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A systematic scoping review exploring variation in practice in specimen mammography for Intraoperative Margin Analysis in Breast Conserving Surgery and the role of artificial intelligence in optimising diagnostic accuracy
No full textPURPOSE: Specimen Mammography (SM) is commonly used in Breast Conserving Surgery (BCS) for intraoperative margin analysis. A systematic scoping review was conducted to identify sources of methodological variation in Specimen Mammography Interpretation (SMI) and assess the role of Artificial Intelligence (AI) techniques to optimise Diagnostic Accuracy (DA). METHODS: Embase, Pubmed, Cochrane and web of science databases were searched. Studies were included if SM was used for margin analysis for BCS with reported DA compared with pathological margin status and data extracted. RESULTS: 1242 unique studies were identified, of which 40 were included. 39/40 studies did not utilise AI for SMI, with 4 studies comparing 2 relevant techniques, giving 43 non-AI study arms for analysis. There was wide variation in SM techniques, including number of views and location of SM. Specialist performing SMI in usual clinical practice was surgeon (13/39 studies;33 %), radiologist(s) (16/39;41 %), surgeon and radiologist (3/39;8 %) or not stated (7/39;18 %) which differed from the study specialist in 15/39 (38 %) of studies. Diagnostic accuracy in studies ranged from sensitivity 19-91.7 % and specificity 25-100 %. CONCLUSIONS: There is marked variation in current techniques used for SM for intraoperative margin analysis with correspondingly disparate DA. Only 1 study applied AI to SMI, and we identify how AI could optimise SMI and a template for future work to apply AI techniques to SMI, reduce unwarranted variation and optimise DA.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo
Utility and limitations of monitoring kidney transplants using capillary sampling
No full textUnknownRDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted
The management of acute complete ruptures of the ulnar collateral ligament of the thumb
No full textAIMS: Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. METHODS: We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. RESULTS: A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm 'endpoint' to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30° of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. CONCLUSION: The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject.Published versionJournal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
Lichen Planus: What is New in Diagnosis and Treatment?
No full textLichen planus (LP), an idiopathic, multifaceted chronic inflammatory disease with a heterogeneous clinical presentation, affects approximately 0.5-1% of the population. The various clinical manifestations of LP fall into three broad categories, namely cutaneous, appendageal, and mucosal, with further subclassification depending on the morphology and distribution patterns of individual lesions. There is mounting evidence that LP has systemic associations, including autoimmune conditions, glucose intolerance, dyslipidemia, and cardiovascular disorders. Cutaneous hypertrophic and mucosal forms of LP are at a heightened risk for malignant transformation. Familiarity with these potential associations in conjunction with long-term follow-up and regular screening could lead to a timely diagnosis and management of concomitant conditions. In addition, the frequent quality of life (QoL) impairment in LP underscores the need for a comprehensive approach including psychological evaluation and support. Several treatment strategies have been attempted, though most of them have not been adopted in clinical practice because of suboptimal benefit-to-risk ratios or lack of evidence. More recent studies toward pathogenesis-driven treatments have identified Janus kinase inhibitors such as tofacitinib, phosphodiesterase-4 inhibitors such as apremilast, and biologics targeting the interleukin-23/interleukin-17 pathway as novel therapeutic options, resulting in a dramatic change of the treatment landscape of LP. This contemporary review focuses on the diagnosis and management of LP, and places emphasis on more recently described targeted treatment options.UnknownNot hel
Early oncological outcomes of delayed radical prostatectomy: A prospective, international, follow-up analysis of the COVIDSurg-Cancer study
