Joseph Frantzias

All Publications

• A case of conservatively managed idiopathic spinal cord herniation presenting with low-pressure headache. Journal of surgical case reports Mancuso-Marcello, M., Frantzias, J., Hardwidge, C. 2024; 2024 (3): rjae063

  Abstract

  Idiopathic spinal cord herniation presenting with low-pressure headache is extremely rare. We present a case of thoracic ventral spinal cord herniation in a 35-year-old lady who presented with low-pressure headaches. To our knowledge, this is only the fourth case described in the literature of spontaneous ventral cord herniation presenting in this way. The patient was managed conservatively with no manifestation of focal neurological symptoms at 12-month follow-up. The proposed aetiology of spontaneous ventral cord herniation is an initial CSF leak via a dural defect, through which the cord subsequently also enters blocking the CSF leak. We endorse a conservative approach for patients who present similarly, secondary to the above pathophysiology.

  View details for DOI 10.1093/jscr/rjae063

  View details for PubMedID 38463745

• Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma NEW ENGLAND JOURNAL OF MEDICINE Hutchinson, P. J., Adams, H., Mohan, M., Devi, B. I., Uff, C., Hasan, S., Mee, H., Wilson, M. H., Gupta, D. K., Bulters, D., Zolnourian, A., McMahon, C. J., Stovell, M. G., Al-Tamimi, Y. Z., Tewari, M. K., Tripathi, M., Thomson, S., Viaroli, E., Belli, A., King, A. T., Helmy, A. E., Timofeev, I. S., Pyne, S., Shukla, D. P., Bhat, D. I., Maas, A. R., Servadei, F., Manley, G. T., Barton, G., Turner, C., Menon, D. K., Gregson, B., Kolias, A. G., British Neurosurg Trainee Res Col, Nihr Global Hlth Res Grp Acquired, RESCUE-ASDH Trial Collaborators 2023; 388 (24): 2219-2229

  Abstract

  Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear.We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group.Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).

  View details for DOI 10.1056/NEJMoa2214172

  View details for Web of Science ID 000976778800001

  View details for PubMedID 37092792

• Combined extradural and intradural approach to a trigeminal nerve hemangiopericytoma with cranial nerve monitoring: a technical note of a rare case JOURNAL OF SURGICAL CASE REPORTS Frantzias, J., Ghimire, P., Thomas, N., Pereira, N., Bhangoo, R., Lavrador, J. 2022; 2022 (10): rjac445

  Abstract

  Hemangiopericytoma (HPC) of the trigeminal nerve is extremely rare. We present a case of a large cystic HPC of the mandibular division of the trigeminal nerve, only the third case described in the literature, with both intradural and extradural components. We describe the surgical approach, assisted by neurophysiological techniques of mapping and monitoring including blink reflex and triggered electromyography. Additionally, we report a method of monitoring of the sensory branches of the trigeminal nerve, poorly described in the literature, through peripheral and direct nerve stimulation and recording of transcranial somatosensory evoked potentials.

  View details for DOI 10.1093/jscr/rjac445

  View details for Web of Science ID 000871665100002

  View details for PubMedID 36299911

  View details for PubMedCentralID PMC9592151

• Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland STROKE AND VASCULAR NEUROLOGY Loan, J. M., Tominey, S., Baweja, K., Woodfield, J., Chambers, T. G., Haley, M., Kundu, S. S., Tang, H., Wiggins, A. N., Poon, M. C., Brennan, P. M., Sodium Subarachnoid Haemorrhage Sa 2023; 8 (3): 207-216

  Abstract

  Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH.We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression.175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I-III, modified Fisher 2-4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia.In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care.

  View details for DOI 10.1136/svn-2022-001583

  View details for Web of Science ID 000859908700001

  View details for PubMedID 36150732

  View details for PubMedCentralID PMC10359796

• The changing landscape of cerebral revascularization surgery: A United Kingdom experience. Frontiers in radiology Gallagher, M. J., Frantzias, J., Kailaya-Vasan, A., Booth, T. C., Tolias, C. M. 2022; 2: 981501

  Abstract

  We describe the chronological trends in cerebral revascularization surgery through a single-surgeon experience; and we review whether in the context of giant and fusiform cerebral aneurysms, flow-diverting stents have impacted on the use of cerebral revascularization surgery.We review our single institution prospectively collected database of cerebral revascularization procedures between 2006 and 2018. Comparing this to our database of flow-diverting endovascular stent procedures, we compare the treatment of fusiform and giant aneurysms. We describe patient demographics, procedural incidence, complications, and outcomes.Between 2006 and 2018, 50 cerebral revascularization procedures were performed. The incidence of cerebral revascularization surgery is declining. In the context of giant/fusiform aneurysm treatment, the decline in cerebral revascularization is accompanied by a rise in the use of flow-diverting endovascular stents. Thirty cerebral revascularizations were performed for moyamoya disease and 11 for giant/fusiform aneurysm. Four (14%) direct bypass grafts occluded without neurological sequela. Other morbidity included hydrocephalus (2%), transient ischemic attacks (2%), and ischemic stroke (2%). There was one procedure-related mortality (2%). Flow-diverting stents were inserted for seven fusiform and seven giant aneurysms. Comparing the treatment of giant/fusiform aneurysms, there was no significant difference in morbidity and mortality between cerebral revascularization and flow-diverting endovascular stents.We conclude that with the decline in the incidence of cerebral revascularization surgery, there is a need for centralization of services to allow high standards and outcomes to be maintained.

  View details for DOI 10.3389/fradi.2022.981501

  View details for PubMedID 37492660

  View details for PubMedCentralID PMC10365020

• Current decision support tools fail to agree or predict therapeutic decisions in a single cohort of unruptured intracranial aneurysms ACTA NEUROCHIRURGICA Kailaya-Vasan, A., Frantzias, J., Kailaya-Vasan, J., Anderson, I. A., Walsh, D. C. 2022; 164 (3): 771-779

  Abstract

  There is limited evidence to direct the management of unruptured intracranial aneurysms. Models extrapolated from existing data have been proposed to guide treatment recommendations. The aim of this study is to assess whether a consensus-based treatment score (UIATS) or rupture rate estimation model (PHASES) can be used to benchmark UK multi-disciplinary team (MDT) practice.Prospective data was collected on a consecutive series of all patients with unruptured intracranial aneurysms (UIAs) presenting to a major UK neurovascular centre between 2012 and 2015. The agreement between the UIATS and PHASES scores, and their sensitivity and specificity in predicting the real-world MDT outcome were calculated and compared.A total of 366 patients (456 aneurysms) were included in the analysis. The agreement between UIATS and MDT recommendation was low (weighted kappa 0.26 [95% CI 0.19, 0.32]); sensitivity and specificity were also low at 36% and 52% respectively. Groups that the MDT allocated to treatment, equipoise or no treatment had significantly different PHASES scores (p = 0.004). There was no significant difference between the two scores when predicting patients for whom MDT outcome was to recommend aneurysm treatment, but the UIATS score was superior in predicting patients who received an MDT recommendation of 'treatment-equipoise', or 'not-for-treatment' (AUC of 0.73 compared to 0.59 for PHASES).The models studied failed to agree with the consensus view of multi-disciplinary team in a major neurovascular centre. We conclude that decision support tools such as the UIATS and PHASES scores should not be blindly introduced in respective institutions without prior internal validation, as they may not represent the local reality.

  View details for DOI 10.1007/s00701-021-04852-w

  View details for Web of Science ID 000647956300001

  View details for PubMedID 33956233

  View details for PubMedCentralID PMC8913469

• Acute bilateral foot drop with or without cauda equina syndrome-a case series ACTA NEUROCHIRURGICA Demetriades, A. K., Mancuso-Marcello, M., Baig Mirza, A., Frantzias, J., Bell, D. A., Selway, R., Gullan, R. 2021; 163 (4): 1191-1198

  Abstract

  Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded.Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery.Seven patients are presented. The mean age at presentation was 52.1 years (range 41-66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other.When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

  View details for DOI 10.1007/s00701-021-04735-0

  View details for Web of Science ID 000615595200001

  View details for PubMedID 33550516

  View details for PubMedCentralID PMC7966217

• Moving beyond the Border Introduction and Overview BEHIND-THE-BORDER: ASSESSING AND ADDRESSING NON-TARIFF MEASURES Francois, J., Hoekman, B., Francois, J., Hoekman, B. 2019: 1-+

  View details for DOI 10.1080/02688697.2019.1679353

  View details for Web of Science ID 000524971200001

• Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant CHILDS NERVOUS SYSTEM Hanrahan, J., Frantzias, J., Lavrador, J. P., Bodi, I., Zebian, B. 2018; 34 (12): 2519-2523

  Abstract

  Arachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.We report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

  View details for DOI 10.1007/s00381-018-3917-4

  View details for Web of Science ID 000451459100027

  View details for PubMedID 30062591

  View details for PubMedCentralID PMC6224018

• Absolute risk and predictors of the growth of acute spontaneous intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data LANCET NEUROLOGY Salman, R., Frantzias, J., Lee, R. J., Lyden, P. D., Battey, T. K., Ayres, A. M., Goldstein, J. N., Mayer, S. A., Steiner, T., Wang, X., Arima, H., Hasegawa, H., Oishi, M., Godoy, D. A., Masotti, L., Dowlatshahi, D., Rodriguez-Luna, D., Molina, C. A., Jang, D., Davalos, A., Castillo, J., Yao, X., Claassen, J., Volbers, B., Kazui, S., Okada, Y., Fujimoto, S., Toyoda, K., Li, Q., Khoury, J., Delgado, P., Alvarez Sabin, J., Hernandez-Guillamon, M., Prats-Sanchez, L., Cai, C., Kate, M. P., McCourt, R., Venkatasubramanian, C., Diringer, M. N., Ikeda, Y., Worthmann, H., Ziai, W. C., d'Esterre, C. D., Aviv, R. I., Raab, P., Murai, Y., Zazulia, A. R., Butcher, K. S., Seyedsaadat, S., Grotta, J. C., Marti-Fabregas, J., Montaner, J., Broderick, J., Yamamoto, H., Staykov, D., Connolly, E., Selim, M., Leira, R., Moon, B., Demchuk, A. M., Di Napoli, M., Fujii, Y., Anderson, C. S., Rosand, J. 2018; 17 (10): 885–94

  Abstract

  Intracerebral haemorrhage growth is associated with poor clinical outcome and is a therapeutic target for improving outcome. We aimed to determine the absolute risk and predictors of intracerebral haemorrhage growth, develop and validate prediction models, and evaluate the added value of CT angiography.In a systematic review of OVID MEDLINE-with additional hand-searching of relevant studies' bibliographies- from Jan 1, 1970, to Dec 31, 2015, we identified observational cohorts and randomised trials with repeat scanning protocols that included at least ten patients with acute intracerebral haemorrhage. We sought individual patient-level data from corresponding authors for patients aged 18 years or older with data available from brain imaging initially done 0·5-24 h and repeated fewer than 6 days after symptom onset, who had baseline intracerebral haemorrhage volume of less than 150 mL, and did not undergo acute treatment that might reduce intracerebral haemorrhage volume. We estimated the absolute risk and predictors of the primary outcome of intracerebral haemorrhage growth (defined as >6 mL increase in intracerebral haemorrhage volume on repeat imaging) using multivariable logistic regression models in development and validation cohorts in four subgroups of patients, using a hierarchical approach: patients not taking anticoagulant therapy at intracerebral haemorrhage onset (who constituted the largest subgroup), patients taking anticoagulant therapy at intracerebral haemorrhage onset, patients from cohorts that included at least some patients taking anticoagulant therapy at intracerebral haemorrhage onset, and patients for whom both information about anticoagulant therapy at intracerebral haemorrhage onset and spot sign on acute CT angiography were known.Of 4191 studies identified, 77 were eligible for inclusion. Overall, 36 (47%) cohorts provided data on 5435 eligible patients. 5076 of these patients were not taking anticoagulant therapy at symptom onset (median age 67 years, IQR 56-76), of whom 1009 (20%) had intracerebral haemorrhage growth. Multivariable models of patients with data on antiplatelet therapy use, data on anticoagulant therapy use, and assessment of CT angiography spot sign at symptom onset showed that time from symptom onset to baseline imaging (odds ratio 0·50, 95% CI 0·36-0·70; p<0·0001), intracerebral haemorrhage volume on baseline imaging (7·18, 4·46-11·60; p<0·0001), antiplatelet use (1·68, 1·06-2·66; p=0·026), and anticoagulant use (3·48, 1·96-6·16; p<0·0001) were independent predictors of intracerebral haemorrhage growth (C-index 0·78, 95% CI 0·75-0·82). Addition of CT angiography spot sign (odds ratio 4·46, 95% CI 2·95-6·75; p<0·0001) to the model increased the C-index by 0·05 (95% CI 0·03-0·07).In this large patient-level meta-analysis, models using four or five predictors had acceptable to good discrimination. These models could inform the location and frequency of observations on patients in clinical practice, explain treatment effects in prior randomised trials, and guide the design of future trials.UK Medical Research Council and British Heart Foundation.

  View details for PubMedID 30120039

  View details for PubMedCentralID PMC6143589

• 'Noises in the head': a prospective study to characterize intracranial sounds after cranial surgery ACTA NEUROCHIRURGICA Sivasubramaniam, V., Alg, V., Frantzias, J., Acharya, S., Papadopoulos, M., Martin, A. 2016; 158 (8): 1429-1435

  Abstract

  Patients often report sounds in the head after craniotomy. We aim to characterize the prevalence and nature of these sounds, and identify any patient, pathology, or technical factors related to them. These data may be used to inform patients of this sometimes unpleasant, but harmless effect of cranial surgery.Prospective observational study of patients undergoing cranial surgery with dural opening. Eligible patients completed a questionnaire preoperatively and daily after surgery until discharge. Subjects were followed up at 14 days with a telephone consultation.One hundred fifty-one patients with various pathologies were included. Of these, 47 (31 %) reported hearing sounds in their head, lasting an average 4-6 days (median, 4 days, mean, 6 days, range, 1-14 days). The peak onset was the first postoperative day and the most commonly used descriptors were 'clicking' [20/47 (43 %)] and 'fluid moving' in the head [9/47 (19 %)]. A significant proportion (42 %, 32/77) without a wound drain experienced intracranial sounds compared to those with a drain (20 %, 15/74, p < 0.01); there was no difference between suction and gravity drains. Approximately a third of the patients in both groups (post-craniotomy sounds group: 36 %, 17/47; group not reporting sounds: 31 %, 32/104), had postoperative CT scans for unrelated reasons: 73 % (8/11) of those with pneumocephalus experienced intracranial sounds, compared to 24 % (9/38) of those without pneumocephalus (p < 0.01). There was no significant association with craniotomy site or size, temporal bone drilling, bone flap replacement, or filling of the surgical cavity with fluid.Sounds in the head after cranial surgery are common, affecting 31 % of patients. This is the first study into this subject, and provides valuable information useful for consenting patients. The data suggest pneumocephalus as a plausible explanation with which to reassure patients, rather than relying on anecdotal evidence, as has been the case to date.

  View details for DOI 10.1007/s00701-016-2872-7

  View details for Web of Science ID 000379340100001

  View details for PubMedID 27328839

• Exchange nailing for nonunion of diaphyseal fractures of the tibia OUR RESULTS AND AN ANALYSIS OF THE RISK FACTORS FOR FAILURE BONE & JOINT JOURNAL Tsang, S. J., Mills, L. A., Frantzias, J., Baren, J. P., Keating, J. F., Simpson, A. W. 2016; 98B (4): 534-541

  Abstract

  The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures.A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001).Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered.Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion.

  View details for DOI 10.1302/0301-620X.98B4.34870

  View details for Web of Science ID 000374718700016

  View details for PubMedID 27037437

• Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED Tsang, S. J., Mills, L. A., Baren, J., Frantzias, J., Keating, J. F., Simpson, A. W. 2015; 46 (12): 2404-2409

  Abstract

  The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

  View details for DOI 10.1016/j.injury.2015.09.027

  View details for Web of Science ID 000366020000016

  View details for PubMedID 26489394

• The need for training frameworks and scientific evidence in developing scarless surgery: A national survey of surgeons' opinions on single port laparoscopic surgery INTERNATIONAL JOURNAL OF SURGERY Rehman, H., Fitzgerald, J. F., Frantzias, J., Lemon, J., Ahmed, I. 2013; 11 (1): 73-76

  Abstract

  Single port/incision laparoscopic surgery (SPILS) is a recent innovation in minimally invasive surgery whereby operations are performed through a single point of entry. Despite the relative paucity of clinical data, the procedure is increasingly being used to minimise scarring and pain associated with the multiple entry points of traditional laparoscopic surgery. This study aimed to analyse the awareness, experience and opinions of British surgeons regarding SPILS.Electronic, 13-item, self-administered, anonymous questionnaire survey distributed via national/regional surgical mailing lists and websites. Results were collated and analysed with SPSS v17.0 for Windows (SPSS, Inc, Chicago, IL).342 fully completed responses received, including 72 (21%) Consultants and 189 (55%) higher surgical trainees. Overall 330 (96.5%) were aware of SPILS; there was no significant difference in awareness between grades. Only 37% had assisted or performed SPILS procedures. More consultants performed these than trainees (56.3 vs 32.0%, p < 0.05). Operative experience was limited, with only 6% of those undertaking SPILS performing ≥25 procedures, and 60% performing ≤5. 61.4% believed SPILS takes longer to perform, and 32.8% believed it has higher complication rate. Factors cited as limiting uptake included: lack of evidence (70%), insufficient training opportunities (78%), incorrect instrumentation (70%), increased cost (62%), and hospital policy (44.5%). Patient preference was considered to have negatively affected SPILS uptake by only 9% of respondents. A greater proportion of trainees (94.6% vs 78.9%) felt there were insufficient SPILS training opportunities (p = 0.001).Although awareness of SPILS is high, operative experience is limited and negative perceptions regarding operating time and complications remain. The findings suggest future uptake relies strongly on the availability of evidence, training, instrumentation and reduced costs. Scientific studies are still awaited to assess effectiveness and provide clinical and economic evaluation.

  View details for DOI 10.1016/j.ijsu.2012.11.018

  View details for Web of Science ID 000316936600016

  View details for PubMedID 23220488

• Hydrogen sulphide-releasing diclofenac derivatives inhibit breast cancer-induced osteoclastogenesis in vitro and prevent osteolysis ex vivo BRITISH JOURNAL OF PHARMACOLOGY Frantzias, J., Logan, J. G., Mollat, P., Sparatore, A., Del Soldato, P., Ralston, S. H., Idris, A. I. 2012; 165 (6): 1914-1925

  Abstract

  Hydrogen sulphide (H(2)S) and prostaglandins are both involved in inflammation, cancer and bone turnover, and non-steroidal anti-inflammatory drugs (NSAIDs) and H(2)S donors exhibit anti-inflammatory and anti-tumour properties. H(2)S-releasing diclofenac (S-DCF) derivatives are a novel class of NSAIDs combining the properties of a H(2)S donor with those of a conventional NSAID.We studied the effects of the S-DCF derivatives ACS15 and ACS32 on osteoclast and osteoblast differentiation and activity in vitro, human and mouse breast cancer cells support for osteoclast formation and signalling in vitro, and osteolysis ex vivo.The S-diclofenac derivatives ACS15 and ACS32 inhibited the increase in osteoclast formation induced by human MDA-MB-231 and MCF-7 and mouse 4T1 breast cancer cells without affecting breast cancer cell viability. Conditioned media from human MDA-MB-231 cells enhanced IκB phosphorylation and osteoclast formation and these effects were significantly inhibited following treatment by ACS15 and ACS32, whereas the parent compound diclofenac had no effects. ACS15 and ACS32 inhibited receptor activator of NFκB ligand-induced osteoclast formation and resorption, and caused caspase-3 activation and apoptosis in mature osteoclasts via a mechanism dependent on IKK/NFκB inhibition. In calvaria organ culture, human MDA-MB-231 cells caused osteolysis, and this effect was completely prevented following treatment with ACS15 and ACS32.S-diclofenac derivatives inhibit osteoclast formation and activity, suppress breast cancer cell support for osteoclastogenesis and prevent osteolysis. This suggests that H(2)S-releasing diclofenac derivatives exhibit anti-resorptive properties, which might be of clinical value in the treatment of osteolytic bone disease.

  View details for DOI 10.1111/j.1476-5381.2011.01704.x

  View details for Web of Science ID 000300689800025

  View details for PubMedID 21955294

  View details for PubMedCentralID PMC3372840

• Treatment of Intracerebral Hemorrhage in Animal Models: Meta-Analysis ANNALS OF NEUROLOGY Frantzias, J., Sena, E. S., Macleod, M. R., Salman, R. 2011; 69 (2): 389-399

  Abstract

  Interventions that improve functional outcome after acute intracerebral hemorrhage (ICH) in animals might benefit humans. Therefore, we systematically reviewed the literature to find studies of nonsurgical treatments tested in animal models of ICH.In July 2009 we searched Ovid Medline (from 1950), Embase (from 1980), and ISI Web of Knowledge (from 1969) for controlled animal studies of nonsurgical interventions given after the induction of ICH that reported neurobehavioral outcome. We assessed study quality and performed meta-analysis using a weighted mean difference random effects model.Of 13,343 publications, 88 controlled studies described the effects of 64 different medical interventions (given a median of 2 hours after ICH induction) on 38 different neurobehavioral scales in 2,616 treated or control animals (median 14 rodents per study). Twenty-seven (31%) studies randomized treatment allocation, and 7 (8%) reported allocation concealment; these studies had significantly smaller effect sizes than those without these attributes (p < 0.001). Of 64 interventions stem cells, calcium channel blockers, anti-inflammatory drugs, iron chelators, and estrogens improved both structural outcomes and neurobehavioral scores in >1 study. Meta-regression revealed that together, structural outcome and the intervention used accounted for 65% of the observed heterogeneity in neurobehavioral score (p < 0.001, adjusted r(2) = 0.65).Further animal studies of the interventions that we found to improve both functional and structural outcomes in animals, using better experimental designs, could target efforts to translate effective treatments for ICH in animals into randomized controlled trials in humans.

  View details for DOI 10.1002/ana.22243

  View details for Web of Science ID 000288284900021

  View details for PubMedID 21387381

• The Persisting Burden of Intracerebral Haemorrhage: Can Effective Treatments Be Found? PLOS MEDICINE Josephson, C. B., Frantzias, J., Samarasekera, N., Salman, R. 2010; 7 (10): e1000353

  Abstract

  Colin Josephson, Rustam Al-Shahi Salman, and colleagues discuss the effectiveness of treatments for intracerebral haemorrhage.

  View details for DOI 10.1371/journal.pmed.1000353

  View details for Web of Science ID 000283493200007

  View details for PubMedID 20976102

  View details for PubMedCentralID PMC2957399