Showing papers by "London Bridge Hospital published in 2014"

Treatment for thoracic outlet syndrome

Abstract: Background Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking. Objectives To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracic outlet syndrome. Search strategy We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), CINAHL (January 1981 to June 2009), AMED (January 1985 to June 2009) and reference lists of articles. Selection criteria We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outlet syndrome (neurogenic, vascular, and disputed). The primary outcome measure was change in pain rating on a validated visual analog or similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effects of the interventions. Data collection and analysis Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of bias according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Main results This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention. In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicular neuroplasty of the brachial plexus. There were no adverse effects in either group. Authors conclusions This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence that either is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Free vascularised fibular grafts in orthopaedics

Abstract: Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.

Development of UK recommendations on treatment for post-surgical erectile dysfunction.

Abstract: AimTo develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context. MethodsPubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted. ResultsData from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies. ConclusionBased on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Postural tachycardia syndrome (POTS) and other autonomic disorders in antiphospholipid (Hughes) syndrome (APS)

Abstract: BackgroundAntiphospholipid syndrome (APS) is an autoimmune hypercoagulable disorder that has been shown to cause a large number of cardiac and neurological manifestations. Two recent studies have demonstrated abnormalities in cardiovascular autonomic function testing in APS patients without other cardiovascular or autoimmune disease. However, an association between autonomic disorders such as postural tachycardia syndrome and APS has not previously been described.Methods and resultsData were obtained by retrospective chart review. We identified 15 patients who have been diagnosed with APS and an autonomic disorder. The median age of the patients at the time of data analysis was 39 years. The autonomic disorders seen in these patients included postural tachycardia syndrome, neurocardiogenic syncope and orthostatic hypotension. The majority of patients (14/15) were female and the majority (14/15) had non-thrombotic neurological manifestations of APS, most commonly migraine, memory loss and balance disorder....

Comparison of robotic and manual persistent AF ablation using catheter contact force sensing: an international multicenter registry study.

Abstract: Background Catheter-based contact force sensing (CFS) technology gives detailed information regarding contact between the catheter tip and myocardium. This may result in more effective ablation procedures. The primary objective of this study was comparison of remote robotic navigation (RRN) and Manual CFS ablation. The secondary objective was to compare CFS with non-CFS ablation for both navigation modes. Methods Prospective registries of consecutive cases undergoing their first ablation for persistent atrial fibrillation (AF) from six hospitals in the United Kingdom and South Africa were analyzed: 50 Manual/CFS and 50 RRN/CFS cases were included. Historical control non-CFS ablation patients were matched by propensity score, giving a total 200 patient cohort. Results RRN/CFS was associated with improved single procedure 1-year success rates (64% vs 36%, P = 0.01) and shorter fluoroscopy times (41% reduction, P 0.5). Conclusions A combination of RRN and CFS is associated with improved success rates at 1 year and fluoroscopy times for persistent AF ablation, compared with Manual ablation and non-CFS RRN ablation.

Hughes syndrome/APS. 30 years on, what have we learnt? Opening talk at the 14th International Congress on antiphospholipid antibodies Rio de Janiero, October 2013

Abstract: It is 30 years to the month since our initial publications describing the syndrome. Prior to 1983 there had been case reports of lupus patients who could have had antiphospholipid features. Possibly one of the earliest was a case described by William Osler in 1895 – a 40-year-old male with lupus who developed a stroke. My own interest stemmed from our work in the early 1970s on brain-reactive antibodies in cerebral lupus. In 1975, during a year ‘on loan’ from Hammersmith to the University of the West Indies in Jamaica, I became interested in ‘Jamaican neuropathy’ – a virus-induced myelopathy which, both clinically, as well as its frequently positive antinuclear antibodies and false-positive tests for syphilis, resembled ‘lupoid sclerosis’. I was influenced by the work of Joyce Rausch, here in the audience, focusing on the structural similarities between the DNA backbone and that of phospholipids. Perhaps there was a subset of antibodies which reacted with neuronal phospholipids? Back at Hammersmith, we set up assays for antiphospholipid antibodies (aPL) – work led by two of my research fellows, the late Aziz Gharavi andNigel Harris. We used cardiolipin, partly because of the ‘syphilis’ link, and partly, as my then-technician Chris Bunn recently reminded me, because we had a stock of unused cardiolipin in the lab. For me, the late 1970s and early 1980s were productive years. Our large clinics and regular all-day ward rounds soon picked up a strong clinical scent – that which we called at first the ‘anticardiolipin syndrome’. We changed the name two years later to the antiphospholipid syndrome (APS). I believe that those early descriptions have stood us in reasonably good stead – clinically, at least (Table 1). Our first international conference was held in 1984, followed by the second in 1986 after our move to St Thomas’ Hospital (Figure 1). Since then, APS conferences have been held every two to three years, culminating in today’s meeting in Rio, Brazil, with 650 attendees. In those intervening meetings, so much has been learnt.

What is the better treatment for single digit dupuytren's contracture: surgical release or collagenase clostridium histolyticum (Xiapex) injection?

Abstract: The purpose of this study was to compare the initial and final outcome range of motion in the MCP-J and PIP-J of single digit Dupuytren's Contracture treated with either open surgical excision or manipulation after collagenase clostridium histolyticum (CCH; Xiapex) injection. Material: Ten patients in either group. The range of motion measurements were statistically compared using the student t-test with a p-value of 0.05. There was no statistical difference in the pre-treatment status of the total active range of movement (TAM) between the two groups. Results: Open surgical release achieved a statistically better initial outcome in combined total passive range of movement than the xiapex group (p = 0.0047), but at the final outcome the better TAM measurement at the MCP-J after surgery was not statistically significant. However, the total active range of movement was statistically better at the PIP-J level in the xiapex group (p = 0.01) and the MCP-J and PIP-J combined total active range of movement was statistically better in the xiapex group (p = 0.0258). Conclusion: Surgery achieved better initial outcome at both MCP-J and PIP-J levels, and at discharge, only extension in the MCP-J level was statistically better after open excision. However the final outcome was statistically better at the PIP-J level in extension (p = 0.006) and total active movement (TAM) (p = 0.008) after treatment with collagenase clostridium histolyticum. Further studies are required to assess the long-term differences between the two groups and to investigate the outcomes for patients with multi-digit involvement.

Periprocedural stroke risk in patients undergoing catheter ablation for atrial fibrillation on uninterrupted warfarin.

Abstract: BACKGROUND: Catheter ablation is an effective treatment for symptomatic individuals with atrial fibrillation (AF) but is associated with a risk of periprocedual stroke. Recent data suggest that this risk may be abolished if catheter ablation is performed with uninterrupted warfarin (UW). We sought to compare the incidence, severity and timing of periprocedural stroke between 2 periprocedural anticoagulation protocols: bridging low-molecular-weight heparin (LMWH) and UW. METHODS AND RESULTS: Periprocedural stroke (≤14 days) was assessed in 2,855 ablations performed in 1,813 patients. Thromboembolic stroke occurred in 11/1,653 (0.7%) procedures with bridging LMWH and in 5/1,202 (0.4%) procedures on UW (P = 0.5). Four of the 5 strokes (80%) on UW occurred despite a therapeutic INR and a mean activated clotting time of ≥300 seconds and 4/5 strokes (80%) occurred in patients with a CHADS2 score of 0. Eleven of 16 (69%) strokes overall occurred within 24 hours of the procedure. All 4 strokes resulting in major neurological deficit occurred in the LMWH group. Major bleeding complications occurred in 6.0% of patients in the bridging LMWH group compared to 4.0% in the UW group (P = 0.02). CONCLUSIONS: In contrast to existing data, periprocedural stroke still occurs despite therapeutic anticoagulation throughout the operative period. The optimal strategy to protect patients against thromboembolic stroke remains unclear.

Acute double flexor tendon ruptures following injection of collagenase clostridium histolyticum (Xiapex) for Dupuytren's contracture

Abstract: We report a case of acute (24 h) double flexor tendon rupture of the little finger after a single injection of collagenase clostridium histolyticum into a palmar Dupuytren's contracture cord which caused metacarpophalangeal joint contracture. Tendon surgery was performed 48 h postinjury with primary repair and standard rehabilitation but it resulted in poor active flexion due to adhesions. Previous papers have suggested that a needle inserted into the flexor tendon can be detected prior to the injection of collagenase by asking the patient to actively move the finger, but our test on an awake patient showed that when a 27-gauge needle was inserted into the flexor tendons through a thick palmar cord, the syringe did not move significantly when the patient moved the finger, and therefore this test does not minimise the risk of iatrogenic tendon injury when using collagenase (Xiapex) for Dupuytren's contracture.

Erectile Dysfunction: A Marker of Increased Cardiovascular Risk

Abstract: See related article, pp 672–678 Erectile dysfunction (ED) is now recognized as a marker of increased cardiovascular risk both acutely and chronically and considered an early manifestation of generalized vascular disease predicting all-cause mortality, cardiovascular mortality, coronary events, stroke, and peripheral artery disease in men with and without known coronary artery disease.1 Importantly, ED shares with coronary artery disease similar risk factors and is principally vasculogenic, reflecting the common denominator of endothelial dysfunction.2 ED is defined as the inability to obtain or maintain a penile erection to support satisfactory sexual performance, and when affecting men with and without cardiac symptoms in the age group 30 to 60 years seems to be a significant predictor of subsequent cardiovascular events. Vlachopoulos et al3–5 have over several years studied the independent link between ED and cardiovascular disease (CVD) using biomarkers as a means of identifying the men most at risk of a cardiovascular event. Their latest contribution to the expanding and important literature identifies aortic stiffness as a marker of increased cardiovascular risk in men presenting with ED (this issue).6 Previously, the same workers have identified the unfavorable effect on the circulating levels of biomarkers …