ORCID Profile
0000-0003-0655-1877
Current Organisation
John Hunter Hospital
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Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.SURGE.2018.08.007
Abstract: Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.
Publisher: Wiley
Date: 21-06-2021
DOI: 10.1111/ANS.17020
Abstract: Prior studies of telehealth report high levels of patient satisfaction, but within carefully selected clinical scenarios. The COVID‐19 pandemic led to telehealth replacing face‐to‐face care for many surgical consultations across a variety of situations. More evidence is needed regarding patient perceptions of telehealth in surgery, in particular, exploring barriers and facilitators associated with its sustained implementation beyond the pandemic. Survey invitations were emailed to a convenience s le of surgical patients by their surgeon following a telehealth consultation during the COVID‐19 pandemic. Surgeons were recruited from a s le ( n = 683) who completed a survey on telehealth (distributed via email to all Australian Fellows of the Royal Australasian College of Surgeons). Mixed methods analysis was performed of the patient survey data. A total of 1166 consultations were captured: 50% routine reviews, 17% initial appointments and 20% post‐operative reviews. Video‐link was used in 49% of consultations. The majority of patients (94%), were satisfied with the quality of their surgical telehealth consultation and 75% felt it delivered the same level of care as face‐to‐face encounters. Telehealth was convenient to use (96%) and led to cost savings for 60% of patients. When asked about future appointment preferences after the pandemic, 41% indicated they would prefer telehealth (24% video‐link and 17% telephone) over face‐to‐face appointments. There was a perception by patients that telehealth consultation fees should be less than face‐to‐face consultation fees. Patient satisfaction with surgical telehealth consultations is high. Barriers to more widespread implementation include financial, clinical appropriateness, technical and confidentiality concerns.
Publisher: Wiley
Date: 14-09-2000
DOI: 10.1046/J.1440-1622.2000.01918.X
Abstract: A group of patients referred to general surgeons for the treatment of gall bladder stones was studied to evaluate the role of a numerical symptom scoring system (biliary symptom score (BSS)) as a tool to improve the assessment of patients and reduce the incidence of post-cholecystectomy symptoms. Fifty-seven patients with gallstones and abdominal symptoms referred to general surgeons were studied. All patients were interviewed by a surgeon in training independently from the treating surgeon and given a subjective and objective assessment of their symptoms (using the BSS) they were then categorized into biliary, non-biliary and possible biliary groups. The results of the interviews remained unknown to the treating surgeon throughout the period of study. The symptom status of all patients was reevaluated 6-12 months later the patients' outcome was compared with their initial objective score and the subjective assessment by the independent assessor and with the treating surgeon's initial assessment. Fifty-one patients were able to be analysed. Subjective independent assessment and BSS were closely correlated (phi = 0.89). Use of the BSS improved the accuracy of the independent assessor from 53% (subjective assessment) to 69%, but this was at the cost of recommending cholecystectomy in 30% of the patients with non-biliary symptoms. The accuracy of experienced consultant general surgeons was 98% with a single case of post-cholecystectomy syndrome (2%). Numerical BSS improves diagnostic accuracy for a surgeon in training by reducing the number of patients classified with possible biliary symptoms, but it remains significantly less accurate than the subjective clinical assessment of an experienced consultant general surgeon.
Publisher: BMJ
Date: 02-05-1987
DOI: 10.1136/BMJ.294.6580.1128-A
Abstract: Patient falls and falls with injury are the largest category of reportable incidents and a significant problem in hospitals. Patients are an important part of fall prevention therefore, we asked patients who have fallen about reason for fall and how falls could be prevented. There were two categories for falls: the need to toilet coupled with loss of balance and unexpected weakness. Patients asked to be included in fall risk communication and asked to be part of the team to prevent them from falling. Nurses need to share a consistent and clear message that they are there for patient safety.
Publisher: Wiley
Date: 26-02-2021
DOI: 10.1111/ANS.16693
Publisher: Wiley
Date: 30-05-2023
DOI: 10.1111/ANS.18551
Abstract: Risk assessment for emergency laparotomy (EL) is important for guiding decision‐making and anticipating the level of perioperative care in acute clinical settings. While established tools such as the American College of Surgeons National Surgical Quality Improvement Program calculator (ACS‐NSQIP), the National Emergency Laparotomy Audit Risk Prediction Calculator (NELA) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity calculation (P‐POSSUM) are accurate predictors for mortality, there has been increasing recognition of the benefits from including measurements for frailty in a simple and quantifiable manner. Psoas muscle to 3rd lumbar vertebra area ratio (PM:L3) measured on CT scans was proven to have a significant inverse association with 30‐, 90‐ and 365‐day mortality in EL patients. A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016–2017, and had contemporaneous abdomino‐pelvic CT scans. Radiological sarcopenia was measured as PM:L3 ratios. ASC‐NSQIP, NELA and P‐POSSUM were retrospectively calculated. Univariate and multivariate logistic regression modelling was used to assess these ratios and scores, as well as American Society of Anaesthesiologists (ASA) classification separated into ASA I‐III and IV/V (simplified ASA), as potential predictors of 30‐, 90‐ and 365‐day mortality. PM:L3, simplified ASA, ACS‐NSQIP, NELA and P‐POSSUM were each statistically significant predictors of 30‐day, 90‐day and 365‐day mortality ( P 0.001). Logistic regression models of 30‐, 90‐ and 365‐day mortality combining PM:L3 ( P = 0.001) and simplified ASA ( P 0.001) exhibited AUCs of 0.838 (0.780, 0.896), 0.805 (0.751, 0.860) and 0.775 (0.729, 0.822), respectively, which were comparable to that of ACS‐NSQIP and NELA. Combining the semi‐physiological parameter ASA classification with PM:L3 provides a quick and simple alternative to the more complex established risk assessment scores and is superior to PM:L3 alone.
Publisher: Royal College of Surgeons of England
Date: 10-2012
DOI: 10.1308/003588412X13171221592294
Abstract: Hepaticojejunostomy is the standard biliary bypass technique for peri ullary cancer when trial dissection reveals unresectable disease or endoscopic stent placement is not possible. This anastomosis can be technically demanding and potentially difficult. The simpler technique of hepaticocholecystoenterostomy (HCE) has only previously been reported in very limited numbers and without outcome data. All patients undergoing HCE for the management of peri ullary cancer were identified from a prospectively maintained computerised database of a single surgeon and were reviewed retrospectively. The HCE technique achieves a biliary bypass by two anastomoses, using the gallbladder as a conduit. It involves an anastomosis of the infundibulum of the gallbladder to the common hepatic duct followed by a second anastomosis of the gallbladder fundus to the proximal small bowel. From 1996 to 2010, 30 patients with pancreatic adenocarcinoma required a biliary bypass after a failed trial of Whipple procedure (80%) or failed endoscopic stenting (20%). There were 19 men and 11 women with a mean age of 64.5 years. The mean operative time for HCE alone was 92 minutes. The mean length of hospital stay was nine days. There was a single grade 2 complication (readmission with gastric emptying delay) and a single grade 3 complication (bile leak requiring reoperation). Thirty-day mortality was zero and the mean survival was 12 months (with one patient still alive at the time of writing). There were no readmissions with recurrent biliary obstruction or cholangitis. One patient had developed an incisional hernia by the 24 month follow-up appointment. HCE in peri ullary cancer is safe and effective in selected patients. It involves two simple anastomoses with good access rather than one more demanding anastomosis. Morbidity, patency and overall survival are comparable with contemporary published series of hepaticojejunostomy.
Publisher: Wiley
Date: 24-03-2008
Publisher: Wiley
Date: 04-1996
DOI: 10.1111/J.1445-2197.1996.TB01165.X
Abstract: Laparoscopic surgery has been widely embraced, often without adequate data concerning the range and incidence of complications. In the present series, our experience of complications requiring Intensive Care Unit (ICU) admission following laparoscopic surgery is described. The records of patients requiring ICU admission at John Hunter Hospital (JHH) following laparoscopic surgery over a 39 month period were retrospectively reviewed by an independent multidisciplinary panel. Twenty-three ICU admissions were identified. Twenty-one followed general surgical laparoscopic procedures and two followed gynaecological laparoscopies. Ten cases were operated on initially at JHH and 13 were transferred from other hospitals. During the study period, 2444 laparoscopic surgical cases were performed at JHH 725 general surgical procedures (1.37% admitted to ICU) and 1719 gynaecological procedures (no ICU admissions). Twelve cases suffered surgical complications (including five gastrointestinal tract perforations and three biliary tract injuries) and 11 cases were admitted for non-surgical problems. In 75% of surgical complications there was delay in diagnosis of more than 24 h. The duration of ICU stay for surgical complications (16.4 days) was significantly longer than for the non-surgical group (3.9 days). There was a greater likelihood of ICU admission following general surgical rather than gynaecological laparoscopy. Fifty-two per cent of the admissions were for surgical complications. Surgical complications are characterized by delay in diagnosis and longer ICU admission periods. Strategies to prevent some of these complications are discussed.
Publisher: Wiley
Date: 20-02-2020
DOI: 10.1111/ANS.15726
Publisher: Wiley
Date: 07-1998
DOI: 10.1111/J.1445-2197.1998.TB04814.X
Abstract: Patients referred to general surgeons for the treatment of gall-bladder stones were studied to evaluate the role of sincalide cholescintigraphy as a gall-bladder stress test in an effort to identify a group of patients whose pain was non-biliary in origin and who would not be improved by cholecystectomy. Ten asymptomatic controls and 57 patients with gallstones and abdominal symptoms were studied. All patients were interviewed by an independent assessor who identified a group of patients in whom the role of gallstones in their presentation was uncertain (clinically possibly biliary group). All patients and controls underwent sincalide cholescintigraphy. The surgeons remained blinded to the study results throughout the study period. All patients were re-evaluated 6-12 months later to establish the ultimate diagnosis based on their therapeutic response. Several parameters of gall-bladder function were studied from analysis of the sincalide cholescintigram. Lag time, ejection period, ejection rate and ejection fraction did not differ significantly among controls, patients proven to have non-biliary disease and patients proven to have biliary disease. There were significant differences in mean gall-bladder filling fraction between proven biliary and proven non-biliary groups. However, the group of patients with clinically possibly biliary symptoms could not accurately be separated into those who benefited from cholecystectomy and those who improved without surgery on the basis of this parameter. Significant differences in gall-bladder filling fraction between symptomatic and asymptomatic gallstone patients were identified suggesting reduced gall-bladder compliance in symptomatic patients. However, the sincalide cholescintigram failed to emerge as a useful gall-bladder stress test. Even in the 1990s, assessment by an experienced surgeon appears to be the most appropriate way to select patients for cholecystectomy.
Publisher: Wiley
Date: 09-1997
Publisher: Wiley
Date: 09-2017
DOI: 10.1111/ANS.14105
Publisher: Wiley
Date: 04-1995
Publisher: Wiley
Date: 1996
DOI: 10.1111/J.1445-2197.1996.TB00693.X
Abstract: Operative cholangiograms during the year of introduction of laparoscopic cholecystectomy were reviewed to examine their quality and interpretation. 149 operative cholangiogram films (34 open and 115 laparoscopic) were reviewed retrospectively by a panel and scored for their ability to demonstrate biliary anatomy and detect bile duct stones. Cholangiography performed by the cystic duct was of similar quality, whether performed laparoscopically or open. Cholangiography via the cystic duct (conventional films) produces superior results for both anatomical delineation and detection of choledocholithiasis (80% adequate) than cholangiography performed by direct gallbladder puncture (29-35% adequate). There is no clear evidence to suggest that an intra-operative specialist radiological review of cholangiograms performed by the cystic duct would improve the detection of bile duct stones.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-04-2020
Publisher: Wiley
Date: 10-1998
DOI: 10.1111/J.1445-2197.1998.TB04662.X
Abstract: Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P = 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P = 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient's death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.
Publisher: Elsevier BV
Date: 07-1993
Abstract: Collagen I is the most abundant protein found in the body. Its quaternary structure has been extensively characterised and consists of filaments arranged into bundles. In this study we used scanning tunnelling microscopy to image the collagen I filaments and fibrils directly. The images suggested that filaments are arranged into a left-handed helical structure with a periodicity of about 10nm. Such a structure potentially adds increased tensile strength to the collagen fibrils.
Publisher: Elsevier BV
Date: 10-2007
DOI: 10.1016/J.HLC.2006.10.008
Abstract: A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare.
Publisher: Elsevier BV
Date: 03-1991
DOI: 10.1016/S0272-6386(12)80478-1
Abstract: Twenty-three unselected hemodialysis patients with functioning access arteriovenous fistulae were studied prospectively to determine the best technique for detecting stenoses within the fistulae. Combined clinical assessment and fistula assessment monitoring were compared with transbrachial angiography. Fistula assessment monitoring was more accurate (96%) than combined clinical assessment (accuracy, 52%) in stenosis detection. Complications of angiography occurred in 17% of patients there were no complications of fistula assessment monitoring. Fistula assessment monitoring was better than combined clinical assessment in predicting clinical outcome for arteriovenous fistulae over 6 months and was as good as angiography. Routine fistula assessment monitoring could reduce inappropriate angiography and detect clinically significant silent stenoses. It is an ideal method for monitoring arteriovenous access fistulae.
Publisher: Wiley
Date: 29-05-2008
DOI: 10.1111/J.1445-2197.2008.04540.X
Abstract: Two recent meta-analyses suggest that operative common bile duct (CBD) exploration (laparoscopic or open) may be superior to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis when the gall bladder is in situ. Much of the published work regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution, both hepatobiliary and general surgeons carry out cholecystectomy, with differing levels of expertise in laparoscopic bile duct exploration. ERCP and laparoscopic antegrade trans ullary endobiliary stents are available. We reviewed the management of choledocholithiasis in this setting. A retrospective review of all patients undergoing cholecystectomy during 2004 and 2005 at John Hunter and Belmont Hospitals (Newcastle, Australia) was conducted. The overall incidence of choledocholithiasis was 10.3% (70 of 681). Fifty patients underwent preoperative ERCP, with choledocholithiasis confirmed in only 24 patients (therapeutic rate 30%). Thirty-one patients underwent CBD exploration with 100% clearance through an open approach (12 patients) and 58% clearance through a laparoscopic approach (11 of 19 patients). Hepatobiliary surgeons carried out 22 of 31 CBD explorations (clearance rate 82%) and placed 13 trans ullary antegrade endobiliary stents. In comparison, general surgeons carried out nine CBD explorations (clearance rate 56%) and placed only four antegrade stents. This series suggests that preoperative ERCP is significantly overutilized, laparoscopic CBD exploration is less successful than open CBD exploration and that antegrade trans ullary intraoperative endobiliary stenting is underutilized by non-hepatobiliary surgeons.
Publisher: Wiley
Date: 16-05-2022
DOI: 10.1111/ANS.17759
Abstract: Emergency Laparotomy (EL) is recognized as high‐risk surgery with high mortality. Established surgical risk assessment tools (NELA Risk Prediction Calculator, P‐POSSUM, ACS‐NSQIP) are accurate predictors of morbidity and mortality. However, their multicomponent complexity limits their use in practice. Sarcopenia is associated with poorer surgical outcomes. This study tests for an association between a simple measure of radiological sarcopenia and mortality in EL patients in an Australian cohort. A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016–2017. All patients had a contemporaneous abdomino‐pelvic CT scan. Radiological sarcopenia was measured as the ratio of total psoas muscle area (PM) to L3 vertebral body cross sectional area (PM:L3). Patients were followed up to 12 months. Primary outcomes were 30‐, 90‐ and 365‐day mortality. The mean 30‐day mortality predictions for NELA, P‐POSSUM and ACS‐NSQIP were 11.36%, 17.28% and 11.30% respectively. PM:L3 ratio was associated with 30‐, 90‐ and 365‐day mortality ( P 0.001) and sex ( P 0.001) and negatively correlated with age ( r = −0.4612 P 0.001). Radiological sarcopenia had a weak negative correlation with NELA ( r = −0.2737 P 0.001), P‐POSSUM ( r = −0.1880 P 0.001) and ACS‐NSQIP ( r = −0.2351 P 0.001). The latter three metrics were significantly correlated ( r 0.5696 P 0.001). Radiological sarcopenia (CT‐assessed PM:L3) is a significant predictor of mortality in EL patients in Australia. The results of this study suggest that radiological sarcopenia is equivalent to established risk assessment tools. The more timely and easily accessible CT‐assessed PM:L3 metric is potentially automatable and may have significant utility in clinical practice.
Publisher: Oxford University Press (OUP)
Date: 1994
Publisher: Springer Science and Business Media LLC
Date: 2011
Publisher: Elsevier BV
Date: 02-2020
DOI: 10.1016/J.JSS.2019.09.024
Abstract: The National Emergency Laparotomy Audit (NELA) highlights the importance of identifying high-risk patients due to the potential for significant morbidity and mortality. The NELA risk prediction calculator (NRPC) was developed from data in England and Wales and is one of several calculators available. We seek to determine the utility of NRPC in the Australian population and compare it with Portsmouth Physiological and Operative Severity Score for the enumeration of mortality and Morbidity (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculators. A retrospective review of all emergency laparotomies undertaken at four Australian centers was performed between January 2016 and December 2017. Data extracted from patient records were used to calculate NRPC, ACS-NSQIP, and P-POSSUM scores for 30-day mortality risk. The sensitivity of NRPC was assessed using the NELA high-risk cohort score of ≥10% and this was compared with the other two calculators. There were 562 (M = 261, mean age = 66 [±17] y) patient charts reviewed in the study period. 59 patients died within 30 d (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high-risk group. Using the NELA high-risk cutoff, NRPC identified 52 deaths of 205 (25.4%) high-risk patients, P-POSSUM identified 46 of 245 (18.8%), and ACS-NSQIP identified 46 of 201 (22.9%). Using the McNemar test, no significant difference was noted between NRPC and P-POSSUM (P = 0.07) or NRPC and ACS-NSQIP (P = 0.18). In the Australian context, the NRPC is a highly sensitive and useful tool for predicting 30-day mortality in high-risk emergency laparotomy patients and is comparable with P-POSSUM and ACS-NSQIP calculators.
Publisher: Wiley
Date: 05-07-2017
DOI: 10.1111/ANS.14097
Publisher: Wiley
Date: 08-2002
DOI: 10.1046/J.1445-2197.2002.02475.X
Abstract: Hernia repair is one of the most frequently performed operations in general surgery - a total of 39 000 elective inguinal hernia repairs were performed in public and private hospitals in Australia between July 1998 and June 1999 - and, as such, even minor alterations in outcome and resource use have appreciable impact. However, decisions regarding choice of operation for hernia repair remain controversial. The purpose of the present paper is to critically evaluate the evidence available regarding recently introduced open mesh repair techniques and to try to identify meaningful directions for future hernia research. A thorough search of all published surgical literature was undertaken. Medline, EMBASE and the Cochrane databases were searched by title, by key words and by author. References in review articles and in textbooks were pursued. The manufacturing companies were contacted for trials evaluating their product. Eight original articles evaluating either the Kugel Patch, the PerFix Plug or the Prolene Hernia System were located. None of these trials directly compared two or more of these repair systems. To date, there has been no published review of the evidence regarding the newer mesh repair techniques. With one exception, all of these articles qualify as Level IV evidence. Highlighted is the lack of evidence regarding chronic significant posthernioplasty pain - this has an incidence of 6-12%. This complication is 3-5 times more common than recurrence after open repair, is clinically relevant, is poorly understood and has been poorly studied. Arguably it is a more important end point than recurrence. Only one study comparing the newer techniques of open hernia repair (PerFix Plug) constitutes level II evidence. The PerFix Plug appears to be quicker to insert and uses a smaller incision. Chronic significant posthernioplasty pain is a more important endpoint in hernia research than is recurrence, and this review concludes with a proposal for a multicentre, randomized, controlled trial evaluating the incidence of chronic significant posthernioplasty pain following elective mesh repair of primary, unilateral -hernias.
Publisher: Wiley
Date: 09-2019
DOI: 10.1111/IMJ.14157
Abstract: The 2017 National Bowel Cancer Screening Program report records a median time from positive faecal occult blood test to colonoscopy of 53 days. There is some intrinsic delay in accessing specialist medical opinion prior to colonoscopy. To examine the effect of the introduction of a Direct Access Colonoscopy Service (DACS). Using prospectively maintained databases, patients undergoing normal service (NS) colonoscopy and those referred to DACS were compared. The primary outcome measure was the time from general practitioner (GP) referral to colonoscopy. Secondary outcome measures included the proportion of patients who met the current recommended 30 days from GP referral to colonoscopy, and the proportion of patients who waited longer than 90 days. There were 289 patients in the NS group, and 601 patients who progressed on the DACS pathway. The demographics of both groups were comparable. DACS patients had a median waiting time of 49 days, significantly shorter than NS patients whose median wait was 79 days (P < 0.0001). Approximately 15.1% patients in the DACS group had their colonoscopy within 30 days from GP referral, significantly better than in the NS group (4.5%, P < 0.001). In the NS group, 41.2% patients waited longer than 90 days from GP referral to colonoscopy, compared with 16.3% in the DACS group (P < 0.001). DACS reduces waiting times to colonoscopy and is associated with an increased proportion of patients undergoing colonoscopy in a timely manner.
Publisher: Wiley
Date: 07-07-2000
DOI: 10.1046/J.1440-1622.2000.01893.X
Abstract: John Hunter Hospital is the major trauma centre for a region covering more than 25,000 square kilometres. The helicopter primary retrieval service for trauma is paramedic staffed and protocol driven. The aim of the present study was to assess the overtriage rate created by such protocols, and to assess the benefit to patient outcomes that may be attributable to the service. The John Hunter Hospital trauma database was used to identify all cases arriving by helicopter in 1996, as well as their demographic details, injury severity score, details of the accident and outcome. An expert panel reviewed the medical records for the 184 primary retrievals. Using a consensus model, estimates of time delay or saving were calculated and likelihood of benefit, no benefit or harm was assessed. A total of 3087 trauma patients were assessed at John Hunter Hospital in 1996, of which 8% arrived by helicopter. Of the primary retrievals, 67.6% had an injury severity score of 9 or less, with only 17.9% having a score of 16 or greater. Twelve patients were discharged from Emergency and 36% were discharged within 48 h. The overall mortality was 5.0%. Twenty-five per cent of patients were retrieved within 35 km of John Hunter Hospital with minimal attributable benefit. Overall 1.7% of patients were felt to have been potentially harmed, 17.3% to have benefited and 81.0% to have had no attributable benefit related to the helicopter use. Although the majority of retrievals are for minor injuries, the service provides benefit for the region. There is potential for harm, however, where base hospitals are overflown in situations where patients have airway compromise, and where patient transfer is delayed due to helicopter activation. Primary helicopter tasking to trauma cases within 35 km of the major trauma centre is seldom beneficial.
Publisher: MDPI AG
Date: 06-12-2020
DOI: 10.3390/JCM9123954
Abstract: Background: Hypertriglyceridemia-associated acute pancreatitis (HTGAP) has been linked with increased severity and morbidity. In this study, triglyceride levels were measured in all patients admitted with acute pancreatitis (AP) to establish the incidence of HTGAP in an Australian center. Methods: A prospective cohort with AP was collated over an 18-month period in a single tertiary referral hospital. HTGAP was defined as AP with triglycerides ≥ 11.2 mmol/L (1000 mg/dL). Incidence, clinical co-morbidities, severity and management strategies were recorded. Results: Of the 292 episodes of AP, 248 (85%) had triglycerides measured and were included. HTGAP was diagnosed in 10 of 248 (4%) AP cases. Type 2 diabetes, obesity, alcohol misuse and gallstones were common cofactors. The HTGAP group demonstrated severe hypertriglyceridemia compared to the non-HTGAP group (median 51 mmol/L vs. 1.3 mmol/L). Intensive care unit (ICU) admissions were significantly increased (odds ratio (OR) 16 95% CI 4–62) in the HTGAP group (5/10 vs. 14/238 admissions, p 0.001) and constituted 26% (5/19) of total ICU admissions for AP. Four patients received intravenous insulin with fasting and had a rapid reduction in triglyceride levels by 65–77% within 24 h one patient had mild hypoglycemia secondary to therapy. Conclusion: HTGAP occurred in 4% of AP cases and was associated with higher risk of ICU admission. Intravenous insulin and fasting appear safe and efficacious for acutely lowering triglyceride levels in HTGAP.
Publisher: AMPCo
Date: 10-1996
Publisher: Wiley
Date: 03-1990
Publisher: Elsevier BV
Date: 2017
DOI: 10.4158/EP15785.CR
Publisher: American Society of Clinical Oncology (ASCO)
Date: 02-2017
DOI: 10.1200/JCO.2017.35.4_SUPPL.499
Abstract: 499 Background: Borderline resectable pancreas cancers (BRPC) often require vascular reconstruction, have higher rates of operative margin positivity and confer a poor prognosis. In 2014, our high-volume pancreatectomy, gastrointestinal tumor multidisciplinary treatment (GI MDT) group endorsed a consensus anatomical definition of BRPC consistent with NCCN criteria. Diagnostic and staging tests were standardized and a neoadjuvant chemoradiotherapy protocol adopted with the goals to (1) improve R0 resection rate and (2) prevent futile surgery in rapidly progressive disease. Methods: Neoadjuvant chemoradiotherapy (CRT) consisted of 50.4Gy in 28# and concurrent capecitabine 830mg/m2 bd. Pancreatectomy was planned 4-8 weeks later unless repeat imaging showed progressive disease. Comprehensive, prospectively defined data items were collected on all patients (pts) diagnosed with BRPC. Results: Nine pts have been diagnosed with BRPC by the GI MDT. Seven pts received full dose of CRT, one pt progressed during CRT hence stopped early and one pt didn’t receive CRT due to significant deterioration beforehand. CRT was tolerable in all eight pts who received it there were no dose modifications for toxicity. Post-CRT, three pts underwent curative-intent resection and all are still alive (494, 319 and 172 days post-CRT). One was found to have a solitary liver metastasis during surgery (resected), R1 resection (SMV margin involvement) of T3N1 tumor and is receiving palliative chemotherapy. Two other pts underwent R0 resections (T3N0, T3N1) with histopathologic response to CRT. Four pts showed progressive disease on post-CRT imaging (all local & distant progression) and subsequently received palliative therapy. Median survival (first dose CRT to death) in the 5 CRT pts who have succumbed was 509 days (range 363-577). Conclusions: In this small prospective, unselected cohort the majority of pts diagnosed with BRPC demonstrated disease progression during/after neoadjuvant CRT and did not proceed to surgical resection, underscoring the poor prognosis of this pancreas cancer subset. Neoadjuvant CRT is well tolerated and did not preclude subsequent surgery in those patients with stable disease.
Publisher: Oxford University Press (OUP)
Date: 31-01-2005
DOI: 10.1002/BJS.4944
Publisher: Wiley
Date: 05-12-2000
Publisher: Wiley
Date: 2013
DOI: 10.1111/ANS.12028
Publisher: Wiley
Date: 21-07-2016
DOI: 10.1111/ANS.13676
Abstract: Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy ( LC ) and pre or postoperative endoscopic retrograde cholangiopancreatography ( ERCP ). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP , the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP ( SSLCE ) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two‐stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans‐cystic exploration and equivalent to the standard two‐stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.
Publisher: Wiley
Date: 12-2016
DOI: 10.1111/ANS.13797
Publisher: AMPCo
Date: 04-2020
DOI: 10.5694/MJA2.50508
Publisher: BMJ
Date: 07-2023
DOI: 10.1136/BMJOPEN-2022-070159
Abstract: The Australian population presenting with surgical pathology is becoming older, frailer and more comorbid. Shared decision-making is rapidly becoming the gold standard of care for patients considering high-risk surgery to ensure that appropriate, value-based healthcare decisions are made. Positive benefits around patient perception of decision-making in the immediacy of the decision are described in the literature. However, short-term and long-term holistic patient-centred outcomes and cost implications for the health service require further examination to better understand the full impact of shared decision-making in this population. We propose a novel multidisciplinary shared decision-making model of care in the perioperative period for patients considering high-risk surgery in the fields of general, vascular and head and neck surgery. We assess it in a two arm prospective randomised controlled trial. Patients are randomised to either ‘standard’ perioperative care, or to a multidisciplinary (surgeon, anaesthetist and end-of-life care nurse practitioner or social worker) shared decision-making consultation. The primary outcome is decisional conflict prior to any surgical procedure occurring. Secondary outcomes include the patient’s treatment choice, how decisional conflict changes longitudinally over the subsequent year, patient-centred outcomes including life impact and quality of life metrics, as well as morbidity and mortality. Additionally, we will report on healthcare resource use including subsequent admissions or representations to a healthcare facility up to 1 year. This study has been approved by the Hunter New England Human Research Ethics Committee (2019/ETH13349). Study findings will be presented at local and national conferences and within scientific research journals. ACTRN12619001543178.
Publisher: Royal College of Surgeons of England
Date: 11-2014
DOI: 10.1308/003588414X14055925058832
Abstract: Acute general surgical units (AGSUs) are changing the way in which acute appendicitis is managed. In the AGSU at John Hunter Hospital, some patients wait more than 48 hours from admission to undergo an appendicectomy, usually because they are not unwell enough to precipitate an operation before that time. We analysed this subgroup of appendicectomy patients to determine how effectively they are being managed and how this might be improved. A retrospective review of prospectively collected data was conducted of all patients who received an appendicectomy while admitted under the AGSU at John Hunter Hospital in the five years between January 2009 and December 2013. A total of 1,039 appendicectomies were performed in the study period, with 81 patients (7.8%) waiting hours for their operation (delayed appendicectomy group). Overall, the negative appendicectomy (NA) rate was 21.6% the NA rate in delayed appendicectomies was 50.62% and a non-therapeutic operation occurred in 47% of this group (n=38). No significant difference was found in the incidence of perforation/gangrenous appendicitis between patients having surgery in hours and the delayed appendicectomy groups (11.2% vs 9.9%, p=0.85). A combination of negative diagnostic imaging result, a normal white cell count and normal C-reactive protein (ie a negative ‘triple test’) was the best predictor of a negative appendicectomy (p=0.0158, negative predictive value: 0.91, 95% confidence interval: 0.59–0.99), in the delayed appendicectomy group. In the delayed appendicectomy group, the incidence of perforation/gangrenous appendicitis was not significantly different from that found in patients having appendicectomy performed sooner. However, the NA and non-therapeutic operation rates were unacceptably high. An appendix triple test can improve diagnostic accuracy significantly without an unacceptable rise in the rates of perforation/gangrenous appendicitis.
Publisher: Wiley
Date: 09-2004
Publisher: OMICS Publishing Group
Date: 2013
Publisher: Elsevier BV
Date: 1992
DOI: 10.1016/0014-4827(92)90152-X
Abstract: Fetal embryonic fibroblasts attach and spread on thrombospondin (TSP). Adhesion is tight and focal adhesion plaques and "spots" are formed. We have investigated the receptors responsible for this adhesion. Unstimulated cells express the vitronectin receptor on their surface and this beta 3 integrin molecule contributes to adhesion. Another putative receptor for TSP, termed glycoprotein (GP) 88, which exists as a cytoplasmic pool in unstimulated cells becomes surface expressed when these cells are plated on TSP and localizes to areas of cell adhesion. Western blot analysis of cell lysate confirms GP88 as a TSP binding protein. Studies with fucoidan indicate that the heparan sulfate proteoglycan, known to function as a receptor for TSP, appears to contribute substantially to the TSP attachment of these cells and may be the receptor most important in the initial phases of TSP interaction.
Publisher: Wiley
Date: 06-2019
DOI: 10.1111/IMJ.14149
Abstract: A direct access colonoscopy service (DACS) for the National Bowel Cancer Screening Program has become standard of care in Newcastle public hospitals because of the effect it has on time to colonoscopy. Cost-effectiveness has not been studied to date. The aim of this retrospective study was to analyse the cost-effectiveness of a DACS. Data were collected for patients referred to DACS between January 2014 and June 2016, and patients who were treated on the normal service pathway in 2013 prior to the introduction of the process. A cost-benefit analysis from the patient's and local health district's perspective was undertaken. Introduction of the DACS produces a direct financial gain to patients in the form of reduced direct costs. It produces an indirect financial gain in terms of increased productivity if the patient is in work, and of increased leisure time if not in work. The DACS is modest income generating for the local health district, an evaluation which is sensitive to internal policies for distribution of government funding within a district. The DACS increases the availability of outpatient consultations to other patients, which is not a quantifiable economic benefit, but is likely to be an overall health benefit. The introduction of DACS in the public system in Australia is of financial benefit to patients and to the local health service provider. It is likely to produce health benefits to non-screening patients, by means of freeing consultations to be used for other indications.
Publisher: Wiley
Date: 27-02-2023
DOI: 10.1111/ANS.18342
Publisher: Science Publishing Group
Date: 2020
Publisher: Wiley
Date: 29-10-2003
Publisher: Wiley
Date: 11-1998
DOI: 10.1111/J.1440-1673.1998.TB00540.X
Abstract: Glomus vagale are rare vascular tumours of the paraganglion cells of the vagus nerve, and they usually occur in the carotid space. Tumours can be familial, multicentric, malignant but rarely hormonally active. A rare case is reported of glomus vagale presenting as a supraclavicular mass.
Publisher: Wiley
Date: 11-1991
DOI: 10.1111/J.1445-2197.1991.TB00162.X
Abstract: We report two sets of twins with agenesis and ectopia of the gall-bladder. It is important to be aware of this condition, as many of these patients present with biliary-type pain and have unnecessary laparotomies. The literature on this condition is reviewed.
Publisher: Wiley
Date: 04-2003
DOI: 10.1046/J.1445-1433.2002.02567.X
Abstract: The aim of the present study was to evaluate the utility of nuclear scintigraphic-labelled red cell scanning in the management of bleeding in patients with acute lower gastrointestinal haemorrhage (GIH) who require surgery. A prospective database was used to source data on all patients with lower GIH who underwent technetium-99m (99mTc)-labelled red cell scanning over a 10-year period. A subgroup was identified from cross-reference with the medical records identifying only those patients who continued to bleed and subsequently required laparotomy for further detailed retrospective study. One key question was asked: did the labelled red cell scan influence the type of operation performed by the operating surgeon? The study identified 249 patients who underwent 287 labelled red cell scans for GIH. Forty patients (16%) underwent laparotomy for ongoing bleeding 28/40 (70%) of the red cell scans were positive for bleeding. Six patients (15%) died postoperatively, none because of continued bleeding. The 99mTc-labelled red cell scan was deemed to have been unhelpful in 22 (55%) cases. Twelve of the 22 scans were negative and 10 of the 22 scans were positive but were ignored by the surgeon. The 99mTc-labelled red cell scan influenced the choice of operation in 18 out of 40 patients (45% of the operated group but only 7.2% of the total scanned group). Of these, 15 patients underwent colonic resection and three patients underwent small bowel resection. The present study demonstrates that labelled red cell scanning has only a small role to play in managing lower GIH. The 99mTc-labelled red cell scanning should be used much more selectively. Its use should be limited to patients who continue to bleed after conservative management it may allow these patients to be effectively treated by segmental bowel resection. Its most critical role, however, is probably to prevent suspected small bowel bleeding from being missed at operation.
Publisher: BMJ
Date: 14-10-2000
Abstract: To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis. A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group). Single tertiary referral centre. 302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team. Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation. Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45). Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.
Publisher: Springer Science and Business Media LLC
Date: 04-07-2014
Publisher: Wiley
Date: 05-2004
Publisher: Wiley
Date: 2018
DOI: 10.1111/ANS.14270
No related grants have been discovered for Jonathan Gani.