Staff Publication

Magnetic resonance imaging before breast cancer surgery: results of an observational multicenter international prospective analysis (MIPA) (2022)

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Type of publication:Journal article

Author(s):Sardanelli F, Trimboli RM, Houssami N, Gilbert FJ, Helbich TH, Álvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, Cozzi A, de Andrade DA, de Lima Docema MF, Depretto C, Dominelli V, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, *Ozcan Umit A, Pediconi F, Pinker K, Preibsch H, Raya Povedano JL, Sacchetto D, Scaperrotta GP, Schiaffino S, Schlooz M, Szabó BK, Taylor DB, Ulus ÖS, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Di Leo G.

Citation:European Radiology. 2022 Mar;32(3):1611-1623.

Abstract:Objectives: Preoperative breast magnetic resonance imaging (MRI) can inform surgical planning but might cause overtreatment by increasing the mastectomy rate. The Multicenter International Prospective Analysis (MIPA) study investigated this controversial issue. Methods: This observational study enrolled women aged 18-80 years with biopsy-proven breast cancer, who underwent MRI in addition to conventional imaging (mammography and/or breast ultrasonography) or conventional imaging alone before surgery as routine practice at 27 centers. Exclusion criteria included planned neoadjuvant therapy, pregnancy, personal history of any cancer, and distant metastases. Results: Of 5896 analyzed patients, 2763 (46.9%) had conventional imaging only (noMRI group), and 3133 (53.1%) underwent MRI that was performed for diagnosis, screening, or unknown purposes in 692/3133 women (22.1%), with preoperative intent in 2441/3133 women (77.9%, MRI group). Patients in the MRI group were younger, had denser breasts, more cancers ≥ 20 mm, and a higher rate of invasive lobular histology than patients who underwent conventional imaging alone (p < 0.001 for all comparisons). Mastectomy was planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (noMRI group) (p < 0.001). The additional planned mastectomy rate in the MRI group was 11.3%. The overall performed first- plus second-line mastectomy rate was 36.3% (MRI group) versus 18.0% (noMRI group) (p < 0.001). In women receiving conserving surgery, MRI group had a significantly lower reoperation rate (8.5% versus 11.7%, p < 0.001). Conclusions: Clinicians requested breast MRI for women with a higher a priori probability of receiving mastectomy. MRI was associated with 11.3% more mastectomies, and with 3.2% fewer reoperations in the breast conservation subgroup. Key points: • In 19% of patients of the MIPA study, breast MRI was performed for screening or diagnostic purposes. • The current patient selection to preoperative breast MRI implies an 11% increase in mastectomies, counterbalanced by a 3% reduction of the reoperation rate. • Data from the MIPA study can support discussion in tumor boards when preoperative MRI is under consideration and should be shared with patients to achieve informed decision-making.

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Solving the preoperative breast MRI conundrum: design and protocol of the MIPA study (2020)

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Type of publication:Journal article

Author(s):Sardanelli F, Trimboli RM, Houssami N, Gilbert FJ, Helbich TH, Alvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Andrade DA, de Lima Docema MF, Depretto C, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, *Ozcan, Umit A., Pediconi F, Preibsch H, Raya-Povedano JL, Sacchetto D, Scaperrotta GP, Schlooz M, Szabo BK, Ulus OS, Taylor DB, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Di Leo G.

Citation:European Radiology. 2020 Oct;30(10):5427-5436.