No full textOBJECTIVES: The objective of this study is to compare the early oncological outcomes of delayed (>90 days) versus scheduled (≤90 days) radical prostatectomy (RP). PATIENTS AND METHODS: Patients with prostate cancer due to undergo surgery between March 2020 and June 2020 who were enrolled in the COVIDSurg-Cancer international, observational study were prospectively followed up for 1 year. Time to surgery was defined as the difference between the operation date and the multi-disciplinary team decision to offer surgery. The primary outcome was the positive surgical margin (PSM) rate. Biochemical recurrence (BCR), upgradation and upstaging were secondary oncological outcomes. The Independent t-test and Mann Whitney U test were used to compare means between groups and regression models and were used to investigate factors associated with the primary outcome. RESULTS: Four hundred seventy-six (78.7%) patients underwent RP from 605 that were eligible. Three hundred seven (64.5%) patients underwent scheduled RP, and 169 (35.5%) underwent delayed RP. A small proportion of men (n = 35, 6.8%) did not undergo RP within the 1-year follow-up period. More men with high-risk disease (72.8%) underwent scheduled RP compared to men with intermediate-risk disease (60.2%) (p < 0.05). There was no statistically significant difference in the PSM rate between the two groups (p = 0.512). Delay in surgery was not associated with an increased PSM or BCR on univariable or multivariable analyses. There was statistically significantly greater upstaging (p < 0.05) in the delayed group but no difference in upgradation. CONCLUSION: High-risk men were prioritised for surgery during the COVID-19 pandemic. Our prospective data support previous retrospective, cancer-registry evidence suggesting no adverse oncological impact after delaying RP across all risk groups. Our study is limited by the short follow-up period, and therefore, longer term conclusions cannot be drawn.This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo
Understanding the long-term impact of the COVID-19 pandemic on non-muscle-invasive bladder cancer outcomes: 12-Month follow-up data from the international, prospective COVIDSurg Cancer study
No full textOBJECTIVE: The objective of this study was to report the 12-month oncological outcomes for patients with non-muscle-invasive bladder cancer (NMIBC) within the prospective, international COVIDSurg Cancer study. PATIENTS AND METHODS: Eligible patients were aged ≥18 years and scheduled for elective surgical management of NMIBC with curative intent (transurethral resection of bladder tumour [TURBT] or bladder biopsy) from 21 January to 14 April 2020. The primary outcome was disease recurrence within 12 months of previous elective TURBT/bladder biopsy. Secondary outcomes included disease progression within 12 months of previous elective TURBT/bladder biopsy, site-declared delay to surgery from diagnosis as a consequence of COVID-19 and deviation in standard care due to COVID-19. Comparisons were made to cohorts from the pre-pandemic era. RESULTS: Bladder cancer accounted for 2.2% (n = 446) of patients in the COVIDSurg Cancer study, with data contributed by 27 centres across 12 countries internationally. Within this included cohort, 229 patients had NMIBC and 12-month follow-up data available. On application of National Institute for Health and Care Excellence (NICE) criteria, 47.2% were classified as having high-risk disease. Overall disease recurrence and progression rates were 29.3% and 9.7% at 12 months, respectively. In purely high-risk pre-pandemic cohorts, the International Bladder Cancer Group (IBCG) estimates a recurrence rate of 25% at 12 months, and the European Association of Urology (EAU) NMIBC 2021 scoring model estimates a 12-month progression rate of 3.5%. As a consequence of the COVID-19 pandemic, 10.9% of patients had site-declared delay to TURBT/bladder biopsy; 7.4% did not undergo intravesical therapy or had early discontinuation of this; 9.2% did not undergo early repeat resection for high-risk disease; and 18.3% had a delay to cystoscopic follow-up surveillance. CONCLUSIONS: This prospective study indicates that there were widespread deviations in usual care for NMIBC during the pandemic and that 12-month oncological outcomes appear to be impaired compared to published pre-pandemic outcomes.This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo
Measuring and improving the cradle-to-grave environmental performance of urological procedures
No full textAn urgent need for societal transformation exists to reduce the environmental impact of humanity, because environmental health affects human health. Health care causes ~5% of global greenhouse gas emissions and other substantial and ongoing environmental harms. Thus, health-care professionals and managers must lead ongoing efforts to improve the environmental performance of health systems. Life-cycle assessment (LCA) is a methodology that enables estimation of environmental impacts of products and processes. It models environmental effects from 'cradle' (raw material extraction) to 'grave' (end of useful life) and conventionally reports a range of different impact categories. LCA is a valuable tool when used appropriately. Maximizing its utility requires rational assumptions alongside careful consideration of system boundaries and data sources. Well-executed LCAs are detailed and transparently reported, enabling findings to be adapted or generalized to different settings. Attention should be given to modelling mitigation solutions in LCAs. This important step can guide health-care systems towards new and innovative solutions that embed progress towards international climate agreements. Many urological conditions are common, recurrent or chronic, requiring resource-intensive management with large associated environmental impacts. LCAs in urology have predominantly focussed on greenhouse gas emissions and have enabled identification of modifiable 'hotspots' including electricity use, travel, single-use items, irrigation, reprocessing and waste incineration. However, the methodological and reporting quality of published urology LCAs generally requires improvement and standardization. Health-care evaluation and commissioning frameworks that value LCA findings alongside clinical outcomes and cost could accelerate sustainable innovations. Rapid implementation strategies for known environmentally sustainable solutions are also needed.New Full Text unavailable for 1 year from time of publication. Please click an article to explore additional access options
A lifestyle educational course as an adjunct to biologic administration in patients with severe asthma: A feasibility study
No full textOBJECTIVE: To assess the feasibility and acceptability of adapting a psychoeducation course (Body Reprogramming) for severe asthma and finding suggestions for improvement. METHODS: Severe asthma patients were recruited from a single centre and enrolled in an online group-based course. Each course consisted of four sessions: introduction to BR, stress, exercise, and diet. Participants were asked to complete questionnaires assessing HRQoL, mood, asthma and extra-pulmonary symptoms, pre/post course. Those who attended two or more sessions were invited to provide feedback in interviews. RESULTS: Twenty-eight participants took part in one of the five courses. Thirteen (46 %) attended all four sessions and were sent post-course questionnaires, eight participants (62 %) returned them. Twelve participants provided post course feedback, Themes included: The course as a time to reflect, Appreciation of the group-format, Impact of pre-existing knowledge on enjoyment of the course and Areas of improvement. Maintaining course size, clarification of the course aims and methods were identified as areas of improvement by participants. CONCLUSION: An educational course focused on managing extra-pulmonary symptoms is feasible and of perceived benefit to patients with severe asthma. INNOVATION: BR could be incorporated into a rehab programme for patients with severe asthma with significant extrapulmonary symptoms.This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo
The Royal College of Radiologists National Vulvar Cancer Audit
No full textAIMS: This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity. MATERIALS AND METHODS: Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients. RESULTS: 34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0. CONCLUSION: This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
CLosure of Abdominal MidlineS Survey (CLAMSS): A national survey investigating current practice in the closure of abdominal midline incisions in UK surgical practice
No full textAIM: Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have demonstrated that the small bites technique (SBT) and prophylactic mesh augmentation (PMA) may reduce IH compared to mass closure techniques, but data are lacking on their implementation in contemporary surgical practice. This survey aimed to evaluate the use of the SBT and PMA and to identify factors associated with their adoption. METHOD: Between 22 January 2023 and 16 March 2023, consultant surgeons across the UK were asked to complete a 25-question survey on closure of an elective primary midline incision. RESULTS: Responses were received from 267 of 675 eligible surgeons (39.6%) in 38 NHS Trusts. Respondents were evenly split between tertiary centres (47.6%) and district general hospitals (49.4%). SBT and PMA were used by 19.9% and 3.0% of respondents, respectively. Compared to other techniques, surgeons using the SBT were more likely to close the anterior aponeurotic layer only, use single suture filaments, 2-0 gauge sutures and sharp needle points and routinely dissect abdominal layers to aid closure (all p < 0.001). Attendance at lectures/conferences on SBT (p = 0.043) and basing practice on available evidence (p < 0.001) were independently associated with use of the SBT. The commonest barriers to adopting SBT were a perceived lack of evidence (23.8%) and belief that personal IH rates were low (16.8%). CONCLUSION: A minority of UK consultant surgeons have adopted the SBT or PMA. Practice change should be driven by more widespread dissemination of current evidence and procedural information.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted