John C. Graham

Muscle fiber characteristics in patients with peripheral arterial disease.

PURPOSE There have been conflicting reports of muscle fiber type changes in patients with peripheral arterial disease (PAD). The purpose of this study was to examine the myosin heavy chain (MHC) expression as well as histochemical changes in the gastrocnemius muscle in patients with symptomatic PAD. METHODS Needle biopsy specimens were obtained from the medial gastrocnemius of 14 subjects with PAD (mean age (+/- SD), 69.7 +/- 4.8 yr) and eight activity-matched control subjects (mean age, 65.1 +/- 6.6 yr). Ankle-brachial index was assessed using Doppler ultrasound to determine the hemodynamic status of the patients, and maximal walking performance was determined during a graded treadmill test. Expression of MHC isoforms was determined by SDS-PAGE. RESULTS The proportion of MHC I was significantly smaller in PAD than in the controls (45.6 +/- 9.1% vs 58.8 +/- 15.0%). The proportion of MHC IIx was also larger in the subjects with PAD compared with the controls (22.9 +/- 9.1% vs 16.0 +/- 11.3%). In addition, there was a significant decrease in the cross-sectional area of the type I and type IIA fibers in the subjects with PAD as well as enhanced capillary density. CONCLUSIONS This study showed a significant modification in the expression of MHC isoforms and muscle fiber type in the gastrocnemius in patients with symptomatic PAD. These results suggest that muscle ischemia resulting from PAD is an important factor in causing the adaptations in the contractile apparatus of the muscle.

Effects of fatigue on surgeon performance and surgical outcomes: a systematic review

Background:  Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes.

Systematic review of the impact of volume of oesophagectomy on patient outcome

Purpose:  This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume.

A Systematic Review of Permanent and Semipermanent Dermal Fillers for HIV-Associated Facial Lipoatrophy

The objective of this study was to assess the safety and efficacy of injectable semipermanent and permanent dermal fillers, compared to other facial augmentation techniques, for the management of facial lipoatrophy as a result of highly active antiretroviral therapy (HAART) for HIV infection through a systematic review of the literature. A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was by the application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. One randomized controlled trial (RCT), one pseudo-RCT, two nonrandomized comparative studies, and seven case series were included for review. Injections with permanent and semipermanent dermal fillers improved subjective ratings of appearance and resulted in high patient satisfaction. Although short-term safety appeared favorable, of the seven studies that reported lumps, three studies reported these events in more than 40% of patients. Long-term safety data were lacking. Evidence suggests that permanent and semipermanent dermal fillers achieve their objective, which is to decrease the visible effects of HIV-associated facial lipoatrophy, with high patient satisfaction. Safety appears favorable in the short term, but further studies are required to determine long-term outcomes.

DAMAGE CONTROL SURGERY AND ANGIOGRAPHY IN CASES OF ACUTE MESENTERIC ISCHAEMIA

Background:  Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60–80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia.

Effect of hospital and surgeon volume on patient outcomes following treatment of abdominal aortic aneurysms: a systematic review.

OBJECTIVES This systematic review assessed the efficacy of centralisation for the treatment of unruptured and ruptured abdominal aortic aneurysms. Patient outcomes achieved by low and high volume hospitals/surgeons, including morbidity, mortality and length of hospital stay, were used as proxy measures of efficacy. DESIGN Systematic review was designed to identify, assess and report on peer-reviewed articles reporting outcomes from unruptured and ruptured abdominal aortic aneurysms. No language restriction was placed on the databases searched. MATERIALS Only peer-reviewed journals articles were included. METHODS To ensure the contemporary nature of this review, only studies published between January 1997 and June 2007 were sought. Studies were included if they reported on at least one volume type and patient outcome. RESULTS Twenty two studies were included in this review. In the majority of group assessments, the number of studies reporting statistical significance was similar to the number of studies reporting no statistical significance. CONCLUSION The paucity of studies reporting statistically significant results demonstrates that although this evidence exists, its potential to be overstated must also be taken into account when drawing conclusions as to its efficacy for twenty first century healthcare systems.

Centralization and the relationship between volume and outcome in knee arthroplasty procedures

Background:  Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals.

Supervised exercise training combined with ginkgo biloba treatment for patients with peripheral arterial disease

Objectives: To evaluate whether a combination of supervised exercise training and ginkgo biloba treatment is a better treatment than exercise training alone for patients with peripheral arterial disease. Design: A 24-week double-blind, placebo-controlled ginkgo biloba trial with the first 12-week period as a non-exercise control stage and the second 12-week period as an exercise training stage. Setting: Exercise physiology laboratory. Subjects: Twenty-two subjects with peripheral arterial disease. Interventions: The subjects were randomly allocated into a ginkgo or a placebo group. During the first stage, the ginkgo group ingested standardized ginkgo biloba tablets with a daily dosage of 240 mg, while the placebo group received placebo tablets. During the second stage, all subjects engaged in a supervised treadmill-walking programme while continuing to take the same dosage of ginkgo biloba or placebo tablets. Main measures: Walking capacity on treadmill, oxygen consumption during exercise, peripheral haemodynamics and blood viscosity were measured at baseline, and after the first and the second stages of treatment. Results: The ginkgo group did not show significant changes in most of the measured variables after each stage of treatment, except that the maximal walking time was significantly increased after the combined treatment (from 236 ± 112 seconds to 557 ± 130 seconds, P < 0.001). However, similar response was also found in the placebo group after exercise training (from 384 ± 125 seconds to 820 ± 146 seconds, P < 0.001). Conclusion: Supervised exercise training combined with ginkgo biloba treatment did not produce greater beneficial effects than exercise training alone in patients with peripheral arterial disease.

Radical prostatectomy: a systematic review of the impact of hospital and surgeon volume on patient outcome

Background:  To assess the impact of hospital and surgeon volume on mortality, morbidity, length of hospital stay and costs of radical prostatectomy (RP).

Effects of Supervised Treadmill Walking Training on Calf Muscle Capillarization in Patients With Intermittent Claudication

The aim of this study was to evaluate the effects of supervised treadmill walking training on the calf muscle capillarization in patients with intermittent claudication. The first 12-week period was a nonexercise, within-subject control stage, and the second 12-week period was an exercise training stage. Calf muscle biopsy and functional capacity measurement were performed at baseline, preexercise and postexercise training. In all, 11 subjects completed all procedures. Their average age was (mean ± standard deviation) 73.9 ± 5.5 years and resting ankle-to-brachial systolic blood presure index was 0.57 ± 0.11. After exercise training, the difference between the pretraining and posttraining capillaries in contact with type IIx and IIa muscle fibers for each subject was significantly correlated with an improved pain-free walking time, r = 0.69 and r = 0.62 (both P < .05), respectively. This finding suggests that the change in calf muscle capillarization might contribute to the improved walking capacity following supervised treadmill walking training in patients with intermittent claudication.