Abstract:Despite its high diagnostic performance, the use of breast MRI in the preoperative setting is controversial. It has the potential for personalized surgical management in breast cancer patients, but two of three randomized controlled trials did not show results in favor of its introduction for assessing the disease extent before surgery. Meta-analyses showed a higher mastectomy rate in women undergoing preoperative MRI compared to those who do not. Nevertheless, preoperative breast MRI is increasingly used and a survey from the American Society of Breast Surgeons showed that 41% of respondents ask for it in daily practice. In this context, a large-scale observational multicenter international prospective analysis (MIPA study) was proposed under the guidance of the European Network for the Assessment of Imaging in Medicine (EuroAIM). The aims were (1) to prospectively and systematically collect data on consecutive women with a newly diagnosed breast cancer, not candidates for neoadjuvant therapy, who are offered or not offered breast MRI before surgery according to local practice; (2) to compare these two groups in terms of surgical and clinical endpoints, adjusting for covariates. The underlying hypotheses are that MRI does not cause additional mastectomies compared to conventional imaging, while reducing the reoperation rate in all or in subgroups of patients. Ninety-six centers applied to a web-based call; 36 were initially selected based on volume and quality standards; 27 were active for enrollment. On November 2018, the target of 7000 enrolled patients was reached. The MIPA study is presently at the analytic phase. Key Points • Breast MRI has a high diagnostic performance but its utility in the preoperative setting is controversial. • A large-scale observational multicenter prospective study was launched to compare women receiving with those not receiving preoperative MRI. • Twenty-seven centers enrolled more than 7000 patients. The study is presently at the analytic phase.

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The Impact of Artificial Intelligence on Optimizing Diagnosis and Treatment Plans for Rare Genetic Disorders (2023)

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Type of publication:Journal article

Author(s):Abdallah, Shenouda; Sharifa, Mouhammad; I Kh Almadhoun, Mohammed Khaleel; Khawar, Muhammad Muneeb Sr; Shaikh, Unzla; Balabel, Khaled M; Saleh, Inam; Manzoor, Amima; Mandal, Arun Kumar; *Ekomwereren, Osatohanmwen; Khine, Wai Mon; Oyelaja, Oluwaseyi T.

Citation:Cureus. 15(10):e46860, 2023 Oct.

Abstract:Rare genetic disorders (RDs), characterized by their low prevalence and diagnostic complexities, present significant challenges to healthcare systems. This article explores the transformative impact of artificial intelligence (AI) and machine learning (ML) in addressing these challenges. It emphasizes the need for accurate and early diagnosis of RDs, often hindered by genetic and clinical heterogeneity. This article discusses how AI and ML are reshaping healthcare, providing examples of their effectiveness in disease diagnosis, prognosis, image analysis, and drug repurposing. It highlights AI's ability to efficiently analyze extensive datasets and expedite diagnosis, showcasing case studies like Face2Gene. Furthermore, the article explores how AI tailors treatment plans for RDs, leveraging ML and deep learning (DL) to create personalized therapeutic regimens. It emphasizes AI's role in drug discovery, including the identification of potential candidates for rare disease treatments. Challenges and limitations related to AI in healthcare, including ethical, legal, technical, and human aspects, are addressed. This article underscores the importance of data ethics, privacy, and algorithmic fairness, as well as the need for standardized evaluation techniques and transparency in AI research. It highlights second-generation AI systems that prioritize patient-centric care, efficient patient recruitment for clinical trials, and the significance of high-quality data. The integration of AI with telemedicine, the growth of health databases, and the potential for personalized therapeutic recommendations are identified as promising directions for the field. In summary, this article provides a comprehensive exploration of how AI and ML are revolutionizing the diagnosis and treatment of RDs, addressing challenges while considering ethical implications in this rapidly evolving healthcare landscape.

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Improving the Outcome of Patients With Heart Failure: Assessment of Iron Deficiency and Intravenous Iron Replacement (2023)

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Type of publication:Journal article

Author(s):*Yera, Hassan O; Khan, Ahsan; Akinlade, Olawale M; Champsi, Asgher; Glouzon, Van Nam J; Spencer, Charles.

Citation:Cureus. 15(10):e47027, 2023 Oct.

