Publications by authors named "Sohaib Virk"

42 Publications

Systematic review and meta-analysis of cervical metastases in oral maxillary squamous cell carcinoma.

Cancer Rep (Hoboken) 2021 May 8:e1410. Epub 2021 May 8.

University of Sydney, Camperdown, New South Wales, Australia.

Background: Management of the node-negative neck in oral maxillary squamous cell carcinoma (SCC), encompassing the hard palate and upper alveolar subsites of the oral cavity, is controversial, with no clear international consensus or recommendation regarding elective neck dissection in the absence of cervical metastases.

Aim: To assess the occult metastatic rate in patients with clinically node negative oral maxillary SCC; both as an overall metastatic rate, and a comparison of patients managed with an elective neck dissection at index surgery, compared to excision of the primary with clinical observation of the neck.

Methods And Results: A systematic review was performed by two independent investigators for studies relating to oral maxillary SCC and analysed according to PRISMA criteria. Data were extracted from Pubmed, Ovid MEDLINE, EMBASE, and SCOPUS via relevant MeSH terms. Grey literature was searched through Google Scholar and OpenGrey. Five hundred and fifty-three articles were identified on the initial search, 483 unique articles underwent screening against eligibility criteria, and 29 studies were identified for final data extraction. Incidence of occult metastases in patients with clinically node negative oral maxillary SCC was identified either on primary elective neck dissection or on routine follow up. Meta-analyses were performed. Of 553 relevant articles identified on initial search, 29 were included for analysis. The pooled overall rate of occult metastases in patients initially presenting with clinically node-negative disease was 22.2%. There is a statistically significant effect of END on decreasing regional recurrence demonstrated in this study (RR 0.36, 95% CI 0.24, 0.59).

Conclusion: The results of this systematic review and meta-analysis suggest elective neck dissection for patients presenting with hard palate or upper alveolar SCC, even in a clinically node negative neck.
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http://dx.doi.org/10.1002/cnr2.1410DOI Listing
May 2021

Electrophysiologic and electroanatomic characterization of ventricular arrhythmias in non-compaction cardiomyopathy: A systematic review.

J Cardiovasc Electrophysiol 2021 May 12;32(5):1421-1429. Epub 2021 Apr 12.

Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.

Background: Non-compaction cardiomyopathy (NCCM) is a form of structural heart disease prone to ventricular arrhythmias (VAs) and sudden cardiac death. Non-compacted myocardium may harbor VA substrate, though some reports suggest otherwise.

Objective: This study aimed to characterize the electrophysiologic (EP) features of VA in NCCM.

Methods: We performed a systematic review of case reports, case series, and observational studies.

Results: One hundred and thirty-five cases of NCCM from studies between 2000 and 2020 were included. Mean age was 34 ± 20 years, mean left ventricular (LV) ejection fraction was 42 ± 15% with two cases having late gadolinium enhancement on magnetic resonance imaging. The LV apex was the most common non-compacted segment (86%); 10% involved the right ventricle (RV). Antiarrhythmic failure was documented in 16 cases, of which 50% failed more than one agent. Only 23% of monomorphic VAs localized to regions of non-compaction on electrocardiogram. Most frequently, VAs localized to the RV outflow tract (n = 21), posterior fascicle (n = 19), and anterolateral LV apex (n = 9). All cases with apical exits arose from the non-compacted myocardium. On EPS, 83% of sustained VTs were due to re-entry, 17% due to focal mechanism. Catheter ablation was performed in 39 cases, with 7 requiring more than 1 procedure. Acute VA non-inducibility was achieved in 82% and VA-free survival was reported in 85% over a mean follow-up of 24 months.

Conclusion: The majority of VAs in NCCM arise remotely from non-compacted myocardium, and non-re-entrant mechanism seen in ~1/5th of sustained VTs. Catheter ablation outcomes appear favorable. Further study is needed to understand the pathophysiology of VA in NCCM.
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http://dx.doi.org/10.1111/jce.15026DOI Listing
May 2021

Renal Denervation for the Management of Refractory Ventricular Arrhythmias: A Systematic Review.

JACC Clin Electrophysiol 2021 01 30;7(1):100-108. Epub 2020 Sep 30.

Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia. Electronic address:

Objectives: The authors performed a systematic review and meta-analysis to determine the efficacy of renal denervation (RDN) in patients with refractory ventricular arrhythmias (VA) or electrical storm (ES).

Background: Although catheter ablation is efficacious for the treatment of structural heart disease ventricular tachycardia (VT), there are proportion of patients who have refractory VT despite multiple procedures. In this setting, novel adjunctive therapies such as renal denervation have been performed.

Methods: A systematic review of published data was performed. Studies that evaluated patients undergoing RDN for VA or ES were included. Outcome measures of VA, sudden cardiac death, ES, or device therapy were required. Case reports, editorials, and conference presentations were excluded. Random effects meta-analysis was conducted to explore change or final mean values in the study outcomes.

Results: A total of 328 articles were identified by the literature search. Seven studies met the eligibility criteria and were included in the systematic review, with a total of 121 pooled patients. The weighted mean age was 63.8 ± 13.1 years, ejection fraction 30.5 ± 10.3%, 76% were men, 99% were on a beta blocker, 79% were on amiodarone, 46% had previously undergone catheter ablation, and 8.3% had previously undergone cardiac sympathetic denervation. Meta-analysis demonstrated a significant effect of RDN in reducing implantable cardiac defibrillator therapies, with a standardized mean difference (SMD) of -3.11 (p < 0.001). RDN also reduced the number of VA episodes (SMD -2.13; p < 0.001), antitachycardia pacing episodes (SMD -2.82; p = 0.002), and shocks (SMD -2.82; p = 0.002).

Conclusions: RDN is an effective treatment for refractory VAs and ES, although randomized data are lacking.
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http://dx.doi.org/10.1016/j.jacep.2020.07.019DOI Listing
January 2021

Prognostic impact of atrial fibrillation in hypertrophic cardiomyopathy: a systematic review.

