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Manner H.,Hospital Teaching Hospital of the University Medicine of Mainz | Pech O.,St John of God Hospital | Heldmann Y.,Hospital Teaching Hospital of the University Medicine of Mainz | May A.,Hospital Teaching Hospital of the University Medicine of Mainz | And 6 more authors.
Clinical Gastroenterology and Hepatology | Year: 2013

BACKGROUND & AIMS: Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients. METHODS: We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications. RESULTS: Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias <2 cm, 97% achieved CER (for those with tumors >2 cm, 77%; P = 026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions <2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8-120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died. CONCLUSIONS: Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.© 2013 AGA Institute.


Hurley J.C.,University of Melbourne | Hurley J.C.,St John of God Hospital | Hurley J.C.,Ballarat Health Services | Opal S.M.,Brown University
Journal of Innate Immunity | Year: 2013

The prognostic impact of endotoxemia detection in sepsis is unclear. Endotoxemia is detectable in <70% of patients with Gram-negative (GN) bacteremias. Mortality proportion data were available from 27 published studies of patients with GN bacteremia in various settings. Among ten studies restricted to specific types of GN bacteremia, endotoxemia was associated with significantly increased mortality risk for Neisseria meningitidis (4 studies; 138 bacteremias; OR 26.0; 95% CI, 1.6-321) but not for Salmonella enterica serovar Typhi (3 studies; 36 bacteremias; OR 0.89; 95% CI, 0.01-74.1). For 17 unrestricted studies (319 GN bacteremic patients), endotoxemia was associated with an increased mortality risk with non-Escherichia coli Enterobacteriaceae such as Klebsiella and Enterobacter species (97 bacteremias; OR 3.7; 95% CI, 1.3-10.3). By contrast, E. coli (144 bacteremias; OR 0.78; 95% CI, 0.36-1.7), and non-Enterobacteriaceae species such as Pseudomonas species (78 bacteremias; OR 1.7; 95% CI, 0.7-4.6) had no increased mortality risk. That endotoxemia detection is predictive of mortality among patients bacteremic with non-E. coli Enterobacteriaceae but not E. coli is surprising given the presumed commonality of the hexa-acyl lipid A structure among Enterobacteriaceae species. Copyright © 2013 S. Karger AG, Basel.


Hurley J.C.,University of Melbourne | Hurley J.C.,Ballarat Health Services | Hurley J.C.,St John of God Hospital
BMC Infectious Diseases | Year: 2014

Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT's) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT's versus the broader evidence base. Methods: Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence. Results: Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 - 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT's versus benchmark groups with data available. Conclusions: The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates. © 2014 Hurley; licensee BioMed Central.


Gan P.,St John of God Hospital | Bingham J.,Easington Pty Ltd
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Background: All retractors for laparoscopic operations on the gallbladder or stomach apply an upward force to the under-surface of the liver or gallbladder, most requiring an additional skin incision. The LiVac laparoscopic liver retractor system (LiVac retractor) comprises a soft silicone ring attached to suction tubing and connected to a regulated source of suction. The suction tubing extends alongside existing ports. When placed between the liver and diaphragm, and suction applied, a vacuum is created within the ring, keeping these in apposition. Following successful proof-of-concept animal testing, a clinical study was conducted to evaluate the performance and safety of the retractor in patients. Methods: The study was a dual-centre, single-surgeon, open-label study and recruited ten patients scheduled to undergo routine upper abdominal laparoscopic surgery including cholecystectomy, primary gastric banding surgery or fundoplication. The study was conducted at two sites and was approved by the institutions’ ethics committees. The primary objective of the study was to evaluate the performance of the LiVac retractor in patients undergoing upper abdominal single- or multi-port laparoscopic surgery. Performance was measured by the attainment of milestones for the retractor and accessory bevel, where used, and safety outcomes through the recording of adverse events, physical parameters, pain scales, blood tests and a post-operative liver ultrasound. Results: The LiVac retractor achieved both primary and secondary performance and safety objectives in all patients. No serious adverse events and no device-related adverse events or device deficiencies were reported. Conclusion: The LiVac retractor achieved effective liver retraction without clinically significant trauma and has potential application in multi- or single-port laparoscopic upper abdominal surgery. As a separate incision is not required, the use of the LiVac retractor in multi-port surgery therefore reduces the number of incisions. © 2015, The Author(s).


McDonnell N.J.,St John of God Hospital | Percival V.,King Edward Memorial Hospital for Women | Paech M.J.,University of Western Australia
International Journal of Obstetric Anesthesia | Year: 2013

Amniotic fluid embolism is a rare and potentially catastrophic condition that is unique to pregnancy. The presentation may range from relatively subtle clinical events to sudden maternal cardiac arrest. Despite an increased awareness of the condition, it remains a leading cause of maternal mortality. The underlying mechanisms of amniotic fluid embolism are poorly understood, but current theories support an immune-based mechanism which is triggered by potentially small amounts of amniotic fluid gaining access to the maternal circulation. This can result in a wide spectrum of clinical findings, with cardiovascular and haematological disturbances being prominent. The management of a suspected episode of amniotic fluid embolism is generally considered to be supportive, although in centres with specific expertise, echocardiography may assist in guiding management. Whilst outcomes after an episode of amniotic fluid embolism are still concerning, mortality would appear to have decreased in recent times, likely secondary to an improved awareness of the condition, advances in acute care and the inclusion of less severe episodes in case registries. © 2013 Elsevier Ltd. All rights reserved.


Roche E.,BlackRock | Creed L.,Cluain Mhuire Community Mental Health Service | Macmahon D.,University College Dublin | Brennan D.,St John of God Hospital | Clarke M.,BlackRock
Schizophrenia Bulletin | Year: 2015

Background: Authors of the Diagnostic and Statistical Manual, Fifth Edition (DSM-V) have recommended to "integrate dimensions into clinical practice." The epidemiology and associated phenomenology of formal thought disorder (FTD) have been described but not reviewed. We aimed to carry out a systematic review of FTD to this end. Methods: A systematic review of FTD literature, from 1978 to 2013, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 881 abstracts were reviewed and 120 articles met inclusion criteria; articles describing FTD factor structure (n = 15), prevalence and longitudinal course (n = 41), role in diagnosis (n = 22), associated clinical variables (n = 56), and influence on outcome (n = 35) were included. Prevalence estimates for FTD in psychosis range from 5% to 91%. Dividing FTD into domains, by factor analysis, can accurately identify 91% of psychotic diagnoses. FTD is associated with increased clinical severity. Poorer outcomes are predicted by negative thought disorder, more so than the typical construct of "disorganized speech." Conclusion: FTD is a common symptom of psychosis and may be considered a marker of illness severity. Detailed dimensional assessment of FTD can clarify diagnosis and may help predict prognosis. © 2014 The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.


Raspe C.,Martin Luther University of Halle Wittenberg | Piso P.,St John of God Hospital | Wiesenack C.,St Marienhospital | Bucher M.,Martin Luther University of Halle Wittenberg
Current Opinion in Anaesthesiology | Year: 2012

Purpose of review: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important therapeutic option for selected patients with peritoneal surface malignancies. This aggressive multimodality treatment is complex, not only regarding surgical technique, but also regarding anesthesia. The present review represents our experience in anesthetic care. Recent findings: Improved prognosis compared with systemic chemotherapy alone has recently been demonstrated for cytoreductive surgery when combined with intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of HIPEC is further impacted by these developments. In addition to the ambitious, long-lasting surgery, HIPEC causes significant fluid, blood and protein losses, increased intra-abdominal pressure, systemic hyperthermia, and increased metabolic rate, leading to relevant pathophysiological alterations, and therefore represents a challenge for anesthetist and critical care physicians. Summary: Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Gibson S.,St John of God Hospital | McConigley R.,Curtin University Australia
Supportive Care in Cancer | Year: 2016

Aim: The aim of this study was to identify the incidence, causes, risk factors and interventions for cancer patients requiring unplanned admissions within 14 days of discharge at a large metropolitan private hospital without a co-located emergency department. Methods: Retrospective data were collected on cancer patients who had an unplanned admission within 14 days of discharge during the period December 1, 2011 and May 31, 2012. Data were collected from the inpatient bed administration database and medical record review. Variables collected included demographics, cancer diagnosis, reasons for admission, interventions, and length of stay. Results: A total of 133 oncology patients required 206 unplanned admissions (UPAs). The most common cancer diagnoses associated with unplanned readmission were upper gastrointestinal (25.4 %), colorectal (19.6 %), gynaecological (18.8 %) and breast (13.8 %) cancers. The symptoms most commonly associated with unplanned re-admission were pain (16 %); infection not associated with neutropaenia (15.5 %); fever and febrile neutropaenia (14.6 %); nausea, vomiting and dehydration (13.6 %); dyspnoea (8.3 %) and altered neurological status (7.8 %). The median length of stay (LOS) was 6 days. Length of stay during UPA was decreased for patients with a partner and for those who had a palliative care consult. The need for psychological supports was related to a longer LOS during UPA. Conclusion: Cancer patients are at a significant risk of requiring unscheduled care and admission. Strategies and services to limit the burden on patients and the health care system should be reviewed to minimise the incidence of unplanned admission. © 2015, Springer-Verlag Berlin Heidelberg.


Pech O.,St John Of God Hospital
Digestive Diseases | Year: 2013

The cancer risk of nondysplastic Barrett's esophagus is very low (0.33-0.5 per year). Therefore, any endoscopic ablation technique is an overtreatment. Patients with low-grade intraepithelial neoplasia confirmed by a specialized GI pathologist seem to have a significant risk for developing high-grade intraepithelial neoplasia (HGIN) or cancer. Therefore, endoscopic treatment in this case seems to be justified. However, up to now there has been no prospective study supporting this. In recent years, endoscopic treatment of HGIN and mucosal Barrett's cancer has become a widely accepted treatment approach and even the therapy of choice in many countries. Endoscopic resection (ER) is the best validated treatment method in patients with HGIN and mucosal Barrett's cancer, and is widely used all over the world. In contrast to ablative treatment methods like argon plasma coagulation and radiofrequency ablation, ER allows histological assessment of the resected specimen in order to assess the depth of infiltration of the tumor. However, ER of the neoplastic lesions should always be followed by ablation of the nondysplastic remaining Barrett's esophagus in order to reduce the risk of recurrence or metachronous neoplasia. The long-time complete remission rate with this two-step strategy is ≥95%. A matter of continuing debate is whether patients with Barrett's cancer infiltrating the upper third of the mucosal layer (pT1sm1) can be treated by ER. Data from our and other centers indicate that a subgroup of patients with pT1sm1 adenocarcinomas without the presence of risk factors (poor differentiation grade, lymph or blood vessel infiltration, size >20 mm, ulcerated lesion) have a very low risk for lymph node metastasis (<2%) and endoscopic therapy can be an alternative to radical surgery. © 2013 S. Karger AG, Basel.


Hurley J.C.,University of Melbourne | Hurley J.C.,St John Of God Hospital
Chest | Year: 2014

Ventilator-associated pneumonia (VAP) develops in approximately 20% of patients in the ICU receiving prolonged mechanical ventilation (MV). Among the range of methods for preventing VAP, the evidence base for topical antibiotics (TAs), including selective digestive decontamination, appears to be the most compelling. However, several observations are puzzling, and the contextual influence resulting from concurrent use of both topical placebo and TA within an ICU remains untested. As with herd protection conferred by vaccination, contextual influences resulting from a population-based intervention cannot be estimated at the level of a single trial. Estimating contextual effects requires multilevel random-effects methods. In this way the dispersion in VAP incidence across groups from 206 studies, as cited in various-source systematic reviews, was calibrated. The benchmark mean VAP incidence derived from 49 observational groups of patients receiving MV is 23.7% (95% CI, 20.6%-27.2%). In contrast, for 20 and 15 concurrent control groups from the TA evidence base that did vs did not receive topical placebo, respectively, this incidence is 38% (95% CI, 29%-48%) and 33% (95% CI, 20%-50%). This contextual influence remains significant in a meta-regression model adjusted for group-level variables, such as within a trauma ICU context. The mean VAP incidence for five other categories of control groups from the broader evidence base is within four percentage points of the benchmark. The contextual effect of TA is paradoxic, peculiar, potent, perfidious, and potentially perilous. The TA evidence base requires reappraisal to consider this herd peril. © 2014 American College of Chest Physicians.

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