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Sathianathen N.J.,Monash University | McGuigan S.M.,Epworth HealthCare | Moon D.A.,Epworth HealthCare
BJU International | Year: 2014

Objectives To present the outcomes of men undergoing artificial urinary sphincter (AUS) implantation. To determine the impact a history of radiation therapy has on the outcomes of prosthetic surgery for stress urinary incontinence. Patients and Methods A cohort of 77 consecutive men undergoing AUS implantation for stress urinary incontinence after prostate cancer surgery, including 29 who had also been irradiated, were included in a prospective database and followed up for a mean period of 21.2 months. Continence rates and incidence of complications, revision and cuff erosion were evaluated, with results in irradiated men compared with those of men who had undergone radical prostatectomy alone. The effect of co-existing hypertension, diabetes mellitus and surgical approach on outcomes were also examined. Results Overall, the rate of social continence (0-1 pad/day) was 87% and similar in irradiated and non-irradiated men (86.2 vs 87.5%). Likewise, the incidence of infection (3.4 vs 0%), erosion (3.4 vs 2.0%) and revision surgery (10.3 vs 12.5%) were not significantly different between the groups. There was a far greater incidence of co-existing urethral stricture disease in irradiated patients (62.1 vs 10.4%) which often complicated management; however, AUS implantation was still feasible in these men and, in four such cases, a transcorporal cuff placement was used. There were poorer outcomes in patients with diabetes, and a greater re-operation rate in those men who underwent a transverse scrotal rather than perineal surgical approach, although the differences did not reach statistical significance. Conclusions Previous irradiation in patients may increase the complexity of treatment because of a greater incidence of co-existing urethral stricture disease; however, these patients are still able to achieve a level of social continence similar to that of non-irradiated patients, with no discernable increase in complication rates, cuff erosion or the need for revision surgery. AUS implantation remains the 'gold standard' for management of moderate-to-severe stress urinary incontinence in both irradiated and non-irradiated patients after prostate cancer treatment. © 2013 The Authors. BJU International © 2013 BJU International.


James Cooper D.,Monash University | Rosenfeld J.V.,Monash University | Murray L.,Monash University | Arabi Y.M.,King Saud bin Abdulaziz University for Health Sciences | And 8 more authors.
New England Journal of Medicine | Year: 2011

Background: It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure. Methods: From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months. Results: Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%). Conclusions: In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.) Copyright © 2011 Massachusetts Medical Society.


Semple B.D.,National Health Research Institute | Semple B.D.,Monash University | Kossmann T.,Epworth Healthcare | Morganti-Kossmann M.C.,National Health Research Institute | Morganti-Kossmann M.C.,Monash University
Journal of Cerebral Blood Flow and Metabolism | Year: 2010

Chemokines and their receptors have crucial roles in the trafficking of leukocytes, and are of particular interest in the context of the unique immune responses elicited in the central nervous system (CNS). The chemokine system CC ligand 2 (CCL2) with its receptor CC receptor 2 (CCR2), as well as the receptor CXCR2 and its multiple ligands CXCL1, CXCL2 and CXCL8, have been implicated in a wide range of neuropathologies, including trauma, ischemic injury and multiple sclerosis. This review aims to overview the current understanding of chemokines as mediators of leukocyte migration into the CNS under neuroinflammatory conditions. We will specifically focus on the involvement of two chemokine networks, namely CCL2/CCR2 and CXCL8/CXCR2, in promoting macrophage and neutrophil infiltration, respectively, into the lesioned parenchyma after focal traumatic brain injury. The constitutive brain expression of these chemokines and their receptors, including their recently identified roles in the modulation of neuroprotection, neurogenesis, and neurotransmission, will be discussed. In conclusion, the value of evidence obtained from the use of Ccl2-and Cxcr2-deficient mice will be reported, in the context of potential therapeutics inhibiting chemokine activity which are currently in clinical trial for various inflammatory diseases. © 2010 ISCBFM All rights reserved.


Webster K.E.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth HealthCare
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2012

Purpose: The external knee adduction moment during gait has previously been associated with knee osteoarthritis, and although it has been shown to be greater following anterior cruciate ligament (ACL) reconstruction surgery compared to a control group, it has not been compared between different graft types. Given that the incidence of radiographic knee osteoarthritis appears to be greater following patellar tendon compared to hamstring tendon ACL reconstruction, this study tested the hypothesis that the knee adduction moment would also be increased following patellar tendon ACL reconstruction. Methods: In 48 male participants (16 patellar tendon graft, 16 hamstring graft and 16 controls), the external knee adduction moment was measured during level walking in a gait laboratory at mean of 10 months after surgery. Results: There was no difference in the knee adduction moment between the hamstring and patellar tendon groups, and both patient groups had a significantly reduced knee adduction moment compared to the control group. In the hamstring group, the smaller adduction moment was associated with the patients walking with less knee varus whereas in the patellar tendon group, the smaller moment was associated with the patients walking with a decreased vertical ground reaction force. Conclusions: These results indicate that in male patients during the early stages of recovery from ACL reconstruction, the knee adduction moment is not greater than controls for either hamstring or patellar tendon graft types. Although the knee adduction moment was similar between the two graft types, the overall magnitude of the moment was influenced by different biomechanical factors. Level of evidence: III. © 2011 Springer-Verlag.


Webster K.E.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth HealthCare | Wittwer J.E.,La Trobe University
Gait and Posture | Year: 2012

Following anterior cruciate ligament reconstruction (ACL) patients have altered movement patterns in the reconstructed knee during walking. There is limited information about these alterations over an extended period of time. This study was designed to present a longitudinal analysis of gait patterns following ACL reconstruction surgery. Assessments of level walking were undertaken in 16 participants at a mean 10 months (initial assessment) and again at 3 years (follow-up assessment) after ACL reconstruction surgery. Kinematic and kinetic variables were analysed using a two factor (time, limb) repeated measures ANOVA. Kinematic data showed that patients were able to achieve greater extension about the reconstructed knee at follow-up than at initial assessment. The reconstructed knee was significantly less internally rotated than the contralateral knee at the initial assessment but not at follow-up. Kinetic data showed a significant increase in the external knee extension moment for the reconstructed limb over time. There were also significant increases in the external knee adduction moment for both limbs at the follow-up assessment. The external knee adduction moment was however smaller in the reconstructed knee than the contralateral knee at both assessments. The results indicate that gait variables do change over time and that measurement at a single time point may not reflect the long term outcome of ACL reconstruction surgery. The changes were however small and may not be clinically relevant. However, the consistently reduced external knee adduction moment seen about the reconstructed knee in this study may suggest that factors other than joint moments influence degenerative change over time. © 2012 Elsevier B.V.


Hames K.,Epworth HealthCare
Healthcare Infection | Year: 2013

Background Inappropriate disposal of clinical waste has a considerable environmental and financial impact. Other studies have shown substantial opportunities for improvement in healthcare waste disposal. This study aims to show these opportunities through a clinical waste audit and to gain a greater understanding into approaches required for successful waste disposal behaviour change. Methods A clinical waste audit was conducted in an eight-bed intensive care unit in Melbourne. A baseline audit was followed by a questionnaire and education (in-services and signage). A follow up audit was performed to analyse the effect of education. Results Results of the initial clinical waste audit showed 41% clinical waste, 44% general waste and 14% sharps waste. Post-education, clinical waste was slightly greater than general waste and sharps waste had markedly decreased to 3.5%, however, study limitations were present. The marked decline in sharps waste appears to mainly be due to the clarification of a misnomer regarding disposal of glass. Questionnaires showed a lack of knowledge but a desire to learn, and a preference for learning through signage and in-services. Conclusion The study shows that more than one in-service and increased signage is needed for successful behaviour change. This supports findings that active staff involvement is essential to achieve sustainable waste management.© 2013 Australasian College for Infection Prevention and Control.


Ardern C.L.,La Trobe University | Taylor N.F.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth Healthcare | Webster K.E.,La Trobe University
British Journal of Sports Medicine | Year: 2014

Background The aim of this study was to update our original systematic review of return to sport rates following anterior cruciate ligament (ACL) reconstruction surgery. Method Electronic databases were searched from April 2010 to November 2013 for articles reporting the number of patients returning to sport following ACL reconstruction surgery. Return to sport rates, physical functioning and contextual data were extracted and combined using random-effects meta-analyses. Data from the original review (articles published up to April 2010) were combined with data from the updated search. Results Sixty-nine articles, reporting on 7556 participants, were reviewed. On average, 81% of people returned to any sport, 65% returned to their preinjury level of sport and 55% returned to competitive level sport after surgery. Symmetrical hopping performance (d=0.3) and the contextual factors of younger age (d=-0.3), male gender (OR=1.4), playing elite sport (OR=2.5) and having a positive psychological response (d=0.3) favoured returning to the preinjury level sport. Receiving a hamstring tendon autograft favoured returning to competitive level sport (OR=2.4), whereas receiving a patellar tendon autograft favoured returning to the preinjury level sport (OR=1.2). Conclusions Returning to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.


Webster K.E.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth HealthCare | Leigh W.B.,La Trobe University | Richmond A.K.,Epworth HealthCare
American Journal of Sports Medicine | Year: 2014

Background: Graft rupture of the same knee or injury to the anterior cruciate ligament (ACL) in the contralateral knee is a devastating outcome after ACL reconstruction surgery. While a number of factors have been identified as potentially increasing the risk of subsequent ACL injury, the literature is far from definitive. Purpose: To determine the rates of graft rupture and contralateral ACL injury in a large cohort and to investigate patient characteristics that may be associated with these. Study Design: Case-control study; Level of evidence, 3. Methods: A consecutive cohort of 750 patients who had undergone primary ACL reconstruction surgery with a minimum 3-year follow-up were questioned about the incidence of ACL graft rupture, contralateral ACL injury, family history of ACL injury, and current activity level. Patient databases provided details for age, sex, original injury mechanism, meniscus or articular surface injury, and graft diameter. Results: Responses were received from 561 patients (75%) at a mean ± SD follow-up time of 4.8 ± 1.1 years. Anterior cruciate ligament graft ruptures occurred in 25 patients (4.5%), and contralateral ACL injuries occurred in 42 patients (7.5%). The highest incidence of further ACL injury occurred in patients younger than 20 years at the time of surgery. In this group, 29%sustained a subsequent ACL injury to either knee. The odds for sustaining an ACL graft rupture or contralateral injury increased 6- and 3-fold, respectively, for patients younger than 20 years. Returning to cutting/pivoting sports increased the odds of graft rupture by a factor of 3.9 and contralateral rupture by a factor of 5. A positive family history doubled the odds for both graft rupture and contralateral ACL injury. Conclusion: Patients younger than 20 years who undergo ACL reconstruction are at significantly increased risk for both graft rupture and contralateral ACL injury. Whether age per se is a risk factor or age represents a proxy for other factors remains to be determined. © 2013 The Author(s).


Webster K.E.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth HealthCare
Clinical Biomechanics | Year: 2011

Background: Previous research has shown that patients with anterior cruciate ligament reconstruction have altered movement patterns in the reconstructed knee during walking. In the sagittal plane, graft specific changes in knee joint motion have been reported between hamstring and patellar tendon anterior cruciate ligament reconstruction grafts. This study examined the secondary planes of movement during walking in anterior cruciate ligament reconstructed knees to evaluate the influences of graft type (hamstring or patellar tendon) and control condition (control group or contralateral knee). Methods: In 54 participants (18 patellar tendon graft, 18 hamstring graft and 18 controls) varus-valgus and internal-external rotation was measured during level walking in a gait laboratory at mean of 10 months after surgery. All patients had undergone primary unilateral anterior cruciate ligament reconstruction within 12 months of injury. Findings: For internal-external rotation there was no difference between the graft types and both patient groups had reduced internal rotation (an external rotation offset) and reduced internal rotation range when compared to the control group and contralateral knee. For 31 of 36 patients, internal rotation values were less than the control group mean. The hamstring group had reduced varus rotation compared to both the patellar tendon and control groups, but not when compared to the contralateral knee. Interpretation: The results show that there are differences in tibial rotation during walking in anterior cruciate ligament reconstructed knees compared to both the contralateral knee and uninjured control group. These kinematic alterations may relate to the high incidence of knee osteoarthritis observed in this population over time. Reduced varus in the hamstring group may relate to the graft harvest. © 2010 Elsevier Ltd. All rights reserved.


Ardern C.L.,La Trobe University | Taylor N.F.,La Trobe University | Feller J.A.,La Trobe University | Feller J.A.,Epworth Healthcare | Webster K.E.,La Trobe University
British Journal of Sports Medicine | Year: 2013

Background Psychological factors have been shown to be associated with the recovery and rehabilitation period following sports injury, but less is known about the psychological response associated with returning to sport after injury. The aim of this review was to identify psychological factors associated with returning to sport following sports injury evaluated with the selfdetermination theory framework. Study design Systematic review. Method Electronic databases were searched from the earliest possible entry to March 2012. Quantitative studies were reviewed that included athletes who had sustained an athletic injury, reported the return to sport rate and measured at least one psychological variable. The risk of bias in each study was appraised with a quality checklist. Results Eleven studies that evaluated 983 athletes and 15 psychological factors were included for review. The three central elements of self-determination theory-Autonomy, competence and relatedness were found to be related to returning to sport following injury. Positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly. Fear was a prominent emotional response at the time of returning to sport despite the fact that overall emotions became more positive as recovery and rehabilitation progressed. Conclusions There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.

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