Clin Res Cardiol 2021 Apr 3;110(4):544-554. Epub 2020 Sep 3.

Department of Cardiology, Westmead Hospital, Corner Hawkesbury and Darcy Roads, Westmead, Sydney, NSW, 2145, Australia.

Background: Atrial fibrillation (AF) is an important arrhythmia in hypertrophic cardiomyopathy (HCM).

Objectives: To conduct a systematic review of published literature to: (a) assess the incidence of AF in HCM and (b) examine the impact of AF on risk of thromboembolism, heart failure, sudden death and mortality in HCM.

Methods: Search of all major databases (Pubmed, MEDLINE, Embase, Cochrane, Scopus, Web of Science) was performed to April 2020 using the search terms "atrial fibrillation" AND/OR "hypertrophic cardiomyopathy" in the title or abstract. 51 of the 1,565 citations met the inclusion criteria.

Results: Using random-effects modelling, the estimated pooled prevalence of AF amongst 21,887 HCM patients (36 studies) was 22.3% (95%, 19.9-24.8) and the pooled incidence of AF was 2.5 cases per person-years (95% CI 1.9-3.0). 15,444 patients from 28 studies were included in analysis of outcome data (mean age was 49.9 years; 32.7% female; mean LVEF 69%). Over a median follow up duration of 6.9 years (range 2.8-11.7 years), AF, compared to sinus rhythm (SR), was associated with significantly increased risk of thromboembolism [relative risk (RR) 7.0; 95% CI 4.6-10.7; I = 57%], heart failure (RR 2.8; 95% CI 1.6-4.6; I = 82%), sudden death (RR 1.7; 95% CI 1.3-2.3; I = 0%), and all-cause mortality (RR 2.5; 95% CI 1.8-3.4; I = 69%).

Conclusions: AF is highly prevalent in patients with HCM. The presence of AF is associated with major adverse clinical outcomes. These findings suggest that both, aggressive screening and treatment of AF, are likely to have major prognostic impact on outcomes in HCM. Incidence, prevalence and prognostic impact of AF in HCM. In this systematic review, AF incidence was 2.5 cases per-person years, prevalence was 22.3%. AF in HCM was associated with a seven-fold increased risk of thromboembolism, 2.8-fold increased risk of heart failure, 1.7-fold increased risk of sudden death and 2.5-fold increased risk of all-cause mortality.
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http://dx.doi.org/10.1007/s00392-020-01730-wDOI Listing
April 2021

The quandary of study design in evaluating effectiveness of contact force sensing catheter in atrial fibrillation ablation: Authors' reply.

Europace 2020 05;22(5):840

Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.

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http://dx.doi.org/10.1093/europace/euaa022DOI Listing
May 2020

Remote Magnetic Versus Manual Catheter Navigation for Atrial Fibrillation Ablation: A Meta-Analysis.

Circ Arrhythm Electrophysiol 2019 10 14;12(10):e007517. Epub 2019 Oct 14.

Department of Cardiology, Westmead Hospital, Sydney, Australia (S.A.V., S.K.).

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http://dx.doi.org/10.1161/CIRCEP.119.007517DOI Listing
October 2019

Contact Force and Ablation Index.

Card Electrophysiol Clin 2019 09;11(3):473-479

Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, Australia. Electronic address:

Radiofrequency ablation of arrhythmias depends on durable lesion formation. Catheter tip-tissue contact force (CF) is a key determinant of lesion quality; excessive CF is associated with major complications, whereas insufficient CF increases the risk of electrical reconnection and arrhythmia recurrence. In recent years, CF-sensing catheters have emerged with the ability to directly measure CF and provide operators with real-time feedback. CF-guided ablation has been associated with improved outcomes in observational studies. However, randomized controlled trials have not shown any reduction in procedural durations, fluoroscopy exposure, incidence of major complications, or long-term arrhythmia recurrence with use of CF-sensing catheters.
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http://dx.doi.org/10.1016/j.ccep.2019.05.007DOI Listing
September 2019

Catheter ablation versus medical therapy for treatment of ventricular tachycardia associated with structural heart disease: Systematic review and meta-analysis of randomized controlled trials and comparison with observational studies.

Heart Rhythm 2019 10 29;16(10):1484-1491. Epub 2019 May 29.

Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia. Electronic address:

Background: Catheter ablation (CA) is an established therapeutic modality for ventricular tachycardia (VT).

Objective: We compared the clinical outcomes of CA for VT vs medical therapy from all previously performed randomized controlled trials (RCTs) and compared these to contemporary observational studies.

Methods: A comprehensive database search through to August 2018 identified 8 eligible studies enrolling 797 patients.

Results: In RCTs, VT recurrence and electrical VT storm were significantly reduced in the CA group vs medical therapy group (relative risk [RR] 0.78, 95% confidence interval [CI] 0.64-0.95, P = .01; RR 0.70, 95% CI 0.51-0.94, P = .02, respectively) at a mean follow-up of 22 months. All-cause or cardiac-specific mortality did not differ significantly (RR 0.92, 95% CI 0.67-1.27, P = .62; RR 0.82, 95% CI 0.54-1.26, P = .37, respectively). In 4 observational studies, including 3065 patients with a mean follow-up of 18.2 months, VT recurrence and mortality were significantly lower as compared to the RCTs (28.6% vs 39%, P < .001; 13.2% vs 18%, P = .01, respectively) despite greater incidence of electrical storm (33.2% vs 17%, P < .001), higher prevalence of nonischemic substrate (46.4% vs 3.6%, P < .001), and lower rate of implanted ICDs (68% vs 94.7%, P < .001).

