cold acclimation (P<0.05) and cold acclimation led to diversion of tissue FA from storage to beta-oxidation (P<0.01). In separate experiments, in vivo hepatic lipogenesis rates for saponifiable lipids doubled (P<0.01) and cholesterol synthesis increased one-third (P<0.001). Taken together these data suggest the oxidation and synthesis of lipids occur simultaneously in hepatic tissue possibly to increase prevailing tissue FA concentrations and to generate heat through increased metabolic flux rates.
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http://dx.doi.org/10.1016/j.cbpb.2006.03.013DOI Listing
July 2006

The effects of injection of bovine vaccine into a human digit: a case report.

Environ Health 2005 Oct 11;4:21. Epub 2005 Oct 11.

Orthopaedic Department, Princess Royal Hospital, Lewes Road, Haywards Heath, West Sussex RH16 4EX, UK.

Background: The incidence of needlestick injuries in farmers and veterinary surgeons is significant and the consequences of such an injection can be serious.

Case Presentation: We report accidental injection of bovine vaccine into the base of the little finger. This resulted in increased pressure in the flexor sheath causing signs and symptoms of ischemia. Amputation of the digit was required despite repeated surgical debridement and decompression.

Conclusion: There have been previous reports of injection of oil-based vaccines into the human hand resulting in granulomatous inflammation or sterile abscess and causing morbidity and tissue loss. Self-injection with veterinary vaccines is an occupational hazard for farmers and veterinary surgeons. Injection of vaccine into a closed compartment such as the human finger can have serious sequelae including loss of the injected digit. These injuries are not to be underestimated. Early debridement and irrigation of the injected area with decompression is likely to give the best outcome. Frequent review is necessary after the first procedure because repeat operations may be required.
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http://dx.doi.org/10.1186/1476-069X-4-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1262740PMC
October 2005

Step-wise dis-assembly of trimesic acid: mono- and bis(methanol) solvates.

Chem Commun (Camb) 2004 Jun 10(11):1278-9. Epub 2004 May 10.

Chemistry Department, Loughborough University, Loughborough LE11 3TU, UK.

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http://dx.doi.org/10.1039/b402922dDOI Listing
June 2004

Sound absorption by suspensions of nonspherical particles: measurements compared with predictions using various particle sizing techniques.

J Acoust Soc Am 2003 Oct;114(4 Pt 1):1841-50

Marine & Acoustics Centre, QinetiQ, Winfrith Technology Centre, Dorchester Dorset DT2 8XJ, United Kingdom.

Knowledge of the particle size distribution is required in order to predict ultrasonic absorption in polydisperse particulate suspensions. This paper shows that the method used to measure the particle size distribution can lead to important differences in the predicted absorption. A reverberation technique developed for measuring ultrasonic absorption by suspended particles is used to measure the absorption in suspensions of nonspherical particles. Two types of particulates are studied: (i) kaolin (china clay) particles which are platelike in form; and (ii) calcium carbonate particles which are more granular. Results are compared to theoretical predictions of visco-inertial absorption by suspensions of spherical particles. The particle size distributions, which are required for these predictions, are measured by laser diffraction, gravitational sedimentation and centrifugal sedimentation, all of which assume spherical particles. For a given sample, each sizing technique yields a different size distribution, leading to differences in the predicted absorption. The particle size distributions obtained by gravitational and centrifugal sedimentation are reinterpreted to yield a representative size distribution of oblate spheroids, and predictions for absorption by these spheroids are compared with the measurements. Good agreement between theory and measurement for the flat kaolin particles is obtained, demonstrating that these particles can be adequately represented by oblate spheroids.
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http://dx.doi.org/10.1121/1.1610449DOI Listing
October 2003

The impact of self-retaining retractors on the paraspinal muscles during posterior spinal surgery.

Spine (Phila Pa 1976) 2002 Dec;27(24):2758-62

Department of Musculoskeletal Surgery, Faculty of Medicine, Imperial College of Science, Technology & Medicine, Charing Cross Hospital, London, United Kingdom.

Study Design: This was a prospective pilot study examining pre-, intra- and postoperative measures.

Objectives: The aim of the study was to investigate the effect of muscle retractors on the posterior spinal muscles during posterior spinal surgery.

Summary Of Background Data: Previous studies have identified changes in the structure and function of the back extensor mechanism as a result of low back pain. However, the effect of surgery on the functioning of these muscles, particularly surgical retraction, has received less attention.

Methods: Twenty patients undergoing posterior spinal surgery were recruited into this study, and recordings of intramuscular pressure during surgery were performed using a pressure-monitoring system before insertion of retractors, 5, 30, and 60 minutes into surgery, and on removal of retractors. Before and following use of the retractors, muscle biopsies were taken from the multifidus muscle for analysis using birefringence techniques.

Results: A significant increase in intramuscular pressure (P < 0.001) was observed during surgery. On removal of retractors, this pressure returned to or near to the original value. Analysis of muscle biopsies using calcium activated adenosine triphosphatase birefringence revealed a reduction in muscle function following prolonged use of self-retaining retractors.

Conclusions: A substantial rise in pressure in the erector spinae muscle during posterior spinal surgery was observed, and this appeared to be associated with marked changes in the function of the muscles. This could be an important factor in the generation of operative scar tissue and postoperative dysfunction of the spinal muscles.
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http://dx.doi.org/10.1097/00007632-200212150-00004DOI Listing
December 2002
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