Riaz Agha

Neutrophil-lymphocyte ratio predicts medium-term survival following elective major vascular surgery: a cross-sectional study.

Background: The systemic nature of atherosclerosis compromises medium-term survival following major vascular surgery. Neutrophil—lymphocyte ratio (NLR) is a simple index of systemic inflammatory burden which correlates with survival following percutaneous coronary intervention. Methods: Patients undergoing elective major vascular surgery in 2 tertiary vascular units were identified from prospectively maintained databases. Factors associated with 2-year mortality were assessed by univariate and multivariate analyses. Results: Over a 4-year period, 1021 patients underwent elective major vascular surgery (carotid endarterectomy, abdominal aortic aneurysm repair, lower limb revascularization). Two-year mortality was 11.2%. In multivariate analysis, preoperative NLR > 5 was independently associated with 2-year mortality (multivariate odds ratio [OR] 2.21; 95% confidence interval [CI] 1.22-4.01). Conclusion: Preoperative NLR identifies patients at increased risk of death within 2 years of major vascular surgery. This simple index may facilitate targeted preventive measures for high-risk patients.

A review of the role of mechanical forces in cutaneous wound healing.

Cutaneous wound healing is a complex process with many types of mechanical forces regulating the quality and speed of healing. The role of mechanical forces in regulating tissue growth, repair and remodelling was recognised more than a century ago. Such forces influence gene expression, the synthesis of growth factors and inflammatory mediators and cellular processes like proliferation of many load-sensitive cells. However, the exact mechanisms by which these forces interact with cells and ways to use them to stimulate tissues are still active research fronts. This article sets to review the literature on mechanical forces and their role in cutaneous wound healing.

Use of autologous fat grafting for breast reconstruction: a systematic review with meta-analysis of oncological outcomes.

BACKGROUNDnThere is growing interest in the use of autologous fat grafting (AFG) for breast reconstruction. Concerns have been raised regarding its effectiveness and safety.nnnOBJECTIVEnThe primary objective was to determine the oncological, clinical, aesthetic and functional, patient reported, process and radiological outcomes of AFG.nnnMETHODSnA protocol was published on PROSPERO (CRD42013005254). Types of studies: All original studies.nnnTYPES OF PARTICIPANTSnWomen undergoing reconstruction after surgery for breast cancer. Types of Interventions: AFG techniques for reconstruction. Types of outcome measures: Oncological, clinical, aesthetic and functional, patient reported, process and radiological. Search terms and keywords: The search strategy was devised to find papers regarding AFG for breast reconstruction.nnnDATA SOURCESnElectronic databases were searched from 1st January 1986 to 31st March 2014 including: PubMed, MEDLINE, EMBASE, SCOPUS, The Cochrane Library, and clinical trial registries. Identification and selection of studies: Title and abstract screening and full text assessment undertaken separately by independent researchers. Data extraction, collection and management: Data extracted by two researchers and stored in a standardised database.nnnRESULTSn35 studies were included (3624 patients) with a high degree of patient and surgeon satisfaction over a mean of 1.9 sessions at 18 month follow-up. Fat necrosis was the commonest reported complication (4.4%), biopsy of a subsequent breast lump was required in 2.7% and an interval mammogram in 11.5%. The weighted mean recurrence rate was 4.4% at 24.6 months. Meta-analysis of comparative studies showed no significant difference in oncological event rates between AFG and non-AFG groups (p=0.10).nnnCONCLUSIONnAFG is a potentially useful reconstructive tool, has a relatively low complication rate, with the majority of patients and clinicians satisfied or very satisfied with the results. Long term clinical and radiological follow-up is required. Further research is necessary to confirm oncological ramifications.

Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography – The growing versatility of NLR

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Perioperative Fluid Restriction in Major Abdominal Surgery: Systematic Review and Meta-analysis of Randomized, Clinical Trials

e see front matter 2013 Elsevier Irela http://dx.doi.org/10.1016/j.atherosclerosis.2013.02.008 Arbel et al. are the first group to demonstrate the correlation demonstrated by Ott et al. to contribute to platelet adhesion in pabetween Neutrophil/lymphocyte ratio (NLR) and severity of coronary artery disease (CAD) [1]. NLR is a recent area of increased research interest with 166 citations in 2012, compared to 87 in 2011 indexed in the NIH library [2]. This research has been into a wide range of topics, including the use of NLR in cancer prognostication, cancer chemotherapy susceptibility, identifying high risk vascular surgical patients, non-alcoholic fatty liver disease, Alzheimer’s disease and, in one of the earliest publications in the subject, as a diagnostic marker for appendicitis [3e8]. All that is required to calculate NLR is a white blood cell count (WBC). NLR is calculated by taking the absolute neutrophil count and dividing it by the absolute lymphocyte count [1]. It demonstrates the balance of the Neutrophils e the active inflammatory component, with the Lymphocytes e the regulatory and ‘protective’ component [5]. Therefore, a higher NLR represents a higher level of inflammation [9]. The impact of such sub-acute inflammation on cardiovascular health and atheromatous disease formation is well documented. The interaction between neutrophils and endothelial tissues has been hypothesised to cause increased damage to the endothelium, and

Randomised controlled trials in plastic surgery: a systematic review of reporting quality.

BackgroundFluid management is a fundamental component of surgical care. Recently, there has been considerable interest in perioperative fluid restriction as a method of facilitating recovery following elective major surgery. A number of randomized trials have addressed the issue in various surgical specialities, and a recent meta-analysis proposed uniform definitions regarding fluid amount as well as examining fluid restriction in patients undergoing colonic resection.MethodsMedline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized, controlled trials of perioperative fluid restriction versus “standard” perioperative fluid management, as per definitions formulated previously. All of the studies involved patients undergoing colonic resection. The primary outcome measure was postoperative morbidity. Secondary endpoints included mortality, renal failure, time to first flatus, and length of hospital stay. A random effects model was applied.ResultsSeven randomized, controlled trials with a total of 856 patients investigating standard versus restrictive fluid regimes, as denoted by the definitions, were included. Perioperative fluid restriction had no effect on the risk of postoperative complications (OR 0.49 (95xa0% confidence interval (CI) 0.2–1.18; Pxa0=xa00.101). There was no detectable effect on death and fluid restriction did not reduce hospital stay (Pooled weighted mean difference −0.25; 95xa0% CI 0.72–0.21; Pxa0=xa00.29).ConclusionsPerioperative fluid restriction does not significantly reduce the risk of complications following major abdominal surgery. Furthermore, it does not appear to reduce length of hospital stay.

Time for a new approach to case reports

BackgroundWe recently conducted a systematic review of the methodological quality of randomised controlled trials (RCTs) in plastic surgery. In accordance with convention, we are here separately reporting a systematic review of the reporting quality of the same RCTs.MethodsMEDLINE® and the Cochrane Database of Systematic Reviews were searched by an information specialist from 1 January 2009 to 30 June 2011 for the MESH heading ‘Surgery, Plastic’. Limitations were entered for English language, human studies and randomised controlled trials. Manual searching for RCTs involving surgical techniques was performed within the results. Scoring of the eligible papers was performed against the 23-item CONSORT Statement checklist. Independent secondary scoring was then performed and discrepancies resolved through consensus.ResultsFifty-seven papers met the inclusion criteria. The median CONSORT score was 11.5 out of 23 items (range 5.3–21.0). Items where compliance was poorest included intervention/comparator details (7xa0%), randomisation implementation (11xa0%) and blinding (26xa0%). Journal 2010 impact factor or number of authors did not significantly correlate with CONSORT score (Spearman rhou2009=u20090.25 and 0.12, respectively). Only 61xa0% declared conflicts of interest, 75xa0% permission from an ethics review committee, 47xa0% declared sources of funding and 16xa0% stated a trial registry number. There was no correlation between the volume of RCTs performed in a particular country and reporting quality.ConclusionsThe reporting quality of RCTs in plastic surgery needs improvement. Better education, awareness amongst all stakeholders and hard-wiring compliance through electronic journal submission systems could be the way forward. We call for the international plastic surgical community to work together on these long-standing problems.

The methodological quality of randomized controlled trials in plastic surgery needs improvement: A systematic review

Case reports are popular and represent one of the oldest levels of evidence. Despite this they have attracted much criticism. They can be trivial, their conclusions do not usually undergo further investigation, and they are often questioned as a poor excuse for an unstructured review of the literature. Lessons from the past have given strong warnings against using new drugs based solely on case reports, such as the long-term adverse consequences of fetal exposure to diethylstilboestrol (DES) in pregnancy.1 Case reports are often not cited and hence many journals routinely reject them to protect their impact factors. Indeed, there is evidence that the prevalence of these articles in high impact journals is in decline.2

Use of autologous fat grafting for reconstruction postmastectomy and breast conserving surgery: a systematic review protocol

BACKGROUNDnOur objective was to assess the methodological quality of randomized controlled trials (RCTs) in Plastic Surgery.nnnMETHODSnAn information specialist searched MEDLINE for the period of 1 January 2009 to 30 June 2011 for the MESH heading Surgery, Plastic with limitations for English language, human studies and randomized controlled trials. Results were manually searched for RCTs involving surgical techniques. The papers were then scored with the authors seven point extended version of the Linde Internal Validity Scale (ELIVS). Secondary scoring was then performed and discrepancies resolved by consensus.nnnRESULTSn57 papers met the inclusion criteria. The median ELIVS score was 3.0 with a range of 1.0-6.5. Compliance was poorest with use of intention to treat analysis (4%), blinding of patients (23%) and the handling and reporting of patient withdrawals (25%). There was no statistically significant correlation between journal ELIVS score and 2010 impact factor or number of authors (Spearman rho 0.10 and 0.27 respectively). Multicentre trials had a higher average ELIVS score than single centre ones (3.6 vs 2.7) although this did not reach significance. There was no correlation between the volume of RCTs performed in a particular country and methodological quality.nnnCONCLUSIONnThe methodological quality of RCTs in Plastic Surgery needs improvement.

Levels of evidence in plastic surgery—bibliometric trends and comparison with five other surgical specialties

Introduction There is growing interest in the potential use of autologous fat grafting (AFG) for the purposes of breast reconstruction. However, concerns have been raised regarding the techniques clinical effectiveness, safety and interference with screening mammography. The objective of this systematic review was to determine the oncological, clinical, aesthetic and functional, patient reported, process and radiological outcomes for AFG. Methods and analysis All original studies, including randomised controlled trials, cohorts studies, case–control studies, case series and case reports involving women undergoing breast reconstruction. All AFG techniques performed for the purposes of reconstruction in the postmastectomy or breast conserving surgery setting will be considered. Outcomes are defined within this protocol along; oncological, clinical, aesthetic and functional, patient reported, process and radiological domains. The search strategy has been devised to find papers about ‘fat grafting and breast reconstruction’ and is outlined within the body of this protocol. The full search strategy is outlined within the body of the protocol. The following electronic databases will be searched from 1 January 1986 to 6 June 2013: PubMed, MEDLINE, EMBASE, SCOPUS, CINAHL, PsycINFO, SciELO, The Cochrane Library, including the Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature searches will also be conducted as detailed in our review protocol. Eligibility assessment occurred in two stages, title and abstract screening and then full text assessment. Data were extracted and stored in a database with standardised extraction fields to facilitate easy and consistent data entry. Ethics and dissemination This systematic review will be published in a peer-reviewed journal. It will also be presented at national and international conferences in the fields of plastic, reconstructive and aesthetic surgery and at more general surgical and methodological conferences. It will be disseminated electronically and in print. Brief reports of the review findings will be disseminated directly to the appropriate audiences of surgeons and societies through email and other modes of communication. Updates of the review will be conducted to inform and guide healthcare practice and policy. Protocol Registration PROSPERO—National Institute of Health Research (NIHR) Prospective Register of Systematic Reviews (CRD42013005254)