Conclusion: Meta-analysis of RCT data shows that CA is superior to medical therapy for predominantly postinfarct, scar-related VT in terms of VT recurrence and electrical VT storm, with no reduction in mortality. Real-world observational studies also demonstrate significant reduction in VT recurrence and mortality, despite a sicker cohort, demonstrating replicability and translation of RCT data in the real world.
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http://dx.doi.org/10.1016/j.hrthm.2019.05.026DOI Listing
October 2019

Catheter Ablation of Ventricular Tachycardia in Patients With a Ventricular Assist Device: A Systematic Review of Procedural Characteristics and Outcomes.

JACC Clin Electrophysiol 2019 01 26;5(1):39-51. Epub 2018 Sep 26.

Department of Cardiology, Westmead Hospital, Westmead, Australia; Department of Cardiology, Westmead Applied Research Centre, University of Sydney, Westmead, Australia. Electronic address:

Objectives: This is a systematic review summarizing the procedural characteristics and outcomes of ventricular assist device (VAD)-related ventricular tachycardia (VT) ablation.

Background: Drug-refractory VT refractory commonly develops post-VAD implantation. Procedural and outcome data come from small series or case reports.

Methods: An electronic search was performed using major databases. Primary outcomes were VT recurrence, mortality, and cardiac transplantation. Secondary endpoints were acute procedural success and procedural complications.

Results: Eighteen studies were included, with a total of 110 patients (mean age 59.6 ± 11 years, 89% men; VT storm 34%). Scar-related re-entry was the predominant mechanism of VT (90.3%) and cannula-related VT in 19.3% cases. Electroanatomical mapping interference occurred in 1.8% of cases; there were no reports of catheter entrapment. Noninducibility of clinical VT was achieved in 77.9%; procedural complications occurred in 9.4%. At a mean follow-up of 263.5 ± 267.0 days, VT recurred in 43.6%, 23.4% underwent cardiac transplant, and 48.1% died. There were no procedural-related deaths and no death was directly related to ventricular arrhythmia. In follow-up, there was a significant reduction in implantable cardioverter-defibrillator therapies or shocks (57.1% vs. 23.8%). Ablation allowed VT storm termination in 90% of patients.

Conclusions: VAD-related VT is predominantly related to pre-existing intrinsic myocardial scar rather than inflow cannula site insertion. Catheter ablation is a reasonable treatment strategy, albeit with expectedly high rate of recurrence, transplantation, and mortality related to severe underlying disease.
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http://dx.doi.org/10.1016/j.jacep.2018.08.009DOI Listing
January 2019

Updated systematic review and meta-analysis of the impact of contact force sensing on the safety and efficacy of atrial fibrillation ablation: discrepancy between observational studies and randomized control trial data.

Europace 2019 Feb;21(2):239-249

Department of Cardiology, Westmead Hospital, Sydney, Australia.

Aims: Despite widespread adoption of contact force (CF) sensing technology in atrial fibrillation (AF) ablation, randomized data suggests lack of improvement in clinical outcomes. We aimed to assess the safety and efficacy of CF-guided vs. non CF-guided AF ablation.

Methods And Results: Electronic databases were searched for randomized controlled trials (RCTs) and controlled observational studies (OS) comparing outcomes of AF ablation performed with vs. without CF guidance. The primary efficacy endpoint was freedom from AF at follow-up. The primary safety endpoint was major peri-procedural complications. Secondary endpoints included procedural, fluoroscopy, and ablation duration. Subgroup analyses were performed by AF type and study design. Nine RCTs (n = 903) and 26 OS (n = 8919) were included. Overall, CF guidance was associated with improved freedom from AF [relative risk (RR) 1.10; 95% confidence interval (CI) 1.02-1.18], and reduced total procedure duration [mean difference (MD) 15.33 min; 95% CI 6.98-23.68], ablation duration (MD 3.07 min; 95% CI 0.29-5.84), and fluoroscopy duration (MD 5.72 min; 95% CI 2.51-8.92). When restricted to RCTs however, CF guidance neither improved freedom from AF (RR 1.03; 95% CI 0.95-1.11), independent of AF type, nor did it reduce procedural, fluoroscopy, or ablation duration. Contact force guidance did not reduce the incidence of major peri-procedural complications (RR 0.89; 95% CI 0.64-1.24).

Conclusion: Meta-analysis of randomized data demonstrated that CF guidance does not improve the safety or efficacy of AF ablation, despite initial observational data showing dramatic improvement. Rigorous evaluation in randomized trials is needed before widespread adoption of new technologies.
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http://dx.doi.org/10.1093/europace/euy266DOI Listing
February 2019

Catheter Ablation Versus Medical Therapy for Atrial Fibrillation in Patients With Heart Failure: A Meta-Analysis of Randomised Controlled Trials.

Heart Lung Circ 2019 May 17;28(5):707-718. Epub 2018 Nov 17.

Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia. Electronic address:

Background: Catheter ablation (CA) is highly efficacious for symptomatic atrial fibrillation (AF) but data predominantly comes from patients with preserved ventricular function. We performed an updated systematic review and meta-analysis of randomised controlled trials (RCT) comparing CA versus medical therapy for AF associated with heart failure (HF).

Methods: Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs reporting clinical outcomes of CA versus medical therapy for AF in HF patients with ≥6 months' follow-up (atrioventricular-node ablation/device therapy studies excluded). Primary endpoint was change in left ventricular ejection fraction (LVEF). Secondary endpoints were 6-minute walk test (6MWT) distance, quality of life (QoL; measured by the Minnesota Living with Heart Failure Questionnaire [MLHFQ]), peri-procedural mortality, major peri-procedural complications and mid-term (≥1-year) survival.

Results: Six RCTs (n=772 patients; mean age 62±11years, LVEF 30±9%) were included. Catheter ablation, compared to medical therapy was associated with: greater improvement in LVEF (mean difference [MD] 5.67%; 95% Confidence Interval [CI], 3-8; I=87%; p<0.001), greater increase in 6MWT distance (MD 25.1 metres; 95% CI, 0.6-50; I=94%; p=0.04), improved QoL with greater reduction in MLHFQ scores (MD 9.03; 95% CI, 2.5-15.6; I=47%; p=0.007), and significantly reduced mid-term mortality (relative risk 0.52; 95% CI, 0.4-0.8; I=0%; p=0.001). Freedom from AF after ≥1 procedure was 71%; major complications occurred in 8% of patients.

Conclusion: Catheter ablation is superior to medical therapy for AF in patients with heart failure resulting in greater improvement in LVEF, quality of life and functional status, with a survival benefit.
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http://dx.doi.org/10.1016/j.hlc.2018.10.022DOI Listing
May 2019

Mechanical Circulatory Support During Catheter Ablation of Ventricular Tachycardia: Indications and Options.

Heart Lung Circ 2019 Jan 17;28(1):134-145. Epub 2018 Oct 17.

Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia. Electronic address:

Mapping of scar-related ventricular tachycardia (VT) in structural heart disease is fundamentally driven by identifying the critical isthmus of conduction that supports re-entry in and around myocardial scar. Mapping can be performed using activation and entrainment techniques during VT, or by substrate mapping performed in stable sinus or paced rhythm. Activation and entrainment mapping requires the patient to be in continuous VT, which may not be haemodynamically tolerated, or, if tolerated, may lead to adverse sequelae related to impaired end organ perfusion. Mechanical circulatory support (MCS) devices may facilitate haemodynamic stability and preserve end organ perfusion during sustained VT to permit mapping for long periods. Available options for haemodynamic support include an intra-aortic balloon pump (IABP), TandemHeart left atrial to femoral artery bypass system (CardiacAssist Inc., Pittsburgh, PA, USA), Impella left ventricle (LV) to aorta flow-assist system (Abiomed, Danvers, MA, USA), and extracorporeal membrane oxygenation (ECMO); the bypass and assist devices provide far better augmentation of cardiac output than IABP. MCS has potential key advantages including maintenance of vital organ perfusion, reduction of intra-cardiac filling pressures, reduction of LV volumes, wall stress, and myocardial consumption of oxygen, and improvement of coronary perfusion during prolonged periods of VT induction and/or mapping. Observational studies show MCS allows for longer duration of mapping, and increased likelihood of VT termination, without an increased risk of peri-procedural mortality or VT recurrence in follow-up, despite being used in a significantly sicker cohort of patients. However, MCS has increased risk of complications related to vascular access, bleeding, thromboembolic risk, mapping system interference, increase procedural complexity and increased cost. Acute haemodynamic decompensation occurs in ∼11% of patients undergoing VT ablation, and is associated with increased mortality. Prospectively identifying patients at risk of acute haemodynamic decompensation in the peri-procedural period may allow prophylactic MCS. Although observational studies of MCS in patients at high risk of haemodynamic decompensation are encouraging, its benefit needs to be proven in randomised trials. This review will summarise the indication for MCS, forms of MCS, procedural outcomes, complications and utility of MCS during VT ablation.
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http://dx.doi.org/10.1016/j.hlc.2018.10.006DOI Listing
January 2019

Impact of Concomitant Urologic Intervention on Clinical Outcomes After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Am J Clin Oncol 2018 10;41(10):943-948

UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.

Introduction: The impact of concomitant urologic procedures (UPs) on perioperative and long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is uncertain.

Methods: In total, 935 consecutive CRS/HIPEC procedures were performed between 1996 and 2016 in Sydney, Australia. Among these, 73 (7.8%) involved concomitant UP. The association of concomitant UP with 21 perioperative outcomes and overall survival was assessed using univariate and multivariate analyses.

Results: In-hospital mortality was 1.8%. Patients requiring UP were more likely to require transfusion of ≥5 units of red blood cells (P=0.031) and have a complete cytoreduction (79% vs. 60%, P<0.001). On multivariate analysis, UP was not associated with in-hospital mortality (2.7% vs. 1.7%, P=0.407) or grade III/IV morbidity (52% vs. 41%, P=0.376). The incidence of ureteric fistula (4% vs. 1%, P=0.004), return to theater (26% vs. 14%, P=0.005) and digestive fistula (22% vs. 11%, P=0.005) was higher in the UP group. The addition of a UP did not significantly impact overall survival for appendiceal cancer (P=0.162), colorectal cancer (P=0.315), or pseudomyxoma peritonei (P=0.120).

Conclusions: Addition of a UP was not associated with an increased risk of grade III/IV morbidity or poorer long-term survival after CRS/HIPEC.
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http://dx.doi.org/10.1097/COC.0000000000000414DOI Listing
October 2018

Age is not a predictor of prognosis in metastatic cutaneous squamous cell carcinoma of the head and neck.

ANZ J Surg 2018 Apr 7;88(4):E273-E277. Epub 2016 Nov 7.

Sydney Head and Neck Cancer Institute (SHNCI), Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.

Background: Metastatic cutaneous squamous cell carcinoma of the head and neck (cHNSCC) is more common in older patients. It is postulated that the age-related decline in immunity plays a role in cancer predisposition and prognosis. We aimed to investigate the effect of age on outcomes in cHNSCC and compare these with the outcomes of patients with cHNSCC and known immunosuppression.

Methods: Patients with metastatic cHNSCC treated with curative intent were identified from a prospectively collated database of head and neck cancers at the Sydney Head and Neck Cancer Institute. Patients with cHNSCC with known immunosuppression provided a comparison group for analysis of disease-specific outcomes.

Results: The study cohort includes 418 immunocompetent patients with metastatic cHNSCC (median age: 73 years (interquartile range: 65-81 years)) and the control cohort includes 24 patients with metastatic cHNSCC and immunosuppression (median age: 51 years (interquartile range: 42-62 years)). Increasing age was not associated with poorer disease-free or disease-specific survival. Patients in older age groups (70 years and over) had better disease-specific outcomes than patients with long-term immunosuppression. Patterns of disease failure did not differ between different age groups. The number of positive nodes and extra-capsular spread were the only significant prognostic variables in multivariable analysis.

Conclusion: In the context of metastatic cHNSCC, age should not be considered as a marker of poor prognosis. Age should not be considered a surrogate marker of immune function considering the poorer outcomes seen in patients with immunosuppression. Older patients with metastatic cHNSCC should be considered candidates for standard treatment if otherwise medically fit.
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http://dx.doi.org/10.1111/ans.13757DOI Listing
April 2018

Preoperative atrial fibrillation portends poor outcomes after coronary bypass graft surgery: A systematic review and meta-analysis.

J Thorac Cardiovasc Surg 2018 04 22;155(4):1524-1533.e2. Epub 2017 Nov 22.

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute, Sydney, Australia; Institute of Academic Surgery, The University of Sydney, Sydney, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2017.11.048DOI Listing
April 2018

Heart Valve Surgery Performed by Trainee Surgeons: Meta-Analysis of Clinical Outcomes.

Heart Lung Circ 2018 Apr 27;27(4):420-426. Epub 2017 Oct 27.

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.

Background: Cardiac surgical units must balance trainee education with the duty to provide optimal patient care. This is particularly challenging with valvular surgery, given the lower volume and increased complexity of these procedures. The present meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes following valvular surgery.

Methods: Medline, Embase and CENTRAL databases were systematically searched for studies reporting clinical outcomes according to the training status of the primary operator (consultant or trainee). Data were extracted and meta-analysed according to pre-defined endpoints.

Results: Eleven observational studies met the inclusion criteria, reporting on five patient cohorts undergoing mitral valve surgery (n=3975), six undergoing aortic valve replacement (AVR) (n=6236) and three undergoing combined AVR and coronary artery bypass grafting (CABG) (n=3495). Perioperative mortality was not significantly different between trainee and consultant cases for mitral valve surgery (odds ratio [OR] 0.92; 95% confidence interval [CI], 0.62-1.37), AVR (OR 0.67; 95% CI, 0.37-1.24), or combined AVR and CABG (OR 1.07; 95% CI, 0.40-2.85). The incidences of perioperative stroke, myocardial infarction, arrhythmias, acute renal failure, reoperation or wound infection were not significantly different between trainee and consultant cases. There was a paucity of mid-term survival data.

Conclusions: Valvular surgery cases performed primarily by trainees were not associated with adverse perioperative outcomes. These findings suggest the rigorous design of cardiac surgical trainee programs can sufficiently mitigate trainee deficiencies. However, studies with longer follow-up duration and echocardiographic data are required to assess long-term durability and safety.
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http://dx.doi.org/10.1016/j.hlc.2017.10.009DOI Listing
April 2018

Use of colchicine in pregnancy: a systematic review and meta-analysis.

Rheumatology (Oxford) 2018 Feb;57(2):382-387

Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.

Objectives: Colchicine is an anti-inflammatory agent used in the treatment of several rheumatological conditions. The use of colchicine in pregnancy is controversial. The current study aimed to systematically review and meta-analyse the existing data in the literature regarding the safety of colchicine in pregnancy.

Methods: A systematic review was carried out using six electronic databases, identifying all relevant studies where colchicine was administered to pregnant women, and where pregnancy-related outcomes were measured. The primary endpoints were miscarriage and major foetal malformation. Secondary endpoints included birthweight and gestational age at birth.

Results: Four studies were included for meta-analysis. Use of colchicine throughout pregnancy was not associated with an increased incidence of miscarriage or major foetal malformations. The incidence of miscarriage was significantly lower in women who took colchicine compared with those that did not. In women with FMF who took colchicine throughout the pregnancy, there was no significant difference in birthweight or gestational age compared with those who did not take colchicine. When not limited to FMF, colchicine use was associated with a significantly lower birthweight and gestational age compared with a control group including healthy women who did not take colchicine.

Conclusions: Colchicine therapy did not significantly increase the incidence of foetal malformations or miscarriage when taken during pregnancy. Colchicine therapy for FMF should not be withheld on this basis during pregnancy.
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http://dx.doi.org/10.1093/rheumatology/kex353DOI Listing
February 2018

p16 expression in cutaneous squamous cell carcinoma of the head and neck is not associated with integration of high risk HPV DNA or prognosis.

Pathology 2017 Aug 26;49(5):494-498. Epub 2017 Jun 26.

Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, NSW, Australia. Electronic address:

Head and neck cutaneous squamous cell carcinoma (HNcSCC) can present with cervical metastases without an obvious primary. Immunohistochemistry for p16 is established as a surrogate marker of human papillomavirus (HPV) in oropharyngeal cancer. p16 expression in HNcSCC needs to be elucidated to determine its utility in predicting the primary site. The aim of this study was to evaluate the rate of p16 expression in HNcSCC and its association with prognostic factors and survival. p16 immunohistochemistry was performed on 166 patients with high risk HNcSCC (2000-2013) following histopathology review. Chromogenic in situ hybridisation (CISH) for HPV was performed. Fifty-three (31.9%) cases showed strong, diffuse nuclear and cytoplasmic p16 expression including 14 (41%) non-metastatic and 39 (29.5%) metastatic tumours (p=0.21). HPV CISH was negative in all cases. p16 expression significantly increased with poorer differentiation (p=0.033), but was not associated with size (p=0.30), depth of invasion (p=0.94), lymphovascular invasion (p=0.31), perineural invasion (p=0.69), keratinisation (p=0.99), number of involved nodes (p=0.64), extranodal extension (p=0.59) or survival. Nearly 32% of HNcSCCs, particularly poorly differentiated HNcSCCs, show p16 expression. A primary HNcSCC should be considered in p16 positive neck node metastases in regions with high prevalence of HNcSCC. p16 expression is not associated with improved survival in HNcSCC.
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http://dx.doi.org/10.1016/j.pathol.2017.04.002DOI Listing
August 2017

Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes.

J Thorac Cardiovasc Surg 2017 07 22;154(1):127-136. Epub 2017 Mar 22.

The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia. Electronic address:

Objective: This meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR).

Methods: Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints.

Results: Four randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR.

Conclusions: In patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess long-term survival and freedom from reintervention.
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http://dx.doi.org/10.1016/j.jtcvs.2017.03.039DOI Listing
July 2017

Systematic review and meta-analysis on the impact of preoperative atrial fibrillation on short- and long-term outcomes after aortic valve replacement.

J Cardiovasc Surg (Torino) 2017 Dec 20;58(6):943-950. Epub 2017 Mar 20.

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia -

Introduction: This systematic review and meta-analysis was performed to evaluate the impact of preoperative atrial fibrillation (preAF) on early and late outcomes after aortic valve replacement (AVR).

Evidence Acquisition: Medline, EMBASE, and CENTRAL were systematically searched for studies that reported AVR outcomes according to the presence or absence of preAF. Data were independently extracted by two investigators; a meta-analysis was conducted according to predefined clinical endpoints. Studies including patients undergoing concomitant atrial fibrillation surgery were excluded.

Evidence Synthesis: Six observational studies with 8 distinct AVR cohorts (AVR± concomitant surgery) met criteria for inclusion, including a total of 6693 patients. Of these, 1014 (15%) presented with preAF. Overall, perioperative mortality was increased in patients with preAF (odds ratio [OR] 2.33; 95% CI: 1.48-3.67; P<0.001). Subgroup analysis of patients undergoing isolated AVR also demonstrated preAF as a risk factor for perioperative mortality (OR 2.49; 95% CI: 1.57-3.95; P<0.001). PreAF was also associated with acute renal failure (OR 1.42; 95% CI: 1.07-1.89; P=0.02) but not stroke (OR 1.11; 95% CI: 0.59-2.12; P=0.74). Late mortality was significantly higher in patients with preAF (hazard ratio [HR] 1.75; 95% CI: 1.33-2.30; P<0.001). This relationship remained true when only patients who underwent isolated AVR were analyzed (HR 1.97; 95% CI: 1.11-3.51; P=0.02).

Conclusions: PreAF is associated with an increased risk of early- and late-mortality after AVR. These data support the more widespread utilization of concomitant AF ablation.
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http://dx.doi.org/10.23736/S0021-9509.17.09814-7DOI Listing
December 2017

Impact of Obesity on Outcomes in Adults Undergoing Elective Posterior Cervical Fusion.

Spine (Phila Pa 1976) 2017 Feb;42(4):261-266

Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.

Study Design: Retrospective study of prospectively collected data.

Objective: To determine the effect of obesity (body mass Index > 30) on postoperative morbidity and mortality after elective posterior cervical fusion in adults.

Summary Of Background Data: In those with spine disease, obesity has been shown to portend poorer general and disease-specific functional health status. The effect of obesity on outcomes after spine surgery, especially posterior cervical fusion, however, remains unclear. Previous studies have been contradictory to one another and largely limited by small sample sizes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent posterior cervical fusion between 2005 and 2012. Patients were separated into cohorts based on obesity status. Univariate analysis and multivariate logistic regression were used to analyze the effect of obesity on postoperative morbidity and mortality.

Results: There was a significantly higher rate of only venous thromboembolism (VTE) in the obese group compared with nonobese cohort (3.5% vs. 0.6%, P = 0.015). On multivariate analysis, obesity was found to be an independent predictor (odds ratio 6.15; 95% confidence interval [CI], 1.26-30.20; P = 0.02) for VTE.

Conclusion: The present study demonstrated that patients with obesity can safely undergo posterior cervical fusion surgery. Although obesity predisposed to an elevated risk of VTE, postoperative mortality and morbidity were otherwise not significantly increased in this population.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000001711DOI Listing
February 2017

A systematic review on robotic coronary artery bypass graft surgery.

Ann Cardiothorac Surg 2016 Nov;5(6):530-543

The Collaborative Research (CORE) group, Macquarie University, Sydney, Australia.

Background: Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival.

Methods: Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB).

Results: The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques.

Conclusions: A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.
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http://dx.doi.org/10.21037/acs.2016.11.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135550PMC
November 2016

p16 expression independent of human papillomavirus is associated with lower stage and longer disease-free survival in oral cavity squamous cell carcinoma.

Pathology 2016 Aug 28;48(5):441-8. Epub 2016 Jun 28.

Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; University of Sydney, Camperdown, NSW, Australia; Chris O'Brien Lifehouse, Camperdown, NSW, Australia. Electronic address:

There is limited information regarding the incidence of p16 expression, its association with human papillomavirus (HPV) and prognosis in oral cavity squamous cell carcinoma (OSCC). The role of p16 in OSCC is evaluated in 215 cases using tissue microarrays (TMAs). p16 immunohistochemistry and HPV in situ hybridisation were performed on TMAs following histopathology review of 215 patients with OSCC in the Sydney Head and Neck Cancer Institute database. Thirty-seven (17.2%) cases showed p16 expression without association with HPV. p16 expression significantly decreased with increasing pT category (p=0.002). p16 expression was associated with longer disease-specific survival on univariable analysis (p=0.044) but not on multivariable analysis adjusting for depth of invasion. Amongst patients receiving adjuvant radiotherapy, patients with p16 expression had significantly longer disease-free and overall survival. p16 expression was seen in early stage OSCCs and was associated with better survival following surgery and radiotherapy. While not an independent predictor of survival, p16 may mediate its effects by contributing to reduced proliferative capacity, leading to smaller tumour size and lower invasive potential.
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http://dx.doi.org/10.1016/j.pathol.2016.03.015DOI Listing
August 2016

Laminectomy and fusion vs laminoplasty for multi-level cervical myelopathy: a systematic review and meta-analysis.

Eur Spine J 2017 01 24;26(1):94-103. Epub 2016 Jun 24.

NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.

Background: Surgical approaches for multi-level cervical spondylotic myelopathy (CSM) include posterior cervical surgery via laminectomy and fusion (LF) or expansive laminoplasty (EL). The relative benefits and risks of either approach in terms of clinical outcomes and complications are not well established. A systematic review and meta-analysis was conducted to address this topic.

Methods: Electronic searches were performed using six databases from their inception to January 2016, identifying all relevant randomized controlled trials (RCTs) and non-RCTs comparing LF vs EL for multi-level cervical myelopathy. Data was extracted and analyzed according to predefined endpoints.

Results: From 10 included studies, there were 335 patients who underwent LF compared to 320 patients who underwent EL. There was no significant difference found postoperatively between LF and EL groups in terms of postoperative JOA (P = 0.39), VAS neck pain (P = 0.93), postoperative CCI (P = 0.32) and Nurich grade (P = 0.42). The total complication rate was higher for LF compared to EL (26.4 vs 15.4 %, RR 1.77, 95 % CI 1.10, 2.85, I  = 34 %, P = 0.02). Reoperation rate was found to be similar between LF and EL groups (P = 0.52). A significantly higher pooled rate of nerve palsies was found in the LF group compared to EL (9.9 vs 3.7 %, RR 2.76, P = 0.03). No significant difference was found in terms of operative time and intraoperative blood loss.

Conclusions: From the available low-quality evidence, LF and EL approaches for CSM demonstrates similar clinical improvement and loss of lordosis. However, a higher complication rate was found in LF group, including significantly higher nerve palsy complications. This requires further validation and investigation in larger sample-size prospective and randomized studies.
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http://dx.doi.org/10.1007/s00586-016-4671-5DOI Listing
January 2017

Association Between HbA1c Variability and Risk of Microvascular Complications in Adolescents With Type 1 Diabetes.

J Clin Endocrinol Metab 2016 09 17;101(9):3257-63. Epub 2016 May 17.

Institute of Endocrinology and Diabetes (S.A.V., K.C.D., Y.H.C., P.B.-A., S.H., A.P., A.C., M.E.C.), The Children's Hospital at Westmead, Sydney 2145, New South Wales, Australia; School of Women's and Children's Health (S.A.V., M.E.C.), University of New South Wales, Sydney 2031, New South Wales, Australia; and Discipline of Child and Adolescent Health (K.C.D., Y.H.C., M.E.C.), University of Sydney, Sydney 2006, New South Wales, Australia.

Context: There is a paucity of data regarding the association between glycosylated hemoglobin (HbA1c) variability and risk of microvascular complications in adolescents with type 1 diabetes (T1D).

Objective: To investigate the association between HbA1c variability and risk of microvascular complications in adolescents with T1D.

Design: Prospective cohort study from 1990 to 2014 (median follow-up, 8.1 y).

Setting: Tertiary pediatric hospital.

Participants: A total of 1706 adolescents (aged 12-20 minimum diabetes duration 5 y) with median age of 15.9 years (interquartile range, 14.3-17.5) and diabetes duration of 8.1 years (6.3-10.8).

Main Outcome Measures: Glycemic variability was computed as the SD of all HbA1c measurements (SD-HbA1c) after diagnosis. Retinopathy was detected using 7-field fundal photography, renal function assessed using albumin excretion rate, peripheral neuropathy detected using thermal and vibration threshold testing, and cardiac autonomic neuropathy (CAN) detected using time- and frequency-domain analyses of electrocardiogram recordings. Generalized estimating equations were used to examine the relationship between complications outcomes and HbA1c variability, after adjusting for known risk factors, including HbA1c, diabetes duration, blood pressure, and lipids.

Results: In multivariable analysis, SD-HbA1c was associated with early retinopathy (odds ratio [OR] 1.32; 95% confidence interval, 1.00-1.73), albuminuria (OR 1.81; 1.04-3.14), increased log10 albumin excretion rate (OR 1.10; 1.05-1.15) and CAN (OR 2.28; 1.23-4.21) but not peripheral neuropathy.

Conclusions: Greater HbA1c variability predicts retinopathy, early nephropathy, and CAN, in addition to established risk factors, in adolescents with T1D. Minimizing long term fluctuations in glycemia may provide additional protection against the development of microvascular complications.
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http://dx.doi.org/10.1210/jc.2015-3604DOI Listing
September 2016

Insulin Pump Therapy Is Associated with Lower Rates of Retinopathy and Peripheral Nerve Abnormality.

PLoS One 2016 6;11(4):e0153033. Epub 2016 Apr 6.

Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.

Objective: To compare rates of microvascular complications in adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI).

Research Design And Methods: Prospective cohort of 989 patients (aged 12-20 years; diabetes duration >5 years) treated with CSII or MDI for >12 months. Microvascular complications were assessed from 2000-14: early retinopathy (seven-field fundal photography), peripheral nerve function (thermal and vibration threshold testing), autonomic nerve abnormality (heart rate variability analysis of electrocardiogram recordings) and albuminuria (albumin creatinine ratio/timed overnight albumin excretion). Generalized estimating equations (GEE) were used to examine the relationship between treatment and complications rates, adjusting for socio-economic status (SES) and known risk factors including HbA1c and diabetes duration.

Results: Comparing CSII with MDI: HbA1C was 8.6% [70mmol/mol] vs. 8.7% [72 mmol/mol]) (p = 0.7), retinopathy 17% vs. 22% (p = 0.06); microalbuminuria 1% vs. 4% (p = 0.07), peripheral nerve abnormality 27% vs. 33% (p = 0.108) and autonomic nerve abnormality 24% vs. 28% (p = 0.401). In multivariable GEE, CSII use was associated with lower rates of retinopathy (OR 0.66, 95% CI 0.45-0.95, p = 0.029) and peripheral nerve abnormality (OR 0.63, 95% CI 0.42-0.95, p = 0.026), but not albuminuria (OR 0.46, 95% CI 0.10-2.17, p = 0.33). SES was not associated with any of the complication outcomes.

Conclusions: In adolescents, CSII use is associated with lower rates of retinopathy and peripheral nerve abnormality, suggesting an apparent benefit of CSII over MDI independent of glycemic control or SES.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153033PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822832PMC
August 2016

Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Meta-Analysis of Clinical Outcomes and Cost-Effectiveness.

Curr Pharm Des 2016 ;22(13):1965-77

The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.

Objective: Transcatheter aortic valve implantation (TAVI) has emerged as a feasible alternative treatment to conventional surgical aortic valve replacement (AVR) for high-risk patients with aortic stenosis. The present systematic review aimed to assess the comparative clinical and cost-effectiveness outcomes of TAVI versus AVR, and meta-analyse standardized clinical endpoints.

Methods: An electronic search was conducted on 9 online databases to identify all relevant studies. Eligible studies had to report on either periprocedural mortality or incremental cost-effectiveness ratio (ICER) to be included for analysis.

Results: The systematic review identified 24 studies that reported on comparative clinical outcomes, including three randomized controlled trials and ten matched observational studies involving 7906 patients. Meta-analysis demonstrated no significant differences in regards to mortality, stroke, myocardial infarction or acute renal failure. Patients who underwent TAVI were more likely to experience major vascular complications or arrhythmias requiring permanent pacemaker insertion. Patients who underwent AVR were more likely to experience major bleeding. Eleven analyses from 7 economic studies reported on ICER. Six analyses defined TAVI to be low value, 2 analyses defined TAVI to be intermediate value, and three analyses defined TAVI to be high value.

Conclusion: The present study demonstrated no significant differences in regards to mortality or stroke between the two therapeutic procedures. However, the cost-effectiveness and long-term efficacy of TAVI may require further investigation. Technological improvement and increased experience may broaden the clinical indication for TAVI for low-intermediate risk patients in the future.
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http://dx.doi.org/10.2174/1381612822666160219120713DOI Listing
December 2016

Margin to tumor thickness ratio - A predictor of local recurrence and survival in oral squamous cell carcinoma.

Oral Oncol 2016 Apr 6;55:49-54. Epub 2016 Feb 6.

Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia; Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.

Objectives: To assess whether small oral squamous cell carcinomas (OSCC) require the same margin clearance as large tumors. We evaluated the association between the ratio of the closest margin to tumor size (MSR) and tumor thickness (MTR) with local control and survival.

Methods And Methods: The clinicopathologic and follow up data were obtained for 501 OSCC patients who had surgical resection with curative intent at our institution. MTR and MSR were computed and their associations with local control and survival were assessed using multivariable Cox-regression model. Survival curves were generated using the Kaplan-Meier method.

Results: MTR was a better predictor of disease control than MSR. MTR was a predictor of local failure (p=0.033) and disease specific death (p=0.038) after adjusting for perineural invasion, lymphovascular involvement, nodal status, and radiotherapy. A threshold MTR value of 0.3 was identified, above which the risk of local recurrence was low.

Conclusion: The ratio of margin to tumor thickness was an independent predictor for local recurrence and disease specific death in this cohort. A MTR>0.3 can serve as a useful tool for adjuvant therapy planning as it combines tumor thickness and margin clearance, two well established prognostic factors. The minimum safe margin can be calculated by multiplying the tumor thickness by 0.3. Further prospective studies in other institutions are warranted to confirm the prognostic utility of MTR and assess the generalizability of our threshold values.
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http://dx.doi.org/10.1016/j.oraloncology.2016.01.010DOI Listing
April 2016

Equivalent outcomes after coronary artery bypass graft surgery performed by consultant versus trainee surgeons: A systematic review and meta-analysis.

J Thorac Cardiovasc Surg 2016 Mar 11;151(3):647-654.e1. Epub 2015 Nov 11.

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, Australia.

Objective: In recent years, concerns have been raised about the learning opportunities available to cardiac surgical trainees. This meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes after coronary artery bypass graft (CABG) surgery.

Methods: Medline, EMBASE, and the Cochrane Library were systematically searched for studies that reported CABG outcomes according to the training status of the primary operator (consultant vs trainee). Data were independently extracted by 2 investigators; a meta-analysis was conducted according to predefined clinical endpoints.

Results: Sixteen observational studies (n = 52,966) met criteria for inclusion, with 8 studies (n = 36,479) reporting propensity-adjusted analyses. Trainee cases were associated with increased aortic crossclamp duration (mean difference: 4.80; 95% confidence interval [CI], 0.76-8.83) and cardiopulmonary bypass duration (mean difference: 4.24; 95% CI, 0.00-8.47). Perioperative mortality was similar for CABG performed primarily by trainees versus consultants (odds ratio 0.98; 95% CI, 0.81-1.18). No significant difference was found in the incidence of perioperative stroke, myocardial infarction, acute renal failure, reoperation for bleeding, or wound infection. Trainee operator status was not associated with increased midterm mortality (hazard ratio 1.00; 95% CI, 0.90-1.11). In subgroup analysis that included 5 studies and 8025 patients, off-pump CABG trainee cases were not associated with increased perioperative mortality or morbidity.

Conclusions: With appropriate supervision, conventional CABG can be performed by trainee surgeons without an adverse impact on perioperative outcomes or midterm survival. Data regarding off-pump CABG are limited, and further research is warranted to ascertain the impact of trainee operator status on long-term outcomes after off-pump CABG.
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http://dx.doi.org/10.1016/j.jtcvs.2015.11.006DOI Listing
March 2016