ORCID Profile
0000-0002-5092-4370
Current Organisations
University of Melbourne
,
Austin Health
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Publisher: Wiley
Date: 19-09-2022
DOI: 10.1111/ANS.17185
Publisher: Oxford University Press (OUP)
Date: 05-05-2023
Abstract: Although guidelines recommend the use of perioperative chemical thromboprophylaxis for antireflux surgery, the optimal timing for its initiation is unknown. The aim of this study was to investigate whether perioperative timing of chemical thromboprophylaxis affects bleeding, symptomatic venous thromboembolism, and complication rates in patients undergoing antireflux surgery. This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Overall, chemical thromboprophylaxis was given early (before surgery or intraoperatively) in 1099 (25.6 per cent) patients, and after surgery in 3202 (74.4 per cent) patients, with comparable exposure doses between the two groups. Symptomatic venous thromboembolism risk was unrelated to chemical thromboprophylaxis timing (0.5 versus 0.6 per cent for early and postoperative chemical thromboprophylaxis respectively (odds ratio (OR) 0.97, 95 per cent c.i. 0.41 to 2.47, P = 1.000). Postoperative bleeding developed in 34 (0.8 per cent) patients, and 781 intraoperative adverse events were identified in 544 (12.6 per cent) patients. Both intraoperative bleeding and complications were associated with significantly higher postoperative morbidity affecting multiple organ systems. Importantly, compared with postoperative chemical thromboprophylaxis, early administration increased the risk of postoperative bleeding ((1.5 versus 0.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 2.94, 95 per cent c.i. 1.48 to 5.84, P = 0.002)) and intraoperative adverse events ((16.1 versus 11.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 1.48, 95 per cent c.i. 1.22 to 1.80, P & 0.001)), as well as independently predicted their occurrences. Intraoperative adverse events and bleeding that occur during and after antireflux surgery are associated with significant morbidity. Compared with postoperative chemical thromboprophylaxis, early initiation of chemical thromboprophylaxis confers a significantly higher risk of intraoperative bleeding complications, without appreciable additional protection from symptomatic venous thromboembolism. Therefore, postoperative chemical thromboprophylaxis should be recommended for patients undergoing antireflux surgery.
Publisher: Wiley
Date: 14-11-2022
DOI: 10.1111/ANS.17363
Publisher: Elsevier BV
Date: 06-2021
Publisher: Elsevier BV
Date: 08-2021
Publisher: Oxford University Press (OUP)
Date: 25-09-2020
DOI: 10.1002/BJS.12050
Publisher: Oxford University Press (OUP)
Date: 11-2018
DOI: 10.1093/JSCR/RJY320
Publisher: Wiley
Date: 17-12-2020
DOI: 10.1111/CODI.15431
Abstract: This study aimed to describe the change in surgical practice and the impact of SARS‐CoV‐2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS‐CoV‐2 pandemic. This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS‐CoV‐2. Centres entered data from their first recorded case of COVID‐19 until 19 April 2020. The primary outcome was 30‐day mortality. Secondary outcomes included anastomotic leak, postoperative SARS‐CoV‐2 and a comparison with prepandemic European Society of Coloproctology cohort data. From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty‐day mortality was 1.8% (38/2073), the incidence of postoperative SARS‐CoV‐2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS‐CoV‐2 (14/1601, 0.9%) and highest in patients with both a leak and SARS‐CoV‐2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58–14.06), postoperative SARS‐CoV‐2 (16.90, 7.86–36.38), male sex (2.46, 1.01–5.93), age years (2.87, 1.32–6.20) and advanced cancer stage (3.43, 1.16–10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%). Surgeons need to further mitigate against both SARS‐CoV‐2 and anastomotic leak when offering surgery during current and future COVID‐19 waves based on patient, operative and organizational risks.
Publisher: Oxford University Press (OUP)
Date: 24-03-2021
DOI: 10.1093/BJS/ZNAB101
Abstract: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351 best case 196, worst case 816) or non-cancer surgery (733 best case 407, worst case 1664). Both exceeded the NNV in the general population (1840 best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.
Publisher: Wiley
Date: 09-08-2021
DOI: 10.1111/ANAE.15560
Abstract: We aimed to determine the impact of pre‐operative isolation on postoperative pulmonary complications after elective surgery during the global SARS‐CoV‐2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre‐defined sub‐group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS‐CoV‐2 infection. Patients who isolated pre‐operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS‐CoV‐2 incidence and high‐income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre‐operative testing use of COVID‐19‐free pathways or community SARS‐CoV‐2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care.
Publisher: Elsevier BV
Date: 11-2022
Publisher: Baishideng Publishing Group Inc.
Date: 28-11-2020
Publisher: Wiley
Date: 03-09-2021
DOI: 10.1111/JGH.15670
Abstract: The role of circulating mitochondrial DNA (cmtDNA) in transplantation remains to be elucidated. cmtDNA may be released into the circulation as a consequence of liver injury yet recent work also suggests a causative role for cmtDNA leading to hepatocellular injury. We hypothesized that elevated cmtDNA would be associated with adverse events after liver transplantation (LT) and conducted an observational cohort study. Twenty‐one patients were enrolled prospectively prior to LT. Postoperative complications were observed in 47.6% ( n = 10). Seven patients (33.3%) had early allograft dysfunction (EAD), and six patients (28.5%) experienced acute cellular rejection within 6 months of LT. cmtDNA levels were significantly elevated in all recipients after LT compared with healthy controls and preoperative s les (1 361 937 copies/mL [IQR 586 781–3 399 687] after LT 545 531 copies/mL [IQR 238 562–1 381 015] before LT and 194 562 copies/mL [IQR 182 359–231 515] in healthy controls) and returned to normal levels by 5 days after transplantation. cmtDNA levels were particularly elevated in those who developed EAD in the early postoperative period ( P 0.001). In all patients, there was initially a strong overall positive correlation between cmtDNA and plasma hepatocellular enzyme levels ( P 0.05). However, the patients with EAD demonstrated a second peak in cmtDNA at postoperative day 7, which did not correlate with liver function tests. The early release of plasma cmtDNA is strongly associated with hepatocellular damage however, the late surge in cmtDNA in patients with EAD appeared to be independent of hepatocellular injury as measured by conventional tests.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-09-2022
Publisher: Wiley
Date: 24-08-2021
DOI: 10.1111/ANAE.15563
Abstract: SARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery) recent (1–6 weeks before surgery) previous (≥7 weeks before surgery) or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS‐CoV‐2 2.2% (50/2317) in patients with peri‐operative SARS‐CoV‐2 1.6% (15/953) in patients with recent SARS‐CoV‐2 and 1.0% (11/1148) in patients with previous SARS‐CoV‐2. After adjustment for confounding factors, patients with peri‐operative (adjusted odds ratio 1.5 (95%CI 1.1–2.0)) and recent SARS‐CoV‐2 (1.9 (95%CI 1.2–3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS‐CoV‐2 (1.7 (95%CI 0.9–3.0)). Overall, venous thromboembolism was independently associated with 30‐day mortality (5.4 (95%CI 4.3–6.7)). In patients with SARS‐CoV‐2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri‐operative or recent SARS‐CoV‐2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS‐CoV‐2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
Publisher: Wiley
Date: 29-03-2021
DOI: 10.1111/COA.13749
Abstract: The aim of this study was to evaluate the differences in surgical capacity for head and neck cancer in the UK between the first wave (March‐June 2020) and the current wave (Jan‐Feb 2021) of the COVID‐19 pandemic. REDcap online‐based survey of hospital capacity. UK secondary and tertiary hospitals providing head and neck cancer surgery. One representative per hospital was asked to report the capacity for head and neck cancer surgery in that institution. The principal measures of interests were new patient referrals, capacity in outpatients, theatres and critical care therapeutic compromises constituting delay to surgery, de‐escalated surgery and therapeutic migration to non‐surgical primary modality. Data were returned from approximately 95% of UK hospitals with a head and neck cancer surgery specialist service. 50% of UK head and neck cancer patients requiring surgery have significantly compromised treatments during the second wave: 28% delayed, 10% have received radiotherapy‐based treatment instead of surgery, and 12% have received de‐escalated surgery. Surgical capacity has been more severely constrained in the second wave (58% of pre‐pandemic level) compared with the first wave (62%) despite the time to prepare. Some hospitals are overwhelmed by COVID‐19 and unable to offer essential cancer surgery, but all have neighbouring hospitals in their region retaining good (or even normal) capacity. It is noteworthy that very few patients have been appropriately redirected away from the hospitals most constrained by their burden of COVID‐19. The paucity of an effective central or regional strategic response to this evident mismatch between demand and surgical capacity is to the detriment of our head and neck cancer patients.