Abstract:Background Iron deficiency (ID) has been shown to be a significant co-morbidity in patients with heart failure (HF), independent of their anaemia status. Correction of ID has been shown to improve quality of life, recurrent heart failure hospitalizations and morbidity. A quality improvement project was designed to improve the assessment and treatment of iron deficiency in HFatients in our tertiary care centre. Methods and results An initial baseline dataset was collected, followed by two cycles of interventions to help improve the care of HF patients admitted to our hospital over a two-month period. The Plan-Do-Study-Act (PDSA) cycle approach was applied, with the first intervention involving raising awareness of the importance and need to assess the iron status of HF patients through education provided to doctors, nurses and patients. Furthermore, information leaflets were produced and disseminated across the medical wards and through social media forums. The post-intervention datasets were collected and compared to the baseline outcomes. Baseline data showed that only four (20%) of heart failure patients had their iron status checked. Following the interventions, screening for ID increased to 80% (16), of which 85% (11) of those who identified as iron deficient received intravenous iron replacement. Conclusion The project was successful in improving the practice of screening for iron deficiency and intravenous replacement of iron in patients with HF.

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The development and acceptability of an educational and training intervention for recruiters to neonatal trials: the TRAIN project (2023)

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Type of publication:Journal article

Author(s):Smith, V; Delaney, H; Hunter, A; Torgerson, D; Treweek, S; Gamble, C; Mills, N; Stanbury, K; Dempsey, E; Daly, M; O'Shea, J; Weatherup, K; *Deshpande, S; Ryan, M A; Lowe, J; Black, G; Devane, D.

Citation:BMC Medical Research Methodology. 23(1):265, 2023 Nov 11.

Abstract:BACKGROUND: Suboptimal or slow recruitment affects 30-50% of trials. Education and training of trial recruiters has been identified as one strategy for potentially boosting recruitment to randomised controlled trials (hereafter referred to as trials). The Training tRial recruiters, An educational INtervention (TRAIN) project was established to develop and assess the acceptability of an education and training intervention for recruiters to neonatal trials. In this paper, we report the development and acceptability of TRAIN. METHODS: TRAIN involved three sequential phases, with each phase contributing information to the subsequent phase(s). These phases were 1) evidence synthesis (systematic review of the effectiveness of training interventions and a content analysis of the format, content, and delivery of identified interventions), 2) intervention development using a Partnership (co-design/co-creation) approach, and 3) intervention acceptability assessments with recruiters to neonatal trials. RESULTS: TRAIN, accompanied by a comprehensive intervention manual, has been designed for online or in-person delivery. TRAIN can be offered to recruiters before trial recruitment begins or as refresher sessions during a trial. The intervention consists of five core learning outcomes which are addressed across three core training units. These units are the trial protocol (Unit 1, 50 min, trial-specific), understanding randomisation (Unit 2, 5 min, trial-generic) and approaching and engaging with parents (Unit 3, 70 min, trial-generic). Eleven recruiters to neonatal trials registered to attend the acceptability assessment training workshops, although only four took part. All four positively valued the training Units and resources for increasing recruiter preparedness, knowledge, and confidence. More flexibility in how the training is facilitated, however, was noted (e.g., training divided across two workshops of shorter duration). Units 2 and 3 were considered beneficial to incorporate into Good Clinical Practice Training or as part of induction training for new staff joining neonatal units. CONCLUSION: TRAIN offers a comprehensive co-produced training and education intervention for recruiters to neonatal trials. TRAIN was deemed acceptable, with minor modification, to neonatal trial recruiters. The small number of recruiters taking part in the acceptability assessment is a limitation. Scale-up of TRAIN with formal piloting and testing foreffectiveness in a large cluster randomised trial is required.

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A study analyzing the clinical, histopathological and immunological profile of patients with cutaneous vasculitis: IgA vasculitis and IgA-negative vasculitis (2023)

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Type of publication:Journal article

Author(s):Kakroo S.N.; Khan M.A.; Beg M.A.; *Kakroo B.

Citation:Journal of Pakistan Association of Dermatologists. 33(4) (pp 1562-1568), 2023. Date of Publication: October 2023.

Abstract:Background Skin is frequently involved in small-vessel vasculitis. Based on immunofluorescence studies, it can be IgA type (Henoch-Schoenlein purpura) or IgA-negative type i.e. leukocytoclastic vasculitis. Clinically, palpable purpura is the hallmark of the disease. Both subtypes can be associated with variable systemic involvement. Objective To compare the clinical, histopathological and immunological profile of patients with IgA and IgA-negative vasculitis with special reference to renal involvement. Methods Seventy-five patients presenting to the outpatient clinic of a tertiary care hospital with a clinical diagnosis of palpable purpura were enrolled in the study. All patients had a thorough clinical examination and detailed history, and results were documented on a pre-made proforma. Results On direct immunofluorescence findings, 40 patients had IgA vasculitis and 35 IgA-negative vasculitis. The mean age of presentation was 38.8 years in IgA vasculitis and 54.3 years in IgA-negative vasculitis. IgA vasculitis presented with frequent cutaneous (n=27, 67.5%, itching or pain) and systemic symptoms (n=18, 45%, abdominal and joints) seventeen (42.5%) as compared to IgA-negative subgroup (25.4% and 11.4%, respectively). Morphologically, palpable purpura was seen in both groups, but 11.4% patients in IgA-negative vasculitis group presented with ulcerated lesions. Patients of both groups had vessel wall fibrin deposition and necrosis, inflammatory infiltrate in the vessel wall, erythrocyte extravasation, unclear dust and endothelial swelling in descending frequencies. Complement 3 (C3) was the commonest immunoreactant (n=71; 94.7%) followed by fibrinogen (n=59; 78.7%) and immunoglobulin A (IgA) [n=40; 53.3%]. Abnormal urine microscopy findings were detected in (n=28; 70%) patients with IgA vasculitis and in (n=2; 5.7%) with IgA-negative vasculitis. Serum creatinine was raised in 12 (30%) patients with IgA vasculitis and 7 (20%) patients with IgA-negative vasculitis. Other laboratory tests had similar frequency in two groups. Conclusion IgA vasculitis was seen in a relatively younger age group in comparison to IgA-negative vasculitis. C3 was the commonest immunoreactant staining the blood vessel wall followed by fibrinogen and IgA. Renal involvement occurred more frequently in the IgA vasculitis.

P2.23-07 Crucial, Complex, Caring: A Professional Development Framework for Lung Cancer Nurse Specialists (2023)

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Type of publication:Conference abstract

Author(s):Clayton K.J.; Fenemore J.; Barton P.; Roberts J.; Ivey S.; *McAdam J.; Shepherd P.; Magee L.

Citation:Journal of Thoracic Oncology. Conference: 2023 World Conference on Lung Cancer. Singapore Singapore. 18(11 Supplement) (pp S397), 2023. Date of Publication: November 2023.

Abstract:Introduction: Lung cancer specialist nursing is a varied, valuable and rewarding career, and the need for lung cancer nurse specialists (LCNS) is increasing. Lung Cancer Nursing UK (LCNUK) wants to encourage nurses to aspire to becoming an LCNS, and to support those already working in lung cancer teams to flourish professionally. We want employers to recognise LCNS' capabilities and to recruit and reward them accordingly. LCNUK therefore set out to draft the first professional development framework for LCNS. The Framework is intended to guide nurses, line managers and employers on the core skills, knowledge and expertise that LCNS will gain and demonstrate as they progress in role. Method(s): LCNUK convened a working group which reviewed exemplars and supporting literature., aligned with the four pillars of advanced practice. Feedback on the draft was sought from expert stakeholders and was approved by the LCNUK Steering Committee. The Framework was developed in a collaboration between LCNUK and MSD, who funded a policy consultancy to provide support. LCNUK retained editorial independence. Result(s): The Framework sets out the qualifications, clinical skills, knowledge, leadership and management and research capabilities that LCNUK expects aspiring and existing LCNS to demonstrate or be working towards. It includes case studies of nurses' career journeys and an example of a successful case for job matching and re-banding. The Framework is available on the LCNUK website at. Conclusion(s): The Framework asserts the crucial role of LCNS in managing safety-critical and complex patient care and in leading service delivery and improvement. We hope it will prove a valuable tool to nurses, employers and policymakers in understanding the complexity and importance of this essential role. Following collaboration with European lung cancer nursing colleagues, via ELCC 2022, while not implemented the value and importance of the framework has been acknowledged by Croatian colleagues.The framework has also been welcomed and acknowledged by the devolved nations of the United Kingdom, Wales, Scotland and Northern Ireland.

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Setting up a Complex Abdominal Wall Reconstruction Unit: Our first 12 months' experience in a District General Hospital (2023)

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Type of publication:Conference abstract

Author(s):*Bhandari M.; *George J.; *Chakravartty S.; *Parampalli U.; *McCloud J.; *Cheetham M.

Citation:British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Harrogate United Kingdom. 110(Supplement 6) (pp vi50-vi51), 2023.

Abstract:Aims: Incisional hernias are distressing post-operative complications which develop in 25% of surgical incisions. We present our initial experience of setting up a Complex Abdominal Wall Reconstruction (CAWR) unit in line with international guidelines and Get It Right First Time (GIRFT) model of care. Method(s): A bespoke CAWR Multidisciplinary Team was established in our trust in January 2022, comprising 2 colorectal surgeons, 2 bariatric surgeons and anaesthetists (who performed the preoperative Botox injections and optimized high-risk patients). The unit had support from radiologists, the weight management service, and the orthotics department. We had approval from our governance, drugs and therapeutics team. Pathways for risk stratification, risk modification with pre-optimisation, standardised surgical techniques and post-operative care were created. Result(s): Between January and December 2022, 8 MDT meetings held and 52 patients were discussed. The average BMI was 34 (22-50.5) All patients underwent a preoperative CT scan to delineate the anatomy of the hernia. The median size of the defect was 6 cm (range 3 to 22 cm). Open Rives-Stoppa repair was performed in 19 patients, with transversus abdominal muscle release in 6 and 3 patients had laparoscopic repair. One recurrence and 2 superficial surgical site infections were noted. 38.4% patients had BOTOX, 40.3% advised preoperative weight loss and 5.7% for bariatric surgery before hernia repair. A high-risk anaesthetic opinion was obtained in for 7.6% and 17% were deemed unfit. Conclusion(s): Our initial experience and data highlight the feasibility of delivery of CAWR service at a non-tertiary unit in line with GIRFT principles. The initial follow-up indicates improved patient outcomes and experience.

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Saving inpatient beds: are day-case total parathyroidectomies possible and safe? (2023)

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Type of publication:Conference abstract

Author(s):*Sultana E.; *McDonald S.; Al-Saadi N.; Chang J.; *Sandhu K.; *Houghton A.

Citation:British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Harrogate United Kingdom. 110(Supplement 6) (pp vi12), 2023.

Abstract:Introduction: Total parathyroidectomy on patients with hyperparathyroidism traditionally required an inpatient hospital stay to monitor patients for postoperative hypocalcaemia. Our centre developed a safe protocol in 2015 which enables total parathyroidectomies to be carried out as a day-case procedure. This protocol, developed in conjunction with the renal physicians, involves giving the patient oral alfacalcidol preoperatively for 5 days and close monitoring of the calcium levels postoperatively to permit safe same day discharge. Method(s): A single centre retrospective study was carried out on all patients who underwent a total parathyroidectomy for hyperparathyroidism between 2005 and 2022. A comparison study was done before and after the protocol was introduced in 2015. Data were collected regarding the patient comorbidities, peri-operative calcium level, post-operative calcium, potassium and parathyroid levels, length of hospital stay, operative procedure details, hospital readmission, and 30-day morbidity. Result(s): 57 patients underwent total parathyroidectomy during the study period (22 before protocol and 35 after the protocol). After introduction of the protocol, 40% of patients were discharged on the same day, compared to only 4.54% previously. The duration of inpatient hospital stay was reduced from 0-13 days to 0-3 days. Reasons for prolonged hospital stay in the remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patient required readmission during the 30-day post-operative period. Conclusion(s): Day-case surgery for total parathyroidectomy can be achieved safely in patients with a preoperative regimen of alfacalcidol and close monitoring of calcium levels post-operatively, emulating a virtual ward round.

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