J. Spark | Flinders University of South Australia (original) (raw)

Papers by J. Spark

Research paper thumbnail of The Incidence of Hyperhomocysteinaemia in Vascular Patients

European Journal of Vascular and Endovascular Surgery, 2003

Hyperhomocysteinaemia has recently been identified as an important risk factor for atheroscleroti... more Hyperhomocysteinaemia has recently been identified as an important risk factor for atherosclerotic vascular disease. Screening for hyperhomocysteinaemia has been recommended, however, the incidence of hyperhomocysteinaemia in vascular patients is not known. To determine the incidence of hyperhomocysteinaemia in vascular patients, to determine the relation of hyperhomocysteinaemia with folate, vitamin B12 levels and lipid profiles in vascular patients. To examine if there is a relationship between the degree of vascular injury and homocysteine concentration. New vascular patients at The Queen Elizabeth Hospital were recruited and divided into peripheral, and aneurysmal presentations. Patients demographics were recorded, blood samples were taken for fasting lipid profile, and homocysteine concentration. Samples were also taken for vitamin B12, plasma and red cell folate levels. Sixty age and sex matched controls were included for comparison. One hundred and twenty-six patients have been recruited, (95 men and 31 women) with a median age of 68 years (61-74 years). The incidence of elevated homocysteine, and cholesterol levels was 33, 47 and 24%. The levels of vitamin B12 and folate were normal in all patients. Homocysteine was elevated in 27% of claudicants, 50% of patients with rest pain and 53% of patients with an aortic aneurysm. There is a high rate of hyperhomocysteinaemia in vascular patients with a higher incidence in patients with rest pain. There was also a high incidence of elevated homocysteine levels in patients with an abdominal aortic aneurysm. The rate of growth of these aneurysms is currently under review. Low folate or B12 concentrations is not the cause of raised homocysteine levels.

Research paper thumbnail of The effect of supervised exercise therapy for intermittent claudication on lower limb lean mass

Journal of Vascular Surgery, 2016

Supervised exercise is currently recommended for the first-line treatment of intermittent claudic... more Supervised exercise is currently recommended for the first-line treatment of intermittent claudication based on improvement in walking capacity. However, the promotion of skeletal muscle atrophy by repetitive ischemia-reperfusion caused by treadmill-based programs remains a concern. Because preservation of skeletal muscle mass (SMM) and lean mass (LM) is integral to functional capacity and longevity, this study measured the effect of standard treadmill-based supervised exercise on SMM and regional lower limb LM in patients with intermittent claudication. Patients with calf claudication caused by infrainguinal peripheral artery disease underwent whole-body dual-energy X-ray absorptiometry scanning before and after completion of a 12-week supervised treadmill exercise program. Total body SMM and lower limb LM were measured according to anatomical regions of the lower limb (thigh vs calf) and side of symptoms. Walking performance was assessed using pain-free walking distance and 6-minute walking distance tests. Thirty-six patients with calf claudication completed exercise training and dual-energy X-ray absorptiometry scanning, allowing analysis of 55 symptomatic and 17 asymptomatic lower limbs. No difference in total body SMM (P = .41) or LM of symptomatic (P = .53) or asymptomatic calves (P = .59) was detected after the program. In contrast, a significant decrease in LM was observed in symptomatic (P = .04) and asymptomatic thighs (P = .005). Pain-free walking distance (P = .001) and the 6-minute walking distance both improved significantly (P = .004) but were not associated with changes in LM. Twelve weeks of standard treadmill-training for intermittent calf claudication did not result in loss of calf LM; however, a significant decrease in bilateral thigh LM was observed, even in patients with unilateral symptoms. Further research on optimum exercise modalities and end points are required to determine the pathophysiology and effects of these changes on function and survival.

Research paper thumbnail of Pre-Operative Anaemia Predicts Poor Outcomes in Patients Undergoing Infra-Inguinal Bypass Surgery

World Journal of Cardiovascular Diseases, 2014

Research paper thumbnail of The impact of abdominal aortic aneurysm on muscle mass and energy expenditure: A novel preliminary investigation

Vascular, Jan 9, 2015

Vascular surgical patients, including those with abdominal aortic aneurysm (AAA), are nutritional... more Vascular surgical patients, including those with abdominal aortic aneurysm (AAA), are nutritionally vulnerable. The aim of this study was to compare resting energy expenditure (REE) of patients with AAA relative to age- and gender-matched controls and explore relationships between aneurysm size and muscle mass. Twenty patients with AAA underwent assessment of REE using indirect calorimetry. Mid-arm circumference and triceps skinfold thickness were measured and corrected arm muscle area calculated. Twenty gender- and age-matched controls were assessed using the same procedures. Mean (SD) age of participants with AAA was 74.7 (7.7) years, size of AAA ranged from 45 to 70 mm. Median (IQR) REE was significantly higher than controls [5990 (5469, 7017) kJ/day versus 5086 (4536, 5886) kJ/day, p = .011; or 69 (64, 80) kJ/kg/day versus 66 (61, 69) kJ/kg/day, p = .046]. While weight-adjusted REE was independent of aneurysm size (r = .200; p = .397), as aneurysm size increased, weight-adjusted...

Research paper thumbnail of Pulsatile varicose veins

Journal of the Royal Society of Medicine, 2000

Research paper thumbnail of The impact of different supervised exercise regimens on endothelial function in patients with intermittent claudication

Vascular, Jan 18, 2014

The impact of supervised exercise training on endothelial function in patients with intermittent ... more The impact of supervised exercise training on endothelial function in patients with intermittent claudication is unclear. This study assesses the impact of treadmill-based supervised exercise training alone or in combination with resistance training on pain free walking distance, flow-mediated dilatation, reactive hyperaemia index, nitric oxide and asymmetric dimethylarginine. Thirty-five patients with intermittent claudication were randomised to 12 weeks of treadmill-only supervised exercise training (Group 1) or a combination of treadmill and lower-limb resistance supervised exercise training (Group 2). Pain free walking distance was assessed by six-minute walk test. Endothelial function was assessed by brachial artery flow-mediated dilatation, reactive hyperaemia index and serum analysis of asymmetric dimethylarginine and nitric oxide. Pain free walking distance improved within Group 1 (160 m to 204 m, p = 0.03) but not Group 2 (181 m to 188 m, p = 0.82), no between group differe...

Research paper thumbnail of Lower pain and faster treatment with mechanico-chemical endovenous ablation using ClariVein(R)

Phlebology: The Journal of Venous Disease, 2014

To assess the efficacy of the ClariVein® system of mechanico-chemical ablation of superficial vei... more To assess the efficacy of the ClariVein® system of mechanico-chemical ablation of superficial vein incompetence. ClariVein® treatment uses a micropuncture technique and a 4-Fr sheath to allow a catheter to be placed 1.5 cm from the saphenofemoral junction. Unlike laser (endovenous laser treatment (EVLT)) or radiofrequency ablation (RFA), no tumescence is required. The technique depends on a wire rotating at 3500 r/min causing endothelial damage whilst liquid sclerosant (1.5% sodium tetradecyl sulphate) is infused. The wire is pulled back whilst continuously infusing sclerosant along the target vessel's length. Initially, 8 mL of dilute sclerosant was used, but this was subsequently increased to 12 mL. No routine post-op analgesia was prescribed and specifically no non-steroidal anti-inflammatory drugs. Procedure times and pain scores (visual analogue scale) were recorded and compared to EVLT and RFA. All patients were invited for duplex post-procedure. Fifty-one great saphenous veins and six short saphenous veins were treated and followed up with duplex in the 10 months from July 2011. No major complications or deep vein thrombosis were reported. Duplex showed patency of three treated veins with two more veins having only a short length of occlusion, giving a technical success rate of 91%. Comparison with 50 RFA and 40 EVLT showed procedure times were significantly less for ClariVein® (23.0 ± 8.3 min) than for either RFA (37.9 ± 8.3 min) or EVLT (44.1 ± 11.4 min). Median pain scores were significantly lower for ClariVein® than RFA and EVLT (1 vs. 5 vs. 6, p < 0.01). Mechanochemical ablation with the ClariVein® system is safe and effective. After some initial failures, the use of 12 mL of dilute sclerosant results in a very high technical success rate >90% which accords with the limited published literature. Procedure times and pain scores are significantly better than for RFA and EVLT. We await the long-term clinical outcomes.

Research paper thumbnail of Change in dietary intake of adults with intermittent claudication undergoing a supervised exercise program and compared to matched controls

Nutrition Journal, 2014

Background: Presence of numerous diet responsive comorbidities and high atherosclerotic burden am... more Background: Presence of numerous diet responsive comorbidities and high atherosclerotic burden among adults with intermittent claudication demands attention is given to diet in an effort to delay progression of peripheral artery disease. The aim of this study was to compare diet of adults with intermittent claudication: (a) against dietary recommendations; (b) following 12 weeks of supervised exercise training; and (c) against non-peripheral artery disease controls. Methods: Diet was assessed using a food frequency questionnaire pre and post supervised exercise training. Pre-exercise diet was compared against Suggested Dietary Targets and against non-peripheral artery disease controls matched for gender, age and body weight. Pre-exercise diet was also compared against post-exercise diet.

Research paper thumbnail of Does Angioplasty Improve the Quality of Life for Claudicants?: A Prospective Study

Annals of Vascular Surgery, 1999

This study aims to analyze the impact of percutaneous transluminal angioplasty (PTA) for claudica... more This study aims to analyze the impact of percutaneous transluminal angioplasty (PTA) for claudication on patients' quality of life (QOL). The patients in this study included 108 claudicants, 74 men and 34 women, with a median age of 67 years (range 40-87 years), who were assessed prior to and at 1, 3, and 6 months following PTA. This is the first report to demonstrate that the previously well-documented improvements in the clinical indicators of lower-limb ischemia are accompanied by improvements in individual QOL domains and in overall global QOL. These findings are detectable within a month following PTA and last at least 6 months. The results of this study may go some way to provide proof of efficacy for the procedure and thus help justify the recently questioned widespread use of PTA in clinical practice.

Research paper thumbnail of Pharmacist influence on prescribing in peripheral arterial disease (PIPER)

Vascular Medicine, 2014

The objective of this study was to determine the association between a specialist clinical pharma... more The objective of this study was to determine the association between a specialist clinical pharmacist working in collaboration with medical staff and prescribing in peripheral arterial disease (PAD). A retrospective cohort study was conducted comparing the influence of a dedicated clinical pharmacist on two samples of patients admitted to a single vascular surgery unit in either 2007 (control group) prior to implementation of a comprehensive clinical pharmacy service or 2009 (comparison group) post implementation. Data were obtained via review of medical records and electronic reports. A total of 685 patients were identified, resulting in 964 admissions. The patient to pharmacist ratio decreased from 62 to 33 patients per day in 2009. More patients were initiated on an antiplatelet (OR 4.6, 95% CI 2.26 to 9.53, p<0.001) and statin (OR 3.4, 95% CI 1.97 to 6, p<0.001) in 2009 compared to 2007. Risk factor modification increased in 2009, resulting in action being taken more often for HbA1c>7% (OR 3.45, 95% CI 1.64 to 7.27, p=0.001), total cholesterol >4 mmol/L in females (OR 14.5, 95% CI 2.67 to 78.6, p=0.002) and blood pressure above target (OR 1.9, 95% CI 1.01 to 3.73, p=0.05) when a comprehensive clinical pharmacist service was available. There was a non-significant reduction in mortality (18.7% (65) to 14.2% (46), p=0.13) and cardiovascular outcomes (5.5% (19) to 4.3% (14), p=0.44) within 12 months of discharge. In conclusion, prescribing of evidence-based medication for PAD and risk factor modification increased with a comprehensive clinical pharmacist service. This study provides important insight into optimising treatment in this patient group and how a pharmacist can be a helpful addition to the multidisciplinary team.

Research paper thumbnail of Correlating clinical indicators of lower-limb ischaemia with quality of life

Cardiovascular Surgery, 1997

The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon qu... more The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon quality of life and to assess the correlation between clinical indicators of lower-limb ischaemia and such quality. A prospective observational study of a consecutive series of 235 patients (144 men and 91 women; median age 68 (range 41-87) years presenting with varying degrees of lower-limb ischaemia graded according to ISCVS criteria was performed. Data was collected at interview before any intervention. Clinical indicators of lower-limb perfusion included: intermittent claudication and maximum walking distance on standardized treadmill testing; ankle:brachial pressure indices and isotope limb blood flow. Quality of life analysis was performed using the EuroQol (EQ) questionnaire. This is a standardized generic instrument for describing health-related quality of life and consists of a descriptive system of five dimensions, each measured on three levels. Thus, a profile and two single indices of quality of life were derived using different methods. Increasing lower-limb ischaemia results in a statistically significant deterioration in both global quality of life and in all EQ-measured quality of life dimensions (P Ͻ 0.01 Kruskal-Wallis, ANOVA). The correlation between clinical indicators and quality of life is statistically significant but not sufficiently close (correlation coefficients Ͻ 0.6) to assume that variations in clinical indicators result in reciprocal variations in quality of life.

Research paper thumbnail of Volume replacement during aortic surgery: Homologous vs. autologous blood?

Cardiovascular Surgery, 1995

The risks of allogeneic transfusion are well known to cardiovascular surgeons and have prompted a... more The risks of allogeneic transfusion are well known to cardiovascular surgeons and have prompted a search for alternatives. Perfluorocarbons were introduced into clinical trials in the early 1980s with the hope that these products would develop into acceptable blood substitutes. Unfortunately, the limited potency, short half-life, and potential toxicity of these early formulations, coupled with unrealistic expectations for efficacy, prevented the perfluorocarbons from playing a significant role in transfusion medicine. Recent changes in formulation to improve efficacy and eliminate toxicity have stimulated renewed interest in perfluorocarbons as alternatives to allogeneic transfusion.

Research paper thumbnail of 8.14 How effective is acute normovolaemic haemodilution (ANH) in vascular patients?

Cardiovascular Surgery, 1997

Research paper thumbnail of 21.13 Isotope limb blood flow as a predictor of outcome in chronic critical leg ischaemia

Cardiovascular Surgery, 1997

F3moropopliteal I gated by graft surveillance results) within I2 months or before the patient's d... more F3moropopliteal I gated by graft surveillance results) within I2 months or before the patient's death.

Research paper thumbnail of How effective is acute normovolaemic haemodilution in femoro-distal bypass surgery?

Cardiovascular Surgery, 2002

Background: Recent guidelines have emphasised the use of autologous blood in the surgical setting... more Background: Recent guidelines have emphasised the use of autologous blood in the surgical setting. The aim of this study was to analyse the efficacy and efficiency of acute normovolaemic haemodilution (ANH) as a blood conservation intervention in patients undergoing elective femoro-distal surgery for critical limb ischaemia.

Research paper thumbnail of Endovascular repair of abdominal aortic aneurysm reduces intraoperative cortisol and perioperative morbidity

Journal of Vascular Surgery, 2005

Research paper thumbnail of Neutrophil-lymphocyte ratio as a prognostic marker of outcome in infrapopliteal percutaneous interventions for critical limb ischemia

Journal of Vascular Surgery, 2014

Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) ... more Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) in recent times. The recent Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial consensus recommended endovascular treatment as a first-line treatment in patients who have a life expectancy that was limited to <2 years. Despite these recommendations, there still remains limited data available to clinicians when seeking to risk stratify patients who present with CLI. The neutrophil-lymphocyte ratio (NLR) has been suggested to be a marker for predicting mortality and patency. This study aimed to investigate the use of the NLR as a prognostic marker for primary patency and mortality after an infrapopliteal endovascular intervention in patients with CLI. All patients who underwent tibial angioplasty for CLI were retrospectively analyzed. Demographics, degrees of stenosis, vessel patency rates, mortality, and comorbidities were recorded. NLRs were calculated from preoperative blood samples. Primary end points were all-cause mortality, primary patency, and amputation-free survival (AFS) within the follow-up period of 12 months. Multivariate Cox proportional hazard models were used to identify independent predictors. Overall survival, AFS, and the probability of a vessel remaining patent were evaluated by standard Kaplan-Meier survival curves and groups compared by the log-rank test. Eighty-three patients were monitored for 12 months. Ninety limbs were identified, with 104 procedural events and 127 vessels undergoing successful angioplasty. The technical success rate was 86%, and patency at 1 year was 19%. Survival at 1 year was 76% and AFS was 61%. Patients with a NLR ≥5.25 had an increased risk of death (hazard ratio, 1.97; 95% confidence interval, 1.08-3.62; P = .03) compared with those with a NLR of <5.25. Furthermore, those with lymphocytes counts of <1.5 × 10(9)/L had higher mortality (hazard ratio, 1.88; 95% confidence interval, 1.02-3.70; P = .045) than those with lymphocyte counts >1.5 × 10(9)/L. The NLR and absolute lymphocyte counts are potentially valuable prognostic indicators for risk stratification of patient's presenting with CLI undergoing infrapopliteal angioplasty.

Research paper thumbnail of Autologous blood transfusion: The benefits to the patient undergoing abdominal aortic aneurysm repair

Journal of Vascular Nursing, 1997

The clinical benefits of using intraoperative autologous blood transfusion during abdominal aorti... more The clinical benefits of using intraoperative autologous blood transfusion during abdominal aortic aneurysm bypass surgery become increasingly apparent when use of autologous and homologous blood transfusions is compared. That homologous blood transfusions carry some risk is widely recognized. When autologous blood is used as a sole source of blood transfusion, the risk of transmission of infectious agents and potential immunologic side effects are avoided. A prospective randomized pilot study comparing autologous and homologous blood transfusion in patients undergoing elective infrarenal abdominal aortic aneurysm bypass surgery was undertaken. The purpose of this study was to determine whether autologous blood salvaged intraoperatively may serve as an alternative to homologous blood by comparing the rate of postoperative infection and duration of hospital stay for patients receiving autologous versus homologous blood transfusions. Fifty patients undergoing abdominal aortic aneurysm bypass surgery were prospectively randomly assigned to receive either a homologous or an autologous blood transfusion, with 27 receiving a homologous blood transfusion and 23 receiving an autologous blood transfusion. The data from this study show that the length of hospital stay of patients receiving an autologous blood transfusion intraoperatively was reduced by a mean of 3 days and the risk of postoperative complications, such as a systemic inflammatory response or sepsis, was reduced by more than 50%. (J Vasc Nuts 1997;15:111-5) Blood transfusion has assumed a major role in the development of modern medical and surgical practice. However, blood transfusion involves side effects and risks that have been well documented over the years. These risks have been dramatically reduced by accurate donor screening, safer blood processing, and more reliable pretransfusion testing. Nevertheless, the risks of some adverse effect serious enough to compromise the outcome of complex surgical procedures is still apparent.

Research paper thumbnail of 8.13 The utilization of cold provocation thermography in upper limb vasospastic conditions

Cardiovascular Surgery, 1997

Research paper thumbnail of Curative resection and reconstruction of the inferior vena cava after extensive infiltration with low-grade endometrial stromal sarcoma

Phlebology / Venous Forum of the Royal Society of Medicine, 2012

Endometrial stromal sarcoma (ESS) rarely infiltrates the great vessels. We report a successful su... more Endometrial stromal sarcoma (ESS) rarely infiltrates the great vessels. We report a successful surgical resection of the inferior vena cava (IVC) after extensive infiltration with metastatic low-grade ESS. A case of presumed recurrence of low-grade ESS demonstrated complete IVC occlusion from tumour thrombus with extensive local disease. Radical resection of the tumour and caval reconstruction was performed. The IVC graft was thrombosed at short-term follow-up. Curative resection of extensive caval infiltration with metastatic low-grade ESS can be achieved. Caval reconstructive procedures may be redundant in the presence of an adequate collateral circulation.

Research paper thumbnail of The Incidence of Hyperhomocysteinaemia in Vascular Patients

European Journal of Vascular and Endovascular Surgery, 2003

Hyperhomocysteinaemia has recently been identified as an important risk factor for atheroscleroti... more Hyperhomocysteinaemia has recently been identified as an important risk factor for atherosclerotic vascular disease. Screening for hyperhomocysteinaemia has been recommended, however, the incidence of hyperhomocysteinaemia in vascular patients is not known. To determine the incidence of hyperhomocysteinaemia in vascular patients, to determine the relation of hyperhomocysteinaemia with folate, vitamin B12 levels and lipid profiles in vascular patients. To examine if there is a relationship between the degree of vascular injury and homocysteine concentration. New vascular patients at The Queen Elizabeth Hospital were recruited and divided into peripheral, and aneurysmal presentations. Patients demographics were recorded, blood samples were taken for fasting lipid profile, and homocysteine concentration. Samples were also taken for vitamin B12, plasma and red cell folate levels. Sixty age and sex matched controls were included for comparison. One hundred and twenty-six patients have been recruited, (95 men and 31 women) with a median age of 68 years (61-74 years). The incidence of elevated homocysteine, and cholesterol levels was 33, 47 and 24%. The levels of vitamin B12 and folate were normal in all patients. Homocysteine was elevated in 27% of claudicants, 50% of patients with rest pain and 53% of patients with an aortic aneurysm. There is a high rate of hyperhomocysteinaemia in vascular patients with a higher incidence in patients with rest pain. There was also a high incidence of elevated homocysteine levels in patients with an abdominal aortic aneurysm. The rate of growth of these aneurysms is currently under review. Low folate or B12 concentrations is not the cause of raised homocysteine levels.

Research paper thumbnail of The effect of supervised exercise therapy for intermittent claudication on lower limb lean mass

Journal of Vascular Surgery, 2016

Supervised exercise is currently recommended for the first-line treatment of intermittent claudic... more Supervised exercise is currently recommended for the first-line treatment of intermittent claudication based on improvement in walking capacity. However, the promotion of skeletal muscle atrophy by repetitive ischemia-reperfusion caused by treadmill-based programs remains a concern. Because preservation of skeletal muscle mass (SMM) and lean mass (LM) is integral to functional capacity and longevity, this study measured the effect of standard treadmill-based supervised exercise on SMM and regional lower limb LM in patients with intermittent claudication. Patients with calf claudication caused by infrainguinal peripheral artery disease underwent whole-body dual-energy X-ray absorptiometry scanning before and after completion of a 12-week supervised treadmill exercise program. Total body SMM and lower limb LM were measured according to anatomical regions of the lower limb (thigh vs calf) and side of symptoms. Walking performance was assessed using pain-free walking distance and 6-minute walking distance tests. Thirty-six patients with calf claudication completed exercise training and dual-energy X-ray absorptiometry scanning, allowing analysis of 55 symptomatic and 17 asymptomatic lower limbs. No difference in total body SMM (P = .41) or LM of symptomatic (P = .53) or asymptomatic calves (P = .59) was detected after the program. In contrast, a significant decrease in LM was observed in symptomatic (P = .04) and asymptomatic thighs (P = .005). Pain-free walking distance (P = .001) and the 6-minute walking distance both improved significantly (P = .004) but were not associated with changes in LM. Twelve weeks of standard treadmill-training for intermittent calf claudication did not result in loss of calf LM; however, a significant decrease in bilateral thigh LM was observed, even in patients with unilateral symptoms. Further research on optimum exercise modalities and end points are required to determine the pathophysiology and effects of these changes on function and survival.

Research paper thumbnail of Pre-Operative Anaemia Predicts Poor Outcomes in Patients Undergoing Infra-Inguinal Bypass Surgery

World Journal of Cardiovascular Diseases, 2014

Research paper thumbnail of The impact of abdominal aortic aneurysm on muscle mass and energy expenditure: A novel preliminary investigation

Vascular, Jan 9, 2015

Vascular surgical patients, including those with abdominal aortic aneurysm (AAA), are nutritional... more Vascular surgical patients, including those with abdominal aortic aneurysm (AAA), are nutritionally vulnerable. The aim of this study was to compare resting energy expenditure (REE) of patients with AAA relative to age- and gender-matched controls and explore relationships between aneurysm size and muscle mass. Twenty patients with AAA underwent assessment of REE using indirect calorimetry. Mid-arm circumference and triceps skinfold thickness were measured and corrected arm muscle area calculated. Twenty gender- and age-matched controls were assessed using the same procedures. Mean (SD) age of participants with AAA was 74.7 (7.7) years, size of AAA ranged from 45 to 70 mm. Median (IQR) REE was significantly higher than controls [5990 (5469, 7017) kJ/day versus 5086 (4536, 5886) kJ/day, p = .011; or 69 (64, 80) kJ/kg/day versus 66 (61, 69) kJ/kg/day, p = .046]. While weight-adjusted REE was independent of aneurysm size (r = .200; p = .397), as aneurysm size increased, weight-adjusted...

Research paper thumbnail of Pulsatile varicose veins

Journal of the Royal Society of Medicine, 2000

Research paper thumbnail of The impact of different supervised exercise regimens on endothelial function in patients with intermittent claudication

Vascular, Jan 18, 2014

The impact of supervised exercise training on endothelial function in patients with intermittent ... more The impact of supervised exercise training on endothelial function in patients with intermittent claudication is unclear. This study assesses the impact of treadmill-based supervised exercise training alone or in combination with resistance training on pain free walking distance, flow-mediated dilatation, reactive hyperaemia index, nitric oxide and asymmetric dimethylarginine. Thirty-five patients with intermittent claudication were randomised to 12 weeks of treadmill-only supervised exercise training (Group 1) or a combination of treadmill and lower-limb resistance supervised exercise training (Group 2). Pain free walking distance was assessed by six-minute walk test. Endothelial function was assessed by brachial artery flow-mediated dilatation, reactive hyperaemia index and serum analysis of asymmetric dimethylarginine and nitric oxide. Pain free walking distance improved within Group 1 (160 m to 204 m, p = 0.03) but not Group 2 (181 m to 188 m, p = 0.82), no between group differe...

Research paper thumbnail of Lower pain and faster treatment with mechanico-chemical endovenous ablation using ClariVein(R)

Phlebology: The Journal of Venous Disease, 2014

To assess the efficacy of the ClariVein® system of mechanico-chemical ablation of superficial vei... more To assess the efficacy of the ClariVein® system of mechanico-chemical ablation of superficial vein incompetence. ClariVein® treatment uses a micropuncture technique and a 4-Fr sheath to allow a catheter to be placed 1.5 cm from the saphenofemoral junction. Unlike laser (endovenous laser treatment (EVLT)) or radiofrequency ablation (RFA), no tumescence is required. The technique depends on a wire rotating at 3500 r/min causing endothelial damage whilst liquid sclerosant (1.5% sodium tetradecyl sulphate) is infused. The wire is pulled back whilst continuously infusing sclerosant along the target vessel's length. Initially, 8 mL of dilute sclerosant was used, but this was subsequently increased to 12 mL. No routine post-op analgesia was prescribed and specifically no non-steroidal anti-inflammatory drugs. Procedure times and pain scores (visual analogue scale) were recorded and compared to EVLT and RFA. All patients were invited for duplex post-procedure. Fifty-one great saphenous veins and six short saphenous veins were treated and followed up with duplex in the 10 months from July 2011. No major complications or deep vein thrombosis were reported. Duplex showed patency of three treated veins with two more veins having only a short length of occlusion, giving a technical success rate of 91%. Comparison with 50 RFA and 40 EVLT showed procedure times were significantly less for ClariVein® (23.0 ± 8.3 min) than for either RFA (37.9 ± 8.3 min) or EVLT (44.1 ± 11.4 min). Median pain scores were significantly lower for ClariVein® than RFA and EVLT (1 vs. 5 vs. 6, p < 0.01). Mechanochemical ablation with the ClariVein® system is safe and effective. After some initial failures, the use of 12 mL of dilute sclerosant results in a very high technical success rate >90% which accords with the limited published literature. Procedure times and pain scores are significantly better than for RFA and EVLT. We await the long-term clinical outcomes.

Research paper thumbnail of Change in dietary intake of adults with intermittent claudication undergoing a supervised exercise program and compared to matched controls

Nutrition Journal, 2014

Background: Presence of numerous diet responsive comorbidities and high atherosclerotic burden am... more Background: Presence of numerous diet responsive comorbidities and high atherosclerotic burden among adults with intermittent claudication demands attention is given to diet in an effort to delay progression of peripheral artery disease. The aim of this study was to compare diet of adults with intermittent claudication: (a) against dietary recommendations; (b) following 12 weeks of supervised exercise training; and (c) against non-peripheral artery disease controls. Methods: Diet was assessed using a food frequency questionnaire pre and post supervised exercise training. Pre-exercise diet was compared against Suggested Dietary Targets and against non-peripheral artery disease controls matched for gender, age and body weight. Pre-exercise diet was also compared against post-exercise diet.

Research paper thumbnail of Does Angioplasty Improve the Quality of Life for Claudicants?: A Prospective Study

Annals of Vascular Surgery, 1999

This study aims to analyze the impact of percutaneous transluminal angioplasty (PTA) for claudica... more This study aims to analyze the impact of percutaneous transluminal angioplasty (PTA) for claudication on patients' quality of life (QOL). The patients in this study included 108 claudicants, 74 men and 34 women, with a median age of 67 years (range 40-87 years), who were assessed prior to and at 1, 3, and 6 months following PTA. This is the first report to demonstrate that the previously well-documented improvements in the clinical indicators of lower-limb ischemia are accompanied by improvements in individual QOL domains and in overall global QOL. These findings are detectable within a month following PTA and last at least 6 months. The results of this study may go some way to provide proof of efficacy for the procedure and thus help justify the recently questioned widespread use of PTA in clinical practice.

Research paper thumbnail of Pharmacist influence on prescribing in peripheral arterial disease (PIPER)

Vascular Medicine, 2014

The objective of this study was to determine the association between a specialist clinical pharma... more The objective of this study was to determine the association between a specialist clinical pharmacist working in collaboration with medical staff and prescribing in peripheral arterial disease (PAD). A retrospective cohort study was conducted comparing the influence of a dedicated clinical pharmacist on two samples of patients admitted to a single vascular surgery unit in either 2007 (control group) prior to implementation of a comprehensive clinical pharmacy service or 2009 (comparison group) post implementation. Data were obtained via review of medical records and electronic reports. A total of 685 patients were identified, resulting in 964 admissions. The patient to pharmacist ratio decreased from 62 to 33 patients per day in 2009. More patients were initiated on an antiplatelet (OR 4.6, 95% CI 2.26 to 9.53, p<0.001) and statin (OR 3.4, 95% CI 1.97 to 6, p<0.001) in 2009 compared to 2007. Risk factor modification increased in 2009, resulting in action being taken more often for HbA1c>7% (OR 3.45, 95% CI 1.64 to 7.27, p=0.001), total cholesterol >4 mmol/L in females (OR 14.5, 95% CI 2.67 to 78.6, p=0.002) and blood pressure above target (OR 1.9, 95% CI 1.01 to 3.73, p=0.05) when a comprehensive clinical pharmacist service was available. There was a non-significant reduction in mortality (18.7% (65) to 14.2% (46), p=0.13) and cardiovascular outcomes (5.5% (19) to 4.3% (14), p=0.44) within 12 months of discharge. In conclusion, prescribing of evidence-based medication for PAD and risk factor modification increased with a comprehensive clinical pharmacist service. This study provides important insight into optimising treatment in this patient group and how a pharmacist can be a helpful addition to the multidisciplinary team.

Research paper thumbnail of Correlating clinical indicators of lower-limb ischaemia with quality of life

Cardiovascular Surgery, 1997

The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon qu... more The objectives of the study were to analyse the impact of increasing lower-limb ischaemia upon quality of life and to assess the correlation between clinical indicators of lower-limb ischaemia and such quality. A prospective observational study of a consecutive series of 235 patients (144 men and 91 women; median age 68 (range 41-87) years presenting with varying degrees of lower-limb ischaemia graded according to ISCVS criteria was performed. Data was collected at interview before any intervention. Clinical indicators of lower-limb perfusion included: intermittent claudication and maximum walking distance on standardized treadmill testing; ankle:brachial pressure indices and isotope limb blood flow. Quality of life analysis was performed using the EuroQol (EQ) questionnaire. This is a standardized generic instrument for describing health-related quality of life and consists of a descriptive system of five dimensions, each measured on three levels. Thus, a profile and two single indices of quality of life were derived using different methods. Increasing lower-limb ischaemia results in a statistically significant deterioration in both global quality of life and in all EQ-measured quality of life dimensions (P Ͻ 0.01 Kruskal-Wallis, ANOVA). The correlation between clinical indicators and quality of life is statistically significant but not sufficiently close (correlation coefficients Ͻ 0.6) to assume that variations in clinical indicators result in reciprocal variations in quality of life.

Research paper thumbnail of Volume replacement during aortic surgery: Homologous vs. autologous blood?

Cardiovascular Surgery, 1995

The risks of allogeneic transfusion are well known to cardiovascular surgeons and have prompted a... more The risks of allogeneic transfusion are well known to cardiovascular surgeons and have prompted a search for alternatives. Perfluorocarbons were introduced into clinical trials in the early 1980s with the hope that these products would develop into acceptable blood substitutes. Unfortunately, the limited potency, short half-life, and potential toxicity of these early formulations, coupled with unrealistic expectations for efficacy, prevented the perfluorocarbons from playing a significant role in transfusion medicine. Recent changes in formulation to improve efficacy and eliminate toxicity have stimulated renewed interest in perfluorocarbons as alternatives to allogeneic transfusion.

Research paper thumbnail of 8.14 How effective is acute normovolaemic haemodilution (ANH) in vascular patients?

Cardiovascular Surgery, 1997

Research paper thumbnail of 21.13 Isotope limb blood flow as a predictor of outcome in chronic critical leg ischaemia

Cardiovascular Surgery, 1997

F3moropopliteal I gated by graft surveillance results) within I2 months or before the patient's d... more F3moropopliteal I gated by graft surveillance results) within I2 months or before the patient's death.

Research paper thumbnail of How effective is acute normovolaemic haemodilution in femoro-distal bypass surgery?

Cardiovascular Surgery, 2002

Background: Recent guidelines have emphasised the use of autologous blood in the surgical setting... more Background: Recent guidelines have emphasised the use of autologous blood in the surgical setting. The aim of this study was to analyse the efficacy and efficiency of acute normovolaemic haemodilution (ANH) as a blood conservation intervention in patients undergoing elective femoro-distal surgery for critical limb ischaemia.

Research paper thumbnail of Endovascular repair of abdominal aortic aneurysm reduces intraoperative cortisol and perioperative morbidity

Journal of Vascular Surgery, 2005

Research paper thumbnail of Neutrophil-lymphocyte ratio as a prognostic marker of outcome in infrapopliteal percutaneous interventions for critical limb ischemia

Journal of Vascular Surgery, 2014

Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) ... more Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) in recent times. The recent Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial consensus recommended endovascular treatment as a first-line treatment in patients who have a life expectancy that was limited to <2 years. Despite these recommendations, there still remains limited data available to clinicians when seeking to risk stratify patients who present with CLI. The neutrophil-lymphocyte ratio (NLR) has been suggested to be a marker for predicting mortality and patency. This study aimed to investigate the use of the NLR as a prognostic marker for primary patency and mortality after an infrapopliteal endovascular intervention in patients with CLI. All patients who underwent tibial angioplasty for CLI were retrospectively analyzed. Demographics, degrees of stenosis, vessel patency rates, mortality, and comorbidities were recorded. NLRs were calculated from preoperative blood samples. Primary end points were all-cause mortality, primary patency, and amputation-free survival (AFS) within the follow-up period of 12 months. Multivariate Cox proportional hazard models were used to identify independent predictors. Overall survival, AFS, and the probability of a vessel remaining patent were evaluated by standard Kaplan-Meier survival curves and groups compared by the log-rank test. Eighty-three patients were monitored for 12 months. Ninety limbs were identified, with 104 procedural events and 127 vessels undergoing successful angioplasty. The technical success rate was 86%, and patency at 1 year was 19%. Survival at 1 year was 76% and AFS was 61%. Patients with a NLR ≥5.25 had an increased risk of death (hazard ratio, 1.97; 95% confidence interval, 1.08-3.62; P = .03) compared with those with a NLR of <5.25. Furthermore, those with lymphocytes counts of <1.5 × 10(9)/L had higher mortality (hazard ratio, 1.88; 95% confidence interval, 1.02-3.70; P = .045) than those with lymphocyte counts >1.5 × 10(9)/L. The NLR and absolute lymphocyte counts are potentially valuable prognostic indicators for risk stratification of patient's presenting with CLI undergoing infrapopliteal angioplasty.

Research paper thumbnail of Autologous blood transfusion: The benefits to the patient undergoing abdominal aortic aneurysm repair

Journal of Vascular Nursing, 1997

The clinical benefits of using intraoperative autologous blood transfusion during abdominal aorti... more The clinical benefits of using intraoperative autologous blood transfusion during abdominal aortic aneurysm bypass surgery become increasingly apparent when use of autologous and homologous blood transfusions is compared. That homologous blood transfusions carry some risk is widely recognized. When autologous blood is used as a sole source of blood transfusion, the risk of transmission of infectious agents and potential immunologic side effects are avoided. A prospective randomized pilot study comparing autologous and homologous blood transfusion in patients undergoing elective infrarenal abdominal aortic aneurysm bypass surgery was undertaken. The purpose of this study was to determine whether autologous blood salvaged intraoperatively may serve as an alternative to homologous blood by comparing the rate of postoperative infection and duration of hospital stay for patients receiving autologous versus homologous blood transfusions. Fifty patients undergoing abdominal aortic aneurysm bypass surgery were prospectively randomly assigned to receive either a homologous or an autologous blood transfusion, with 27 receiving a homologous blood transfusion and 23 receiving an autologous blood transfusion. The data from this study show that the length of hospital stay of patients receiving an autologous blood transfusion intraoperatively was reduced by a mean of 3 days and the risk of postoperative complications, such as a systemic inflammatory response or sepsis, was reduced by more than 50%. (J Vasc Nuts 1997;15:111-5) Blood transfusion has assumed a major role in the development of modern medical and surgical practice. However, blood transfusion involves side effects and risks that have been well documented over the years. These risks have been dramatically reduced by accurate donor screening, safer blood processing, and more reliable pretransfusion testing. Nevertheless, the risks of some adverse effect serious enough to compromise the outcome of complex surgical procedures is still apparent.

Research paper thumbnail of 8.13 The utilization of cold provocation thermography in upper limb vasospastic conditions

Cardiovascular Surgery, 1997

Research paper thumbnail of Curative resection and reconstruction of the inferior vena cava after extensive infiltration with low-grade endometrial stromal sarcoma

Phlebology / Venous Forum of the Royal Society of Medicine, 2012

Endometrial stromal sarcoma (ESS) rarely infiltrates the great vessels. We report a successful su... more Endometrial stromal sarcoma (ESS) rarely infiltrates the great vessels. We report a successful surgical resection of the inferior vena cava (IVC) after extensive infiltration with metastatic low-grade ESS. A case of presumed recurrence of low-grade ESS demonstrated complete IVC occlusion from tumour thrombus with extensive local disease. Radical resection of the tumour and caval reconstruction was performed. The IVC graft was thrombosed at short-term follow-up. Curative resection of extensive caval infiltration with metastatic low-grade ESS can be achieved. Caval reconstructive procedures may be redundant in the presence of an adequate collateral circulation.