Publisher: Springer Science and Business Media LLC
Date: 24-03-2021
Publisher: Oxford University Press (OUP)
Date: 13-06-2020
DOI: 10.1002/BJS.11746
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 18-11-2021
Publisher: Oxford University Press (OUP)
Date: 11-2021
Abstract: There is little evidence around the potentially protective role of previous Bacillus Calmette-Guerin (BCG) vaccination on postoperative mortality in patients with perioperative SARS-CoV-2 vaccination. Prior BCG vaccination did not protect SARS-CoV-2 infected patients against postoperative pulmonary complications and 30-day mortality.
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.AVSG.2018.05.041
Abstract: Endovascular intervention for chronic total occlusions (CTOs) in aortoiliac occlusive disease (AIOD) poses technical challenges. In this manuscript, our experience of fine needle recanalization for the treatment of iliac artery CTO is described. A prospective database recorded treatment of 11 limbs in 11 patients since 2011 using this technique. The majority of these CTO were of the common iliac artery (n = 9). Technical success rate was 91% (n = 10). One failed case was due to tortuous iliac anatomy. There was no restenosis of the treated segments at 8 weeks and no major complications, perforations, major limb loss, or periprocedural mortality. This technique is a safe and viable adjunct for difficult CTO in AIOD with suitable anatomy. It benefits from being a simple, low-profile, low-cost coaxial system and should be part of the armamentarium with other advanced endovascular techniques.
Publisher: American Society of Clinical Oncology (ASCO)
Date: 2021
DOI: 10.1200/JCO.20.01933
Abstract: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9% adjusted odds ratio [aOR], 0.62 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6% aOR, 0.53 95% CI, 0.36 to 0.76). Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.
Publisher: Wiley
Date: 13-04-2021
DOI: 10.1111/ANS.16842
Abstract: In Australia, ethics committees across different states vary in application, requirement and process for the ethical review and approval for clinical research. This may lead to confusion and delays in the enablement of multicentre research projects. This study explores the effect of differing processes for Ethics and Governance in the establishment of the CovidSurg‐Cancer study during the global COVID‐19 pandemic. An anonymous, structured web‐based questionnaire was designed using the Research Electronic Data Capture application (REDCap) platform to capture consultant surgeons, fellows, and trainees experience in the ethics application process. ‘CovidSurg‐Cancer’ was an international multicentre collaborative study to assess the impact of COVID‐19 on the outcomes of patients undergoing cancer surgery. The ethics process to set up this observational study was used as to explore the differing processes applied across Australia. The CovidSurg‐Cancer study was successfully set up in 14 hospitals. Four hospitals approved the study directly as an audit. Of the remaining sites, 10 ethics applications underwent Human Research Ethics Committee review following which two (14%) were subsequently approved as an audit activity and eight hospitals (57%) were given formal ethical approval with waiver of consent. Ethics application acceptance from another Australian Human Research Ethics Committee was provided with six applications however, only three were reciprocated without the requirement for further agreements. A third of (30%) respondents suggested that the details of the application pathway, process and documentation were unclear. Ethics processes are varied across Australia with considerable repetition. A centralized, harmonized application process would enhance collaborative research.
Publisher: Wiley
Date: 21-12-2020
DOI: 10.1002/CNCR.33320
Abstract: The aims of this study were to provide data on the safety of head and neck cancer surgery currently being undertaken during the coronavirus disease 2019 (COVID‐19) pandemic. This international, observational cohort study comprised 1137 consecutive patients with head and neck cancer undergoing primary surgery with curative intent in 26 countries. Factors associated with severe pulmonary complications in COVID‐19–positive patients and infections in the surgical team were determined by univariate analysis. Among the 1137 patients, the commonest sites were the oral cavity (38%) and the thyroid (21%). For oropharynx and larynx tumors, nonsurgical therapy was favored in most cases. There was evidence of surgical de‐escalation of neck management and reconstruction. Overall 30‐day mortality was 1.2%. Twenty‐nine patients (3%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) within 30 days of surgery 13 of these patients (44.8%) developed severe respiratory complications, and 3.51 (10.3%) died. There were significant correlations with an advanced tumor stage and admission to critical care. Members of the surgical team tested positive within 30 days of surgery in 40 cases (3%). There were significant associations with operations in which the patients also tested positive for SARS‐CoV‐2 within 30 days, with a high community incidence of SARS‐CoV‐2, with screened patients, with oral tumor sites, and with tracheostomy. Head and neck cancer surgery in the COVID‐19 era appears safe even when surgery is prolonged and complex. The overlap in COVID‐19 between patients and members of the surgical team raises the suspicion of failures in cross‐infection measures or the use of personal protective equipment. Head and neck surgery is safe for patients during the coronavirus disease 2019 pandemic even when it is lengthy and complex. This is significant because concerns over patient safety raised in many guidelines appear not to be reflected by outcomes, even for those who have other serious illnesses or require complex reconstructions. Patients subjected to suboptimal or nonstandard treatments should be carefully followed up to optimize their cancer outcomes. The overlap between patients and surgeons testing positive for severe acute respiratory syndrome coronavirus 2 is notable and emphasizes the need for fastidious cross‐infection controls and effective personal protective equipment.
Publisher: BMJ
Date: 26-01-2011
Abstract: This article seeks to explore utilitarian conceptions of personhood which for a long time have been employed as part of a rational moral justification for the termination of pregnancy. Michael Tooley's desires-based rights approach to personhood presented in his work Abortion and Infanticide is considered and, it is argued, is found wanting when one considers unconscious adults and their ability to desire life. This article will offer that unconscious sleeping in iduals only have the potential to regain the capacity to value their own life and, as such, under Tooley's formula for personhood, temporarily lose their status as a person. Following this, John Harris's utilitarian views on the status of the sleeping adult will be considered and deconstructed to show that, like Tooley, his ascription for personhood falls down at the sleeping adult. This article illustrates that utilitarian conceptions of personhood leave the sleeping adult human devoid of the rights of a person and hence render the value of this consquentialist theory, with regard to the idea of personhood, in severe doubt. The paper argues that utilitarian conceptions of personhood do little more than obstruct the worthy debate over the morality of abortion.
Publisher: Wiley
Date: 24-04-2022
DOI: 10.1111/CODI.16117
Abstract: The SARS‐CoV‐2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non‐delayed surgery. This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January–April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90–1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69–1.27, P = 0.672). Longer delays were not associated with poorer outcomes. One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID‐19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long‐term survival attributable to delays is likely to be due to micro‐metastatic disease.
Publisher: Wiley
Date: 15-10-2018
DOI: 10.1111/JEP.13048
Abstract: Clinical practice guidelines (CPG) play a major role in patient care in Sri Lanka. This study evaluates the methodological quality of the Sri Lankan CPGs developed in 2007. A total of 94 CPGs developed by several professional colleges in Sri Lanka in the year 2007 were evaluated by 2 independent reviewers using AGREE II instrument for their methodological quality. Item score being ≤3 points was defined as "poor quality". Each domain score was calculated according to AGREE II. A guideline was labelled as "strongly recommended" if 4 or more domains scored above 60%, "recommended for use with certain modification" if only 3 domain scores were above 60% or if 4 or more domain scores were between 30% and 60%, and "not recommended" if 4 or more domains scored less than 30%. Most (22.3%) guidelines were developed by the College of Pathologists. Most of the guidelines (>55%) poorly reported on all the items, except for items 1, 2, and 22 of AGREE II. Median domain scores [range] and the proportion of the guidelines with domain score of <30% were as follows: domain on scope and purpose (33.3% [2.8%-83.3%] 42.6%), stakeholder involvement (14.9% [0.0%-61.1%] 81.9%), rigour of development (6.1% [0.0%-49%] 98.9%), clarity and presentation (30.5% [8.3%-61.1%] 46.8%), and applicability (8.3% [4.2%-14.6%] 100%). All CPGs scored 50% for "editorial independence". Reviewers reported the overall quality was poor in 86 (91.5%). Based on the definitions used in the study, of 94 CPGs, 8 (8.5%) could be recommended to be used with modifications, while 86 (91.5%) could not be recommended for clinical practice. The methodological quality of the CPGs was poor irrespective of the source of development. Major efforts are essential to update the CPGs according to the principles of evidence based medicine.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 30-10-2023
Publisher: Wiley
Date: 08-11-2022
DOI: 10.1002/JGH3.12835
Abstract: During COVID‐19, restrictions to elective endoscopy were introduced worldwide. A reduction in procedures may impact trainees' endoscopy learning. This study aims to assess Australian advanced gastroenterology and general surgery trainees' self‐perceived efficacy and knowledge in endoscopy during the pandemic. All Australian gastroenterology and general surgery trainees in their last 2 years of accredited training were invited to participate through email (2020–2021 and 2021–2022 training cycles). The primary outcome was to assess trainees' self‐efficacy and knowledge regarding gastrointestinal endoscopy. Secondary outcomes included subgroup analysis between gastroenterology and general surgery trainees. Self‐perceived efficacy was assessed with Likert‐scale questions on 20 endoscopy procedures and knowledge was assessed through 21 endoscopy‐related multiple choice questions. Eighty‐one trainees responded to a self‐efficacy questionnaire and 77 responded to the knowledge questionnaire. Over 90% of the trainees were confident or extremely confident in diagnostic endoscopy, but only half demonstrated similar efficacy for therapeutic endoscopy. The efficacy for basic endoscopy procedures was higher for gastroenterology trainees (64.0% vs 51.1%, P 0.001). Last‐year trainee achievement of conjoint committee requirements for upper gastrointestinal endoscopy was achieved in 95.8% of gastroenterology trainees versus 22.2% of surgical trainees ( P 0.001). The median score on the knowledge questionnaire was also higher for the gastroenterology subset (90.5% vs 71.4%, P 0.001). During COVID‐19, endoscopy trainees' self‐efficacy in endoscopic diagnostic procedures was achieved for most trainees. The differences in self‐perceived efficacy and knowledge between gastroenterology and surgical trainees may be reflective of the different opportunities for learning between the two groups.
Publisher: Wiley
Date: 04-2023
DOI: 10.1002/JGH3.12879
Abstract: Hepatocellular carcinoma (HCC) is an aggressive primary malignancy of the liver and is the third most common cause of cancer‐related global mortality. There has been a steady increase in treatment options for HCC in recent years, including innovations in both curative and non‐curative therapies. These advances have brought new challenges and necessary improvements in strategies of disease monitoring, to allow early detection of HCC recurrence. Current serological and radiological strategies for post‐treatment monitoring and prognostication and their limitations will be discussed and evaluated in this review.
Publisher: Wiley
Date: 09-03-2021
DOI: 10.1111/ANAE.15458
Abstract: Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.
Publisher: Wiley
Date: 09-11-2018
DOI: 10.1111/ANS.14898
Abstract: Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia. This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy. A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort. Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.
Publisher: Informa UK Limited
Date: 28-06-2022
Publisher: Oxford University Press (OUP)
Date: 05-2018
DOI: 10.1093/JSCR/RJY086
Publisher: Wiley
Date: 22-09-2022
DOI: 10.5694/MJA2.51725
Abstract: To assess the prevalence and management of anaemia in patients undergoing major abdominal surgery, and the influence of guideline adherence on patient outcomes. Prospective observational cohort study. 56 hospitals in Australia and New Zealand. People aged 18 years or more who underwent major abdominal surgery during two 2-week periods in July 2021. Proportions of patients managed according to Australian National Blood Authority patient blood management guidelines. anaemia prevalence, post-operative complications, length of hospital stay, re-admission within 30 days of discharge. Data were available for 2730 eligible patients (mean age, 56.7 years SD, 17.3 years), including 1558 women (57.1%). Haemoglobin levels prior to surgery were documented for 2461 of 2727 patients (90.2%), 689 of whom had anaemia (28.0%). Pre-operative anaemia assessment and management were associated with lower likelihood of intra-operative (adjusted odds ratio [aOR], 0.33 95% CI, 0.19-0.57) and post-operative blood transfusion (aOR, 0.36 95% CI, 0.25-0.53), and of post-operative complications (aOR, 0.79 95% CI, 0.63-0.99). Tranexamic acid was administered during 128 of 2728 procedures (4.7%) a restrictive transfusion strategy was followed for 96 of the 167 patients who received post-operative blood transfusions (58%). Post-operative anaemia was identified in 1227 of 2069 patients (59.3%) in whom haemoglobin was assessed prior to discharge. The proportion of people re-admitted to hospital within 30 days was larger for patients with anaemia at discharge (169 of 1207 patients followed up, 14.0% v 61 of 825, 7.4%). Haemoglobin assessments were recorded by 30 days after discharge for only 288 patients with post-operative anaemia (24.3%). The management of peri-operative anaemia differs between hospitals in Australia and New Zealand, with consequences for patient outcomes. Patients are often discharged after surgery with anaemia, which is therefore a potential therapeutic target. Australian New Zealand Clinical Trials Registry, ACTRN12621001517864 (retrospective).
Publisher: Oxford University Press (OUP)
Date: 21-06-2021
Abstract: Despite improvements in the genetic and epigenetic analysis of cell-free DNA (cfDNA), there has been limited focus on assessing the preanalytical variables of recovery efficiency following cfDNA extraction and bisulfite modification. Quantification of recovery efficiency after these steps can facilitate quality assurance and improve reliability when comparing serial s les. We developed an exogenous DNA Construct to Evaluate the Recovery Efficiency of cfDNA extraction and BISulfite modification (CEREBIS) after cfDNA extraction and/or subsequent bisulfite modification from plasma. The strategic placement of cytosine bases in the 180 bp CEREBIS enabled PCR lification of the construct by a single primer set both after plasma DNA extraction and following subsequent bisulfite modification. Plasma s les derived from 8 organ transplant donors and 6 serial plasma s les derived from a liver transplant recipient were spiked with a known number of copies of CEREBIS. Recovery of CEREBIS after cfDNA extraction and bisulfite modification was quantified with high analytical accuracy by droplet digital PCR. The use of CEREBIS and quantification of its recovery was useful in identifying problematic extractions. Furthermore, its use was shown to be invaluable towards improving the reliability of the analysis of serial s les. CEREBIS can be used as a spike-in control to address the preanalytical variable of recovery efficiency both after cfDNA extraction from plasma and following bisulfite modification. Our approach can be readily implemented and its application may have significant benefits, especially in settings where longitudinal quantification of cfDNA for disease monitoring is necessary.
Publisher: Elsevier BV
Date: 2021
Publisher: MDPI AG
Date: 09-06-2023
DOI: 10.3390/EPIGENOMES7020011
Abstract: Background: Graft-derived cell-free DNA (gdcfDNA) analysis has shown promise as a non-invasive tool for monitoring organ health following solid organ transplantation. A number of gdcfDNA analysis techniques have been described however, the majority rely on sequencing or prior genotyping to detect donor-recipient mis-matched genetic polymorphisms. Differentially methylated regions of DNA can be used to identify the tissue-of-origin of cell-free DNA (cfDNA) fragments. In this study, we aimed to directly compare the performance of gdcfDNA monitoring using graft-specific DNA methylation analysis and donor-recipient genotyping techniques in a pilot cohort of clinical s les from patients post-liver transplantation. Results: 7 patients were recruited prior to LT, 3 developed early, biopsy-proven TCMR in the first 6 weeks post-LT. gdcfDNA was successfully quantified in all s les using both approaches. There was a high level of technical correlation between results using the two techniques (Spearman testing, rs = 0.87, p 0.0001). gdcfDNA levels quantified using the genotyping approach were significantly greater across all timepoints in comparison to the tissue-specific DNA methylation-based approach: e.g., day 1 post-LT median 31,350 copies/mL (IQR 6731–64,058) vs. 4133 copies/mL (IQR 1100–8422), respectively. Qualitative trends in gdcfDNA levels for each patient were concordant between the two assays. Acute TCMR was preceded by significant elevations in gdcfDNA as quantified by both techniques. Elevations in gdcfDNA, using both techniques, were suggestive of TCMR in this pilot study with a 6- and 3-day lead-time prior to histological diagnosis in patients 1 and 2. Conclusions: Both the graft-specific methylation and genotyping techniques successfully quantified gdcfDNA in patients post-LT with statistically significant concordance. A direct comparison of these two techniques is not only important from a technical perspective for orthogonal validation, but significantly adds weight to the evidence that gdcfDNA monitoring reflects the underlying biology. Both techniques identified LT recipients who developed acute TCMR, with several days lead-time in comparison to conventional diagnostic workflows. Whilst the two assays performed comparably, gdcfDNA monitoring based on graft-specific DNA methylation patterns in cfDNA offers major practical advantages over the donor-recipient genotyping, and hence enhances the potential to translate this emerging technology into clinical practice.
Publisher: Wiley
Date: 07-03-2018
DOI: 10.1111/ANS.14451
Publisher: Oxford University Press (OUP)
Date: 20-04-2023
DOI: 10.1093/BJS/ZNAD092
Abstract: Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling reducing use of anaesthetic gases and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices reducing use of consumables and reducing the use of general anaesthesia. This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.
Publisher: Elsevier BV
Date: 11-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-03-2022
DOI: 10.1002/LT.26388
Abstract: Graft-derived cell-free DNA (gdcfDNA) quantification is a promising, minimally invasive tool for detecting acute T cell-mediated rejection (ATCMR) following liver transplantation (LT). We investigated the utility of measuring hepatocyte-specific methylation in cfDNA (HS-cfDNA) to quantify gdcfDNA, examining its accuracy in detecting ATCMR in a prospective, cross-sectional study. Blood was collected from LT recipients immediately prior to graft biopsy for suspected rejection. HS-cfDNA was quantified using droplet-digital polymerase chain reaction. Prebiopsy liver function tests (LFTs) and HS-cfDNA levels were correlated with biopsy results and the primary outcome of treated biopsy-proven acute rejection (tBPAR). A total of 51 patients were recruited 37 had evidence of rejection on biopsy and 20 required treatment. As much as 11 patients needed inpatient treatment for rejection. HS-cfDNA significantly outperformed LFTs in identifying patients with tBPAR, particularly those needing inpatient treatment (area under the curve, 73.0% 95% confidence interval, 55.4%-90.6% P = 0.01). At a threshold of <33.5% of the total cfDNA fraction, HS-cfDNA had a specificity of 97%, correctly excluding tBPAR in 30/31 patients. Quantifying graft-specific methylation in cfDNA has a major advantage over previous gdcfDNA techniques: it does not require genotyping/sequencing, lending it greater feasibility for translation into transplantation care. Low levels of HS-cfDNA were a strong negative predictor for tBPAR (negative predictive value, 86%) and may have a future role in triaging patients prior to invasive graft biopsies.
Publisher: Oxford University Press (OUP)
Date: 16-07-2020
Publisher: Public Library of Science (PLoS)
Date: 08-09-2023
Publisher: Springer Science and Business Media LLC
Date: 18-02-2023
DOI: 10.1007/S00268-023-06899-5
Abstract: Major abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery. Analysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery. Overall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis. Chemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Daniel Cox.