bluuebunny/crossref_metadata_2025 huggingface dataset:
An electronic tool for health systems to assess and communicate discharge medication access
Authors: Griebe Kristin M , Hencken Laura N , Efta Jessica , Patel Nisha , Stine John J , Bott Brandon , El-Khoury Caren , MacDonald Nancy C
Published: October 2021

Purpose

The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge.

Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board–approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge.

Conclusion

The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system.
1160 LEARN (Urological Teaching in British Medical Schools Nationally): A Multicentre Cross-Sectional Study
Authors: Ng A , Chan V W S , Asif A , Lam C M , Light A , Jayaraajan K , Cambridge W A , Matthew M G , Clement K D , Kulkarni M , Bhatt N R , Khadhouri S , Kasivisvanathan V
Published: October 2021

Introduction

Urology is a common rotation for UK Foundation Year (FY) doctors, and accounts for >25% of acute surgical referrals. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology to be covered during medical school. However, its national uptake remains unknown. LEARN aims to assess undergraduate urology teaching across UK medical schools.

Method

LEARN is the largest ever multicentre cross-sectional study of undergraduate urology teaching. Year 2-5 medical students and FY1 doctors were invited to complete a survey between 3rd October-20th December 2020. The primary objective is to compare current undergraduate urology teaching against the BAUS syllabus. Secondary objectives investigate the type and quantity of teaching provided, the reported performance rate of GMC mandated urological procedures, and the proportion of those considering urology as a career.

Results

A total of 7,611/8,346 (91.2%) responses from 39 medical schools that met the inclusion criteria were analysed. 16.5% of responses were newly appointed FY1 doctors. In their undergraduate training, the most commonly taught topics were urinary tract infection, acute kidney injury and haematuria; the least taught topics were male urinary incontinence, male infertility and erectile dysfunction. 90.6% and 86.3% had reported performing catheterisation as undergraduates on male and female patients respectively, and 16.9% had considered a career in urology.

Conclusion

LEARN provides the largest evaluation of any undergraduate specialty teaching. It has identified areas to improve teaching, to equip the future workforce with the competencies to manage urological pathology, irrespective of future career choice.
1565 In Covid-19 Pandemic, Following the Updated Royal College of Surgeons of England Guidelines in Management of Acute Appendicitis; A General District Hospital Audit
Authors: Dorra A , Abdellatif M , Fahmy W , Salama Y
Published: October 2021

Aim

The Aim of the study is assessment of the compliance with the updated Royal College of Surgeons of England (RCS) guidelines in management of acute appendicitis in a general district hospital during COVID-19 pandemic. Conservative treatment of acute appendicitis is encouraged unless unresponsiveness to treatment or complications ensues.

Method

Collection of retrospective data using hospital coding system was done from 63 patients medical records who were diagnosed with acute appendicitis from April 2020 to June 2020.

Results

The collected data analysis showed adherence to conservative treatment in 16 out of 63 (16/63) patients (25.4%). It succeeded in 10/16 patients (63 %). 6/16 patients were switched to operative intervention (37 %). There were no complications in patients who needed operative intervention after failure of conservative management. Operative management was primarily chosen in 47/63 patients (74.6 %). Re-admissions were 3/16 patients (18.75 %) in conservative group in comparison to 1/47 patient (2.12 %) in primarily operative group.

Conclusions

The work showed a promising rate of success of conservative treatment. However, there is a low level of compliance with RCS guidelines in management of acute appendicitis during COVID-19 pandemic. The study showed increased re-admission rate for conservative management versus primarily operative management pathways. No complications were detected in cases who needed operative intervention after failure of conservative management. Re-auditing is to follow. The study recommends national comparison of data as it might be worthwhile considering primary management of acute appendicitis.
1643 Quality Assessment of Intra-Oral Radiography Within Two Hospitals in South Wales, UK: A Two-Cycle Audit and Introduction to The Updated 2020 Public Health England Quality Grading System
Authors: Aruede G , Jenkins S
Published: October 2021

Aim

To evaluate the quality of intra-oral radiographs taken within two hospitals in South Wales, United Kingdom, and assess the impact of radiographer training, with the aim of reducing the percentage of undiagnostic radiographs to 10% or less in accordance with national performance targets.

Method

Details of intra-oral periapical and occlusal radiographs taken in the two hospitals between the 1st July 2015 and the 30th June 2016 were retrieved. 100 radiographs were randomly selected and assessed. Change was then implemented in the delivery of radiographer training workshops, which involved two hours of both didactic teaching and hands-on skills training. There were 10 workshops and 52 attendees. A second audit cycle was completed, with a further 100 radiographs randomly selected from the 1st December 2018 and 30th April 2019.

Results

There was a 33.2% reduction of undiagnostic radiographs, bringing the total down to 6.3%, meeting the standards of the audit. Feedback from the workshops were also extremely positive; 50% of radiographers grading the quality of the workshops at 10/10.

Conclusions

The workshops were successful in improving the quality of intra-oral radiographs, therefore improving the quality of this service. This blueprint can be shared amongst other hospitals, to sustainably improve the overall quality of dental radiography in the hospital setting. Recent updated guidance in 2020 introduced a new two-point scale radiograph grading system: ‘Acceptable’ and, ‘not acceptable’. Radiographs graded as, ‘not acceptable’, should account for no more than 5% of radiographs. Future audit cycles will follow this new grading system and standard.
1674 Training Opportunities and Safe Staffing Levels – Loop Closure Audit
Authors: Teklay S , Dhillon D , Aslam-Pervez N
Published: October 2021

Aim

It is not uncommon to find rota gaps at junior doctors’ level across many NHS Trusts within United Kingdom – especially in district general hospitals. In the trauma and orthopaedic department at Huddersfield Royal Infirmary, there were significant rota gaps that frequently relied on locum doctors to provide adequate service coverage. The aim of the audit was to determine whether rota gaps had any impact on safe staffing levels, training of core surgical trainees (CSTs) and costs to the department.

Method

Retrospective audit - assess daily staffing levels as per rota for three weeks before and after implementation of recommended better utilisation of the department’s Advanced Clinical Practitioners (ACPs) to cover trauma wards. The audit took place over October 2018 – December 2018.

Results

There were safe staffing levels daily in both audits. Audit 1 demonstrated locum doctors were required to cover 36.6% of ward duties and 42.9% of oncall shifts – costing the department £25, 190. Following implementation of recommendation, where ACPs were rostered to cover trauma, audit 2 reduced the requirements of locum doctors for coverage of ward duties and oncalls to 23.7% and 33.3%, respectively. Protected theatre allocation of CSTs remained less than 1 day/week. The cost of locum doctors in audit 2 was reduced to £17, 050.

Conclusions

Through better utilisation of the department’s ACPs to cover trauma wards, we managed to significantly reduce cost of locum doctors by £8, 140 over a three-week period. We believe CST theatre allocation will also improve from this intervention.
614 Elective Bariatric and Metabolic Surgery in United Kingdom During the Coronavirus Pandemic
Authors: Mamidanna R , Askari A , Patel K , Adil M T , Jain V , Jambulingam P , Whitelaw D , Rashid F , Munasinghe A , Al-Taan O
Published: October 2021

Aim

Elective Bariatric and Metabolic Surgery (BMS) was halted in the UK during the first wave of the Coronavirus (COVID-19) pandemic. Obesity is a predictor of poor outcome in those infected with this virus. This study reports our experience resuming elective weight loss surgery safely amidst the pandemic.

Method

Guidance from national bodies (BOMSS/NICE) were reviewed and a Standard Operating Procedure (SOP) was drafted to accommodate local considerations. Data were prospectively collected on patients undergoing BMS following commencement of elective surgery after the first national lockdown.

Results

A total of 50 patients underwent BMS at our institution within six weeks of resuming the services. The median age was 41 years old and BMI was 43.8(IQR 40.0-48.8 kg/m2). Equal number of patients underwent laparoscopic Sleeve Gastrectomy (SG) and Roux en-Y Gastric Bypass (RYGB). Of these, 9 patients (18%) had revisional surgery and 48 patients (96%) were discharged within 24 hours of their surgery. The rate of readmission within thirty days of surgery was 6% (n = 3) and 1 patient returned to theatre with an obstruction proximal to the jejuno-jenunal anastomosis. None of the patients exhibited symptoms or tested positive for the COVID-19 virus.

Conclusions

With appropriate precautions and protocols, it is feasible and safe to resume BMS, with no increased risk to bariatric patients during the COVID-19 pandemic. This is particularly encouraging for other units in UK to offer BMS after the current lockdown.
736 Current Management Strategies, Perceptions, and Attitudes of the Paediatricians on Childhood Obesity: An Experience from the Middle East
Authors: Al-Saadi H , Kamzari A. Al , Malallah H , AlSheala N , Al-Saadi J , Al-Saadi T
Published: October 2021

Background

Childhood obesity is a public health concern that in expanding globally. Of those aged between 5-19 years in Oman, 32% were found to be overweight in 2016.

Method

An electronic survey was distributed to in-training and post residency paediatricians in Oman.

Results

A total of 69 responses met the inclusion criteria and were analysed. 50% of participants were less than 30 years-old (53.6% female). 70% were in training residency (R1, R2 24.6%, R3, R4 36.2%,) and 30% were post residency. 72% had their training in Oman. About half of participants measure child’s weight and Height, however, only 24.4% document BMI and compare with previous records. 75% regularly obtain family history of obesity and related conditions along with dietary intake. More than half of participants were not confident on discussing weight and related complication with the child, but 62.3 % were confident in discussing it with the parents. 50% were confident in initiating treatment for childhood obesity and providing dietary advice. Attitudes towards exposure to childhood obesity and management varied and overall excellent exposure accounted for less than one third of responses (Medical school 21.7%, Residency 26.1%, 27.5%). In general, only 20.6% believe they are confident in managing childhood obesity and only 29% attended seminar or training on childhood obesity. 93% believe there is a need for a more focused training on childhood obesity prevention and management.

Conclusions

Great efforts need to be targeted towards strengthening Paediatricians’ confidence in childhood obesity prevention and management via in residency-training and continuous professional development.
1139 Effectiveness of One-Anastomosis Gastric Bypass Vs Sleeve Gastrectomy in Short- And Long-Term Weight Loss – A Review
Authors: Jothi A A
Published: October 2021

Aim

Bariatric surgery has been the most efficient treatment option for moderate to severe obesity. Recently, the sleeve gastrectomy (SG) has become the most widely performed bariatric surgery. However, the one-anastomosis gastric bypass (OAGB) has exponentially increased recently and is associated with excellent short- and long-term weight loss benefits. Hence, the aim of this review is to compare the effectiveness of OAGB vs SG in short- (≤ 1 year) and long-term (> 1 year) weight loss.

Method

A comprehensive literature search of PubMed, Scopus and Google Scholar databases were conducted. Search criteria included keywords such as one-anastomosis gastric bypass, mini-gastric bypass, omega-loop gastric bypass, sleeve gastrectomy, short-term weight loss and long-term weight loss. Selection criteria included any randomised controlled trials (RCTs) and cohort studies comparing the effects of OAGB vs SG in weight loss, published from the years 2010 onwards. Only full text studies and papers published in English language were chosen.

Results

nine studies were selected to be reviewed in this study. 62.5% of studies which had reports for short-term weight loss showed that OAGB was able to achieve a significantly greater % excess weight loss (%EWL) or % excess BMI loss (%EBMIL) (P < 0.05). Whereas 80% of studies which had reports for long-term weight loss showed that OAGB achieved a significantly greater %EWL or %EBMIL, up to five years.

Conclusions

This review suggests that OAGB is associated with significantly greater short-and long-term weight loss than SG. However, due to the small number of RCTs on OAGB vs SG, more long-term RCTs should be conducted for greater evaluation.
46 Primary Care Practitioners Have A High Level of Satisfaction with The Current Breast Referral Pathway but The Majority Would Support A Change to Patient Self-Referral
Authors: Russell T , Cooper J , McIntyre M , Ramzi S
Published: October 2021

Aim

Currently, patients must consult with a primary care practitioner (PCP) prior to being referred to secondary care breast services. A change to patient self-referral would arguably reduce primary care workload, improve access for patients, and allow breast units to allocate resources more appropriately; no data currently supports this. This study aims to explore PCP's views on breast referral, evaluate the community breast workload, and to investigate the impact of COVID-19 on referral rates.

Method

An electronic survey was designed on SurveyMonkey.com which aimed to collect both quantitative and qualitative data. The weblink to the survey was sent out via two electronic newsletters. Participants were asked: their role and gender, their level of confidence surrounding breast care, details surrounding their breast workload, how they felt COVID-19 had affected their referral rates, their level of satisfaction with the current pathway, and their opinions on a potential change to patient self-referral.

Results

79 responses were received. PCPs estimated that 7.0% (median) of their total consultations were regarding a breast-related issue and that COVID-19 had not had a significant impact on the rate of referral to breast units (P = 0.75). 84.8% of PCPs were satisfied with the current referral pathway. Whilst 74.5% felt a change to patient self-referral would benefit patients and primary care services, their free text comments highlighted some of their reservations.

Conclusions

PCPs have a high level of satisfaction with the current breast referral pathway, but the majority would be open to a change to patient self-referral to specialist breast units.
86 Adequate Assessment Can Affect the Management of Breast Cancer in The Geriatric Population
Authors: Monib S , Elkorety M , Habashy H
Published: October 2021

Background

Breast cancer (BC) risk increases with age; about a third of patients are diagnosed in age older than 70. Treatment of this age group remains a thorny issue leading to inferior outcome with lower survival rate compared to younger patients.

Aim

We aimed to evaluate performance status tools as well as the outcome of management of breast cancer in the geriatric population.

Method

We have conducted a retrospective database analysis looking into the management of breast cancer patients older than 65 years old presenting to our unit during the period between June 2015 to June 2019. All patients had triple assessment as well as multimodality performance status assessment with their treatment modalities and outcomes recorded and assessed.

Results

We have included 578 patients, 0.8% male and 99.2 % female, and our patients mean age was 71 years. Most of our patients scored one or two on the WHO/ ECOG performance status score, Clinical Frailty Score, as well as ASA-PS score. 3.2% had no treatment, 4.3% had endocrine therapy only, 0.5% had primary endocrine therapy followed by surgery, 92.3 % underwent surgery with 4.1% complication rate. Patients who underwent breast-conserving surgery had adjuvant breast radiotherapy, and 23.7% had adjuvant chest wall radiotherapy, 78.8% had adjuvant endocrine treatment and 4.8% had adjuvant chemotherapy out of which 30.7% had adjuvant chemotherapy and Herceptin.

Conclusions

Patients’ age should trigger the use of objective assessment tools while assessing elderly patients with a new breast cancer diagnosis, and treatment modalities offered should be individualised to reach the optimum outcome.
469 Novel Applications of Cross-Sectional Imaging in Oncoplastic Surgical Planning for Breast Cancer Following Neoadjuvant Chemotherapy
Authors: Begaj A , McLean R , Bhaskar P
Published: October 2021

Background

Cross-sectional imaging using MRI is most commonly used to evaluate the response to neoadjuvant chemotherapy. Furthermore, CT scan of chest, abdomen, and pelvis (CAP) is used in staging the breast cancer. This study seeks to evaluate the feasibility of using preoperative cross-sectional imaging in oncoplastic surgical planning for patients undergoing neoadjuvant chemotherapy for breast cancer.

Method

All female patients who underwent neoadjuvant chemotherapy for breast cancer between January 2019 and January 2020 and underwent breast MRI pre- and post-neoadjuvant chemotherapy and staging CTCAP were included. All images were independently reviewed and analysed by two consultant breast radiologists. Chest wall symmetry, breast volume differences, skin flap thickness, arterial supply to nipple, intercostal perforators and LD pedicle were assessed on both CT and MRI.

Results

Nineteen women were included in this study. Breast measurements were best made by MRI due to difficulty interpreting the CT images when supine. The majority of the patients had a dual arterial supply. There was substantial inter–observer agreement in visualisation of MICAP and AICAP. The inter–observer reliability reduced when the radiologists were asked to visualize the LICAP and the thoracodorsal artery with moderate inter–observer agreement, as the MRI images were difficult to interpret laterally.

Conclusions

This study shows that MRI is suitable to detect most intercostal perforators and is the first study to highlight cross-sectional modalities for assessment of intercostal perforators and may aid preoperative surgical planning and choice of perforator. We have suggested potential addition of CT angiography in cases where the surgeon plans oncoplastic surgery.
496 Perioperative Utility of Tranexamic Acid in Oncological Breast Surgery: A Systematic Review and Meta-Analysis
Authors: Chan K Y , Keogh S , Grealish A , Merrigan A , Tormey S
Published: October 2021

Background

Tranexamic acid (TXA) is a synthetic anti-fibrinolytic agent used in various surgical procedures to achieve haemostasis and reduce blood loss. Recently TXA has seen an increase in perioperative utility as a result of its ease of administration, high therapeutic index and low cost. Its safety and effectiveness in oncological breast surgery (OBS) remain understudied.

Method

PubMed, EMBASE, SCOPUS and other relevant sources were searched for studies investigating the effect of TXA in OBS, published up to October 2020. Primary outcomes of interest were local wound effects. Estimates of effect, when quantitative data was available, were pooled with a random effects model to estimate summary hazard ratios and 95% confidence intervals. Qualitative data was reported using descriptive statistics. Evidence quality was assessed using the Cochrane Collaboration tool.

Results

7 studies involving 1844 patients were included. Quantitative data was available for: mean total drainage volume, duration of drain in-situ and rates of seroma and haematoma formation. A significant reduction in rate of haematoma formation (OR 0.40, 95% CI 0.18-0.89, P = 0.02, I2=28%) was observed in the TXA group. There were no significant differences in the other outcomes. There was no significant increase in rates of adverse events.

Conclusions

Trends were observed in the present meta-analysis, although TXA did not appear to significantly alter the OBS outcomes. Current studies are insufficiently powered to isolate the effects of TXA on surgical morbidity. Further large prospective studies are needed to assess complications and determine the ideal dosage regime. At this juncture, prophylactic TXA in OBS cannot be recommended.
510 Transitioning to an In-House In-Situ Hybridisation Assay Accelerates Indeterminate HER-2 Lesion Results
Authors: Patel B , Schrire T , Potter S
Published: October 2021

Introduction

NICE guidelines 1.6.5 recommend that: ‘HER2 status [should be] available and recorded at the pre-operative multidisciplinary team (MDT) meeting when systemic treatment is discussed,’ to aid decision-making regarding neoadjuvant therapy. However, indeterminate HER2 lesions require additional testing by in-situ hybridisation (ISH). This may lead to delays in treatment decision-making, particularly if the testing is outsourced. Our institution has recently switched to using an in-house ISH assay. We compared time between biopsy and ISH results over two periods before and after the introduction of in-house testing, to assess if this improved the availability of HER-2 results, in line with NICE guidelines.

Method

This audit gained local approval. All breast cancer patients discussed at MDT over a two-month time period before (1/11/18-31/12/18) and after (1/9/20-30/10/20) the introduction of in-house ISH testing were identified retrospectively. The numbers of patients requiring ISH and the median time from biopsy to ISH report were compared in the two groups using the Mann-Whitney U test.

Results

106 cases were analysed before the intervention, 39 (37%) of which required ISH with a median wait time of 30 days (13-87). 90 cases were analysed after the intervention, 13 (14%) of which required ISH with a median wait time of 7 days (5-16) (p < 0.01).

Conclusions

By setting up an in-house ISH assay, we significantly reduced the delay between biopsy and HER2 status result for patients with borderline HER2 results. HER2 status is now available at the pre-operative MDT meeting to optimise treatment decision making, as recommended by NICE.
551 Patient Satisfaction with Telephone Consultations in A One-Stop Breast Clinic During COVID-19 Pandemic
Authors: Phyu S , Bunza R , Vashisht R , Barkeji M , Elfadl D
Published: October 2021

Aim

Telemedicine has gained an important role in medical practice lately, particularly in the outpatient setting. In our unit, virtual consultations were previously used for results clinics only. However, the first wave of COVID-19 pandemic necessitated change of practice to address issues of triage, infection control, cancer target times, and decreased capacity in the face of maintained demand. New patients underwent a telephone consultation followed by a clinic visit one week afterwards to complete triple assessment. We aimed to assess patient satisfaction with the phone consultation and subsequent care.

Method

Patients referred from general practice to the Breast Unit at West Middlesex University Hospital, who had a telephone appointment in the period 15/04/2020 to 15/07/2020, were included. The study was registered with the Clinical governance department. Patients received text messages with anonymised links to an online survey and were contacted over the telephone to explain the survey.

Results

219 successful phone calls were made to eligible patients, and 126 patients responded to the survey (57.5%). 78% felt that they were able to express all or most of their concerns over the phone. 86% spent less than 2 hours in clinic. 87% felt social distancing and safety measures were adequate. More than 75% were overall satisfied with their care.

Conclusions

We further discuss responses to this survey. Patients were largely satisfied; however, areas of improvement were identified, and changes need to be made to ensure telemedicine is used to its full potential and is appropriately incorporated in the post COVID-19 practice.
1093 Pyoderma Gangrenosum Complicating Surgery for Breast Cancer in A Patient with Insulin Treated Diabetes. A Case Report
Authors: Croitoru C , McGoldrick C , Irwin G
Published: October 2021

Aim

Although rare, Pyoderma Gangrenosum (PG) occurs as a significant complication of breast surgery. The early manifestations are similar to necrotising wound infection, so diagnosis and correct management are often delayed.

Method

We present the case of a 51-year-old female, diagnosed with multifocal right breast cancer, who underwent right sentinel lymph node biopsy and bilateral skin-spearing, nipple-sacrificing mastectomies with immediate implant reconstruction (patient’s choice). Her medical history included type 2 diabetes on insulin, hypertension, and obesity. One week postoperatively the right breast wound showed signs of not healing. After 5 weeks of conservative management including input from tissue viability, wound debridement and negative pressure wound therapy (NPWT), the phenomenon of pathergy raised the clinical suspicion of PG which was confirmed histologically.

Results

A multidisciplinary approach was instituted. The patient was started on steroid and non-steroid immune modulation therapy. She underwent further wound debridement, implant removal with NPWT and she received Tamoxifen as adjuvant chemotherapy had to be delayed. The wound healed 27 weeks after initial surgery.

Conclusions

Pyoderma Gangrenosum is an ulcerative skin disorder of unknown aetiology which is associated with systemic illnesses. It needs to be recognised and requires aggressive systemic therapy. There is little information about its long-term evolution.
1290 A Move to Magseed For Breast Conserving Surgery
Authors: Chandrasekar B , Seward J , Ooi J
Published: October 2021

Aim

Wire guided localisation(WGL) to localise non-palpable breast tumours has been the standard for years. WGL has limitations; patient discomfort, fixed scheduling to facilitate insertion on the day of surgery and wire migration. A 2015 audit in our department found that 51% of patients undergoing wide local excision (WLE) used preoperative localisation techniques; of which 84% was WGL. The overall re-excision rate for WLE was 27%. We altered our practice to Magseed localisation from July 2019 to improve patient experience, and surgical efficiency, as there are similar outcomes between WGL and Magseed in the literature. This audit aims to examine if there are improvements in our re-excision rate. We aim to evaluate which is the best method for localisation in our department.

Method

A retrospective audit was conducted following registration with the local audit office. Patients who underwent breast conserving surgery between September 2019 and September 2020 were identified. The surgical approach, re-excision and complications were recorded and compared to the 2015 results.

Results

100 patients underwent WLE in the study period. The percentage of patients undergoing therapeutic mammaplasty was 26% (14% in 2015). 63% underwent preoperative localisation; of which 71% used Magseed and 5% used wire. The overall re-excision rate was 20%.

Conclusions

Our re-audit has demonstrated an increase in patients requiring pre-operative localisation, probably due to the use of primary endocrine treatment during COVID-19. We gladly observed 26% improvement in re-excision rates suggesting success with Magseed.
1330 How Does the Tumour-Free Margin Width After Breast-Conserving Surgery in Patients with Ductal Carcinoma in Situ (DCIS) Impact Local Recurrence Rates?
Authors: Doski S
Published: October 2021

Introduction

In the UK, breast conserving surgery (BCS) has been indicated to completely excise ductal carcinoma in situ(DCIS) to negative margins for around 70% of diagnosed women. The tumour-free radial surgical margin width is an important marker for determining the local recurrence (LR). Setting the margin too wide will result in additional re-excision and too low may result in increased LR rates. This review investigates the different tumour-free margins and its effect on LR.

Method

A literature review was conducted using the Cochrane library and Pubmed database with key terms. Cohort studies of more than 100 participants with a five-year follow up in women over 18 were included.

Results

>2mm versus 0mm: LR was significantly reduced in DCIS from one very-low evidence retrospective cohort studies (N = 1,503). >2mm versus 1-2mm: Meaningful reduction in LR with DCIS was found in one very low-quality retrospective cohort study(N = 433). >2mm versus <1mm: Clinically meaningful reduction in LR for DCIS was found in very low-quality retrospective study (N = 466). >2mm versus 1-2mm: Meaningful reduction in LR with DCIS was found in one very low-quality retrospective cohort study(N = 433).

Conclusions

LR rates were reduced by further increasing the negative margin width in DCIS but only low-quality evidence was available to define these margins. This is an area for further research to enhance patient care and prevent increased LR.
1331 An Observational Study Investigating the Role of Therapeutic Mammoplasty in Breast Tumours Greater Than 40mm
Authors: Marchitelli G , Fung D , Kalra L
Published: October 2021

Aim

For large breast tumours, therapeutic mammoplasty (TM) provides a breast-conserving approach to the conventional mastectomy. The prevalence and outcomes following TM in larger breast tumours is relatively unknown. This study aims to analyse the short-term outcomes and local recurrence rate following TM for breast tumours of varying sizes.

Method

Single-centre retrospective analysis of data from all patients undergoing a TM between June 2016-October 2019. Variables reviewed included age, imaging, tumour size, pre-operative histology, adjuