Reactivation of tectonics, crustal underplating, and uplift after 60 Myr of passive subsidence, Raukumara Basin, Hikurangi-Kermadec fore arc, New Zealand: implications for global growth and recycling of continents

We use seismic reflection and refraction data to determine crustal structure, to map a fore-arc basin containing 12 km of sediment, and to image the subduction thrust at 35 km depth. Seismic reflection megasequences within the basin are correlated with onshore geology: megasequence X, Late Cretaceous and Paleogene marine passive margin sediments; megasequence Y, a similar to 10,000 km(3) submarine landslide emplaced during subduction initiation at 22 Ma; and megasequence Z, a Neogene subduction margin megasequence. The Moho lies at 17 km beneath the basin center and at 35 km at the southern margin. Beneath the western basin margin, we interpret reflective units as deformed Gondwana fore-arc sediment that was thrust in Cretaceous time over oceanic crust 7 km thick. Raukumara Basin has normal faults at its western margin and is uplifted along its eastern and southern margins. Raukumara Basin represents a rigid fore-arc block > 150 km long, which contrasts with widespread faulting and large Neogene vertical axis rotations farther south. Taper of the western edge of allochthonous unit Y and westward thickening and downlap of immediately overlying strata suggest westward or northwestward paleoslope and emplacement direction rather than southwestward, as proposed for the correlative onshore allochthon. Spatial correlation between rock uplift of the eastern and southern basin margins with the intersection between Moho and subduction thrust leads us to suggest that crustal underplating is modulated by fore-arc crustal thickness. The trench slope has many small extensional faults and lacks coherent internal reflections, suggesting collapse of indurated rock, rather than accretion of > 1 km of sediment from the downgoing plate. The lack of volcanic intrusion east of the active arc, and stratigraphic evidence for the broadening of East Cape Ridge with time, suggests net fore-arc accretion since 22 Ma. We propose a cyclical fore-arc kinematic: rock moves down a subduction channel to near the base of the crust, where underplating drives rock uplift, oversteepens the trench slope, and causes collapse toward the trench and subduction channel. Cyclical rock particle paths led to persistent trench slope subsidence during net accretion. Existing global estimates of fore-arc loss are systematically too high because they assume vertical particle paths. Citation: Sutherland, R., et al. (2009), Reactivation of tectonics, crustal underplating, and uplift after 60 Myr of passive subsidence, Raukumara Basin, Hikurangi-Kermadec fore arc, New Zealand: Implications for global growth and recycling of continents, Tectonics, 28, TC5017, doi: 10.1029/2008TC002356

Effect of a Perioperative, Cardiac Output-Guided Hemodynamic Therapy Algorithm on Outcomes Following Major Gastrointestinal Surgery A Randomized Clinical Trial and Systematic Review

Importance: small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm.Objective: to evaluate the clinical effectiveness of a perioperative, cardiac output–guided hemodynamic therapy algorithm.Design, setting, and participants: OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014.Interventions: patients were randomly assigned to a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366).Main outcomes and measures: the primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care–free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay.Results: baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, ?0.3% to 13.9%]; P?=?.07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]).Conclusions and relevance: in a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output–guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rate

When peacekeepers put lives at risk

The ethical duty of Rowan Gillies, International President of Médecins Sans Frontières (MSF), is simple: in crisis-affected countries, he goes to the person who is most sick, regardless of race, religion, politics or sex. Executing the task in the field, however, becomes dangerous and complicated when peacekeeping forces and government-linked humanitarian groups interfere in dispensing humanitarian aid. Dr Gillies\u27 Sydney Ideas lecture can be heard by PODCAST

Salvage free flap reconstruction of deep sternal wound infections post coronary artery bypass: a case series

In Australia, approximately 12,600 coronary artery bypass grafts are performed annually. Deep sternal wound infections occur in 0.2–3.0 per cent of cases. Pedicled flaps, which are the workhorse reconstruction option, are straightforward to harvest with relatively short operative times, but suffer limitations such as their arc of rotation, vulnerability to partial flap necrosis, limited utility in reconstructing larger defects and may not be an option in salvage cases. In the setting of free flap reconstruction of sternal defects, finding suitable recipient vessels around the sternum can be challenging, especially when the left internal mammary artery has been used for cardiac revascularisation. In the scenario where left internal mammary artery has been used for cardiac grafts, most surgeons hesitate to use the right internal mammary artery and vein as recipient vessels due to concerns of sternal devascularisation. This often necessitates using recipient vessels in the base of the neck and the use of either vein grafts to increase pedicle length or arteriovenous loops in a staged fashion

Surgical care by non-surgeons in low-income and middle-income countries: a systematic review.

Anecdotal evidence suggests that task-shifting or the redistribution of responsibilities from fully-trained surgeons to clinicians with fewer qualifications could become a major component of surgical care delivery in many low-income and middle-income countries (LMICs). Our goal was to summarise the scope of surgical task-shifting in LMICs through a systematic review of the medical literature