Audit of middle-ear surgery outcomes in a tertiary referral Australian teaching hospital.

OBJECTIVE: This study aimed to audit middle-ear surgical procedures, provide a record of Australian experiences and allow comparisons with other published audits. METHOD: A retrospective continuous series audit was conducted on 274 patients who underwent tympanoplasty, mastoidectomy and stapedotomy surgery at Westmead Hospital, Sydney. All consecutive surgical procedures, performed by multiple operators at various stages of training but under the care of a single surgeon, were included. RESULTS: Graft uptake was 86.9 per cent in tympanoplasty. Well healed cavities were seen in 72 per cent of mastoidectomies. Although 42 per cent of the patients had one or more co-morbidities, this did not influence the outcome. Hearing improvement was dramatic in stapedotomy and minimally changed in mastoidectomy. Post-operative complications were minimal. CONCLUSION: All forms of middle-ear surgery were effective in achieving their surgical goals. Aural discharge and inflammatory diseases were well controlled with tympanoplasty and mastoid surgery.

Multimodality treatment of intracranial arteriovenous malformations in South Island, New Zealand.

Treatment of intracranial arteriovenous malformations is complex and multidisciplinary. This article presents the treatment model utilized in Christchurch, New Zealand which provides cerebrovascular surgery and interventional neuroradiology to the entire south island (approximate population of 1.1 million). A total of 40 patients treated over a 10 year period (2004-2014) are analysed here. Nine patients were managed surgically and complete resection was achieved in 100% of cases. Permanent mortality was 0% and permanent morbidity was 22% however median mRS improved from 3.0 preoperatively to 1.0 at follow up. Embolisation was utilized in 31 patients (mean age 40), of which 45% presented with haemorrhage, 39% with seizures, 10% with a headache only, and 6% with a deficit. None were found incidentally. The Spetzler-Martin grade 1 cases accounted for 10% of the cohort, 23% were grade II, 42% grade III, 23% grade IV and 3% grade V. A single aneurysm was present in 42% of cases, and multiple in 13%. The nidus was obliterated in 9.6% of cases with a morbidity rate of 6.5% and mortality rate of 3%. Modified Rankin scale improved marginally from 0.9 at diagnosis to 0.88 at final follow up (mean 22 months). There were no cases of recanalization. The total nidus obliteration rate using our algorithm of surgery alone for small accessible lesions, then staged embolization for larger lesions with adjuvant radiosurgery reserved for cases with residual nidus, was 50%.

Outcomes of tumour related epilepsy in a specialised epilepsy surgery unit.

INTRODUCTION: Seizures are an important cause of morbidity in patients with low grade gliomas with approximately 40% of cases drug resistant. The pathogenesis is quite complex and poorly understood. The treatment aims vary between almost purely epilepsy considerations and those that are primarily oncologic. AIM: To determine whether patients who present with seizures and are found to have a low grade glioma have better outcomes when managed through a specialized epilepsy unit compared to the general neurosurgical service. METHODS: A review of the prospectively collected database was performed over a 10 year period to identify 48 adult patients who present with a seizure and were subsequently found to have a low grade glioma. These patients were analysed with respect to management through the specialized epilepsy service or the general neurosurgical service. The primary outcome was Engel classification between the two groups. Secondary outcomes included recurrence, postoperative deficits, delay to surgery, histology, grade and extent of resection. OUTCOMES: The patients managed through the epilepsy service had significantly higher rate of favourable Engel outcomes (I and II) compared to the general neurosurgery service (OR: 13.2, 95% CI: 1.239-140.679; P = 0.033). The epilepsy surgery group patients had a significantly higher delay to surgery (P < 0.001). The patients in the epilepsy service had a significantly higher resection ratio compared to the general neurosurgery service (73% vs 127%, P = 0.014). Rates of recurrence were not different between the two groups. CONCLUSION: Patients with tumour related epilepsy who undergo an intensive presurgical evaluation may obtain better seizure related outcomes.

Injury patterns in patients who "talk and die".

Despite advances in the quality of and access to cerebral imaging, patients with mild head injuries still deteriorate and die in neurotrauma units. The term "talk and die" was first used by Reilly et al. to describe a subset of patients with head injuries who died following what was initially thought to be only a mild traumatic brain injury. A retrospective review of a database from a major Australian trauma center was performed to identify 25 patients who met the "talk and die" criteria between January 2000 and December 2009. The medical records of these patients and their imaging studies were analyzed to identify potentially preventable factors and injury patterns in this group of patients. The factors analyzed included age, modality of injury, therapeutic narcotic usage, seizures, and hyponatremia. Two groups of patients are described herein based on intracranial pathology, with statistically significant differences in age, mechanism, and coagulopathy identified.

Differing association of macrophage subsets with atherosclerotic plaque stability.

AIM: While initial research suggests that M2 macrophages are athero-protective, more recently, proatherogenic functions, such as a greater uptake of lipid than M1 macrophages, have been demonstrated, raising the question of their actual association with plaque stability. The present study, therefore, assessed the association between macrophage subset and plaque stability. Furthermore, it examined whether the fibrocyte, that we have previously identified in the plaque, represents a subset of M2 macrophages. METHODS: Twenty human carotid atherosclerotic plaque specimens were examined for the presence of macrophages using immunohistochemistry for pan macrophages (CD68), M1 (CD64, CD86) and M2 (CD163, CD206) subsets. The slides were assessed by digital whole slide scanning/image analysis to quantify the expression of these markers in the plaque. Comparisons in marker distribution and quantity relative to plaque stability were made. Adoption of a fibrocyte phenotype was assessed by double immunofluorescence staining of the markers with procollagen I. RESULTS: M1 and M2 macrophages were present throughout the plaque including the core and cap. While the levels of CD68 (pan macrophage maker) and CD86 negatively correlated with cap thickness, the levels of the M2 marker, CD163, did not and moreover, did not differ between plaques when they were separated into stable and unstable groups. Notably, collagen production was evident in most but not all M2 macrophages. CONCLUSION: Our findings demonstrate that while macrophage levels in general negatively correlate with plaque cap thickness, levels of M2 macrophages do not. This may be in part due to their ability to produce collagen (ie adopt a fibrocyte phenotype) in the plaque.

Venous thromboembolism following primary total hip arthroplasty.

AIM: In the absence of thromboprophylaxis, venographically detected deep vein thrombosis (DVT) occurs in approximately 50% of patients undergoing primary total hip arthroplasty. Despite the existence of national and international guidelines, thromboprophylaxis may be underused. METHODS: A retrospective review was performed of the clinical incidence of venous thromboembolism (VTE) and thromboprophylactic practice patterns over a nine year period. Patient baseline characteristics, VTE risk factors, prophylactic modalities (mechanical and pharmacological), operation duration, type of prosthesis and fixation, mode of anesthesia, hospital length of stay (LOS) were analyzed. The main efficacy outcome was DVT and/or pulmonary embolism (PE). The primary safety outcome was major bleeding. RESULTS: In-hospital incidence of VTE was 2.5% and 3.8% up to three months post hospital discharge. Median time to postoperative VTE development in-hospital and after discharge was 6.5 days (IQR: 5.0 to 8.0 days) and 29.0 days (IQR: 19.5 to 38.0 days) respectively. 66.7% (95% CI: 30.0 to 90.3%) of all readmissions for VTE occurred within one month post-operatively. There were no readmissions for VTE in patients discharged on extended pharmacological prophylaxis. CONCLUSIONS: The use of prophylactic protocols was associated with relatively low VTE rates up to three months with minimal bleeding complications. A more intense in-hospital and extended prophylaxis beyond hospitalization is recommended in this high risk group of patients.

Improved outcomes with endovascular stent grafts for thoracic aorta transections.

OBJECTIVE: To retrospectively assess the outcome of endovascular stent-graft implantation for thoracic aortic transections (ETAT). DESIGN: Retrospective review. METHODS: 16 patients median age 30 years, treated between May 2000 and April 2007. Median injury severity score was 33 (range 29 to 66) in 14 acute patients; 2 patients had thoracic pseudoaneurysms. The Cook-Zenith endograft was used in eight patients, Medtronic-Talent (6) and Gore-Excluder (2). Average procedure time was 90 minutes, blood loss 100 (range 40 to 3000) mls, screening time 10.8 (range 5.9 to 22.6) minutes, and contrast dose was 195 (range 60 to 400) mls. RESULTS: Graft deployment was successful in all cases. There was one death within 30 days. The left subclavian artery was completely covered in one case, and partially in three. Two patients had Type I endoleak, and one delayed Type II endoleak. One patient had iatrogenic right coronary artery dissection. Two patients developed difficult to treat hypertension, and one acute renal failure. CONCLUSION: Endovascular intervention is a safe and effective treatment for aortic transection in multiple trauma patients. ETAT reduces the major morbidity and mortality associated with open repair in multiple trauma patients. The majority of these patients are young and long-term follow up is necessary to assess graft durability.

Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis.

BACKGROUND: Venous stasis is an important contributing factor in the development of travel-related deep vein thrombosis. This study examined factors affecting popliteal venous blood flow in order to determine the most effective exercise regimen to prevent venous stasis. METHODS: Twenty-one healthy subjects were randomly assigned to various activities over a 9-week period. Subjects remained seated throughout the investigation and 3660 duplex ultrasound examinations were performed by a single examiner using a SonoSite 180 Plus handheld ultrasound. Baseline popliteal vein blood flow velocity, cross-sectional area and volume flow in subjects sitting motionless were assessed in the first 3 weeks.The remaining 6 weeks involved subjects performing airline-recommended activities, foot exercises, foot exercises against moderate resistance and foot exercises against increased resistance in order to determine the most beneficial method for enhancing popliteal venous flow. Sitting with feet not touching the floor and the effect of sleeping were also assessed. RESULTS: The median age of the subjects was 22 years (range: 18-25.5 years), height 171 cm (162.5-180.5 cm) and body mass index 25.3 kg m(-2) (23.2-26.3 kg m(-2)). Blood volume flow in the popliteal vein was reduced by almost 40% with immobility of seated subjects and by almost 2-fold when sitting motionless with feet not touching the floor. Foot exercises against increased resistance positively enhanced volume flow (P < 0.0001). CONCLUSION: Leg exercise regimens enhanced popliteal venous flow during prolonged immobility of seated subjects, reinforcing the importance of regular leg movement to prevent venous stasis during prolonged sitting, such as in long-distance travel.

Deep vein thrombosis in trauma: a prospective study of lower limb orthopedic trauma patients in Tianjin Hospital, China.

AIM: Pulmonary embolism is a third leading cause of death in trauma patients. The prevalence of deep vein thrombosis (DVT) in Asian countries is considered to be less than in Western countries. Our aim was to establish the rate of DVT in orthopedic trauma patients in Tianjin Hospital, to identify DVT risk factors and to support the use of prophylaxis. METHODS: Patients admitted between November 2003 and October 2004 with recent fracture had data collected prospectively to record type of fracture, mechanism of injury, history of DVT, blood transfusion requirements, operation details, extent of postoperative swelling, use of traction, immobilization, bandaging and patient positioning. Each patient had 3 duplex ultrasound examinations, the first within 24 h of admission. Patients requiring surgery had a second ultrasound within 2 days preoperatively, then 7 days postoperatively. Patients not requiring surgery had second and third ultrasound examinations 5 and 14 days after admission. RESULTS: There were 547 patients, median age 39.6 years (interquartile range: 28-50 years). DVT developed in 12.4% (95% confidence interval: 9.7-15.2%), most occurring with femoral shaft fractures (30.6%), 15.8% occurred with hip fractures, 14.5% with fractures around the knee and 10.8% with fractured tibia and fibula. Over half of DVTs (56.7%) developed within 3 days following injury. CONCLUSION: The incidence of DVT in Chinese orthopedic trauma patients approaches that in Western countries. Guidelines for DVT prophylaxis should be applied in China as in Western countries.

Venous thromboembolism following primary total knee arthroplasty.

AIM: Total knee arthroplasty is associated with a high postoperative incidence of venous thromboembolism (VTE). Without thromboprophylaxis, as many as 80% of patients may develop deep vein thrombosis (DVT). Evidence suggests that pharmacological prophylaxis may not be offered due to concern of bleeding with anticoagulants. METHODS: We retrospectively reviewed the clinical incidence of VTE and thromboprophylactic practice patterns over a 9-year period. Patient baseline characteristics, diagnosis, VTE risk factors, prophylactic modalities (mechanical and pharmacological), operation duration, type of prosthesis and fixation, mode of anesthesia, hospital length of stay (LOS) and postoperative complications with particular attention to suspected DVT and/or pulmonary embolism (PE) were analysed. RESULTS: Male to female ratio was 1:2.3, median age 71 (interquartile range, IQR: 65-77) years and hospital LOS of 8 (IQR: 7-11) days. The in-hospital VTE incidence was 3.9% (95% confidence interval, CI: 2.2-6.8%) with a possibly underestimated 3-month rate of 5.7% (95% CI: 1.6-18.6%). In-hospital proximal DVT incidence was 0.7% (95% CI: 0.2-2.5%) and 2.9% (95% CI: 0.5-14.5%) at 3 months. Non fatal PE was 0.7% (95% CI: 1.2-5%). DVT rate was higher with cemented prostheses (P=0.008), with a greater rate of bleeding when heparin was commenced preoperatively (P=0.001). CONCLUSIONS: The rate of in-hospital VTE was kept relatively low with the use of prophylactic protocols with all patients receiving prophylaxis. Given our one and a half and four-fold increase in the out of hospital VTE and proximal DVT incidence, consideration should be given to continued prophylaxis beyond hospitalization in this high-risk group of patients.

Mortality, morbidity and functional outcome after ileorectal anastomosis.

BACKGROUND: Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. The aim of this study was to review postoperative mortality, morbidity and functional results in an effort to identify risk factors predictive of a poor outcome. METHODS: Some 215 patients (118 women and 97 men) with a median age of 33 (interquartile range (i.q.r.) 25-47) years underwent an IRA between November 1990 and December 1999. Median follow-up was 2 years 9 months (i.q.r. 1-5 years). The clinical notes of these patients were reviewed retrospectively to analyse the postoperative course, bowel function and long-term clinical outcome. RESULTS: The indications for surgery included familial adenomatous polyposis (52.1 per cent), Crohn's disease (14.4 per cent), functional bowel disorder (14.4 per cent), ulcerative colitis (8.4 per cent) and colonic carcinoma (4.7 per cent). The overall 30-day mortality and morbidity rates were 0.9 and 26.0 per cent respectively. This included anastomotic leak (6.5 per cent), small bowel obstruction (14.4 per cent), fistula (2.8 per cent) and anastomotic stricture (1.4 per cent). The incidence of fistula and anastomotic stricture was significantly higher in Crohn's disease (P < 0.001 and P = 0.005 respectively). Only 16 of 31 patients with Crohn's disease had a functioning IRA at long-term follow-up. Median stool frequency was 3 (i.q.r. 3-5) per day one year following surgery and did not change with longer follow-up. CONCLUSION: Mortality and morbidity rates following IRA are low. Postoperative fistula and anastomotic stricture are more common in patients with Crohn's disease, approximately half of whom will eventually need a permanent ileostomy. Long-term bowel function for all groups is satisfactory.

Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre.

AIMS: The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs). METHODS: This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records. RESULTS: Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality. DISCUSSION: Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.