Bernie Bourke

TElmisartan in the management of abDominal aortic aneurYsm (TEDY): The study protocol for a randomized controlled trial

BackgroundExperimental studies suggest that angiotensin II plays a central role in the pathogenesis of abdominal aortic aneurysm. This trial aims to evaluate the efficacy of the angiotensin receptor blocker telmisartan in limiting the progression of abdominal aortic aneurysm.Methods/DesignTelmisartan in the management of abdominal aortic aneurysm (TEDY) is a multicentre, parallel-design, randomised, double-blind, placebo-controlled trial with an intention-to-treat analysis. We aim to randomly assign 300 participants with small abdominal aortic aneurysm to either 40 mg of telmisartan or identical placebo and follow patients over 2 years. The primary endpoint will be abdominal aortic aneurysm growth as measured by 1) maximum infra-renal aortic volume on computed tomographic angiography, 2) maximum orthogonal diameter on computed tomographic angiography, and 3) maximum diameter on ultrasound. Secondary endpoints include change in resting brachial blood pressure, abdominal aortic aneurysm biomarker profile and health-related quality of life. TEDY is an international collaboration conducted from major vascular centres in Australia, the United States and the Netherlands.DiscussionCurrently, no medication has been convincingly demonstrated to limit abdominal aortic aneurysm progression. TEDY will examine the potential of a promising treatment strategy for patients with small abdominal aortic aneurysms.Trial registrationAustralian and Leiden study centres: Australian New Zealand Clinical Trials Registry ACTRN12611000931976, registered on 30 August 2011; Stanford study centre: clinicaltrials.gov NCT01683084, registered on 5 September 2012.

Development of the Australasian Vascular Surgical Audit

OBJECTIVE The purpose of this study was to describe the development of the Australasian Vascular Audit that was created to unify audit activities under the umbrella of the Australian and New Zealand Society for Vascular Surgery as a Web-based application. METHODS Constitutional change in late 2008 deemed participation in this audit compulsory for Society members. The Web-based application was developed and tested during 2009. Data for all open vascular surgery and for all endovascular procedures are collected at two points in the admission episode: at the time of operation and at discharge, and entered into the application. Data are analyzed to produce risk-adjusted outcomes. An algorithm has been developed to deal with outliers according to natural justice and to comply with the requirements of regulatory bodies. The Audit is protected by legislated privilege and is officially endorsed and indemnified by the Royal Australasian College of Surgeons. Confidentiality of surgeons and patients alike is ensured by a legally protected coding system and computer encryption system. Validation is by a verification process of 5% of members per year who are randomly selected. The application is completely funded by the Society. RESULTS Data entry commenced on January 1, 2010. Over 40,000 vascular procedures were entered in the first year. The Audit application allows instantaneous on-line access to individual data and to deidentified group data and specific reports. It also allows real-time instantaneous production of log books for vascular trainees. The Audit has already gained recognition in the Australasian public arena during its first year of operation as an important benchmark of correct professional surgical behavior. Compliance has been extremely high in public hospitals but less so in private hospitals such that only 60% of members received a certificate of complete participation at the end of its first year of operation. CONCLUSION An Internet-based compulsory audit of complete surgical practice is possible to create and be maintained by a society of surgeons with a membership of just over 200. The 60% compliance rate for complete data entry has created an immediate constitutional challenge for the Society. Future challenges are to improve total participation to an acceptable level and to ensure accurate data entry via a robust validation system.

Association between metformin prescription and growth rates of abdominal aortic aneurysms

It has been suggested that diabetes medications, such as metformin, may have effects that inhibit abdominal aortic aneurysm (AAA) growth. The aim of this study was to examine the association of diabetes treatments with AAA growth in three patient cohorts.

Results from the Australasian Vascular Surgical Audit: the inaugural year

The Australian and New Zealand Society for Vascular Surgery has incorporated a constitutional change to administer a self‐funded compulsory vascular surgery audit since January 2010. This is a bi‐national quality assurance activity that captures all procedures performed in both countries. Data is collected at two points in the clinical admission; at operation and at discharge and data entry is via the Internet. Security is stringent and confidentiality is guaranteed by Commonwealth privilege. Data privacy is maximized by encryption. The application is flexible and administered by a dedicated administrator with a help‐desk facility. Reports are available to provide real‐time feedback of user performance compared with the peer group data in key categories of arterial surgery. A structured hierarchy for data management has been established to assess four main categories of performance: mortality after aortic surgery, stroke and death after carotid surgery, patency and limb salvage after infrainguinal bypass and patency after arteriovenous access for haemodialysis. Data is analysed using risk‐adjustment techniques and an algorithm for management of underperformance has been followed. Data validation has been performed. The outcomes in all categories have been of a high standard and correction of erroneous data in a single statistical outlier has negated underperformance. The audit has captured only 65% of the estimated procedures in Australia in the first year, but data quality is good. The feasibility of a complete compulsory bi‐national audit has now been established and will be the benchmark for other craft groups in the current environment of accountability.

Metformin prescription is associated with reduced abdominal aortic aneurysm growth in three cohorts

It has been suggested that diabetes medications, such as metformin, may have effects that inhibit abdominal aortic aneurysm (AAA) growth. The aim of this study was to examine the association of diabetes treatments with AAA growth in three patient cohorts.

Millipede burn masquerading as trash foot in a paediatric patient.

affected. Surgical excision is usually curative, however recurrence rates of between 14% and 24% have been reported. Other head and neck tumours encountered for a child this age include neuroblastoma, rhabdomyosarcoma, lymphoma and nonrhabdomyosarcoma soft tissue sarcomas. In the older literature, the terms lipoblastoma, lipoblastomatosis and hibernoma have been used interchangeably, leading to some confusion. At present, the term lipoblastoma is used to refer to the well-encapsulated variety containing more myxoid stroma with peripheral infiltration and distribution throughout all the tissue layers. Lipoblastomatosis currently refers to the more diffuse and infiltrative tumour type, which is distributed in the deep layer and is more likely to recur after surgery. Hibernomas are gray-brown, lobulated tumours arising from brown fat. Histologically, lipoblastomas contain immature fat cells in varying stages of maturity with septae between the cells dividing them into lobules. These are differentiated from myxoid liposarcomas, the most common histological type among children, by observing poorly defined lobulation with larger lobules, atypical nuclei, abnormal mitoses and the presence of mucinous pools. Liposarcomas may resemble lipoblastomas histologically, making diagnosis difficult. Chromosomal analysis might help to differentiate the two. Lipoblastomas are associated with breakpoint abnormalities at chromosomal region 8q11-13, while a distinctive translocation t(12;16) (q13;p11) is observed with myxoid liposarcomas. In contrast, liposarcomas are rare before the age of 5 years, which virtually excludes it from the differential diagnosis of a neck lump in infancy and early childhood. Imaging is not useful in differentiating the two. On computed tomography imaging, the lesion appears radioopaque and non-enhancing with the same Hounsfield density as fat. On MRI, the lesion usually appears lobulated and heterogenous with streaks and whorls and is able to be differentiated from subcutaneous fat on T1and T2-weighted images because of the presence of immature lipoblasts. Unlike subcutaneous fat, lipoblastomas demonstrate high signal intensity on fat suppression, making this a potential diagnostic characteristic. References

Response from Dr Thomson et al. to Mortality rates after surgery in New South Wales

A 22-year-old Australian male presented with an acute, extremely painful lump in his right groin. The mass was 1.5 ¥ 2.0 cm in size and the severity of the pain appeared disproportionate to its size. He reported to have previously experienced a number of similar episodes and following examination, the mass was reduced and an inguinal hernia suspected. Intraoperatively, the hernia did not involve the deep inguinal ring nor protrude through Hesselbach’s triangle. Instead, it became evident that this mass was an interparietal hernia protruding through a defect in the right conjoint tendon (see Fig. 1). The hernia was repaired laparoscopically with a mesh overlay and the patient made an uncomplicated recovery. The conjoint tendon is formed by the convergence of fibres derived from the aponeurosis of the transversus abdominis and internal oblique muscles. This tendinous structure inserts onto the pubic crest and serves to reinforce a point of relative anatomical weakness, contributing stability to the medial aspect of Hesselbach’s triangle. A hernia of the conjoint tendon is considered a special variant of a direct hernia and in Europe is referred to as a Gill-Ogilvie hernia. It is most frequently noted in young athletic males with welldeveloped abdominal musculature and is thought to result from an acquired, narrow defect secondary to rigorous activity and straining. Our literature review indicated that there are few published accounts of these herniae and we believe it is yet to be reported in Australian literature. Interestingly, herniae of the conjoint tendon have a significant incidence in Bugosa, Uganda, and therefore have been described eponymously as ‘Bugosa’ herniae. In symptomatic patients, laparoscopic repair is the treatment of choice because of the ease of the procedure and risk of hernia strangulation. We hope this report encourages discussion of similar herniae and would be interested to hear of other surgeons’ experiences. References

Erratum to: 'TElmisartan in the management of abDominal aortic aneurYsm (TEDY): The study protocol for a randomized controlled trial' [Trials, (2016), 17:43]

Endnote Dylan R. Morris, Margaret A. Cunningham, Anna A. Ahimastos, Bronwyn A. Kingwell, Elise Pappas, Michael Bourke, Christopher M. Reid, Theo Stijnen, Ronald L. Dalman, Oliver O. Aalami, Jan H. Lindeman, Paul E. Norman, Philip J. Walker, Robert Fitridge, Bernie Bourke, Anthony E. Dear, Jenna Pinchbeck1, Rene Jaeggi and Jonathan Golledge: TElmisartan in the management of abDominal aortic aneurYsm (TEDY): The study protocol for a randomized controlled trial. Trials 2015, 16:274

An integrated approach to surgical audit (Re: ANZ J. Surg. 2011; 81: 313–4)

I write in response to the gross misuse of a reference which bears my name. Reference 7 is merely an Internet link to a prelude I wrote in November 2009 for the benefit of members of the Australian and New Zealand Society for Vascular Surgery two months prior to the launch of the Australasian Vascular Audit (AVA). There is nothing in this prelude which describes the mechanism of the AVA. The authors however use this reference to describe the AVA as a ‘previously described IT solution for surgical audit’ that is, before it has even commenced. The authors, therefore, would have absolutely no knowledge of the processes involved in what has subsequently become an international first in surgical audit. Armed with this lack of knowledge, the authors compound their mistake by intimating that the AVA is ‘separate from the clinical workflow’ and contains ‘little or no mechanism for contemporaneous review of collected data’. These are, in fact, but two of many more features about which the AVA can legitimately boast. These authors should stay tuned: AVA manuscripts are in preparation after its first year of operation (almost 45 000 audited procedures).

An integrated approach to surgical audit (Re: ANZ J. Surg. 2011; 81: 313-4): Letters to the editor

I write in response to the gross misuse of a reference which bears my name. Reference 7 is merely an Internet link to a prelude I wrote in November 2009 for the benefit of members of the Australian and New Zealand Society for Vascular Surgery two months prior to the launch of the Australasian Vascular Audit (AVA). There is nothing in this prelude which describes the mechanism of the AVA. The authors however use this reference to describe the AVA as a ‘previously described IT solution for surgical audit’ that is, before it has even commenced. The authors, therefore, would have absolutely no knowledge of the processes involved in what has subsequently become an international first in surgical audit. Armed with this lack of knowledge, the authors compound their mistake by intimating that the AVA is ‘separate from the clinical workflow’ and contains ‘little or no mechanism for contemporaneous review of collected data’. These are, in fact, but two of many more features about which the AVA can legitimately boast. These authors should stay tuned: AVA manuscripts are in preparation after its first year of operation (almost 45 000 audited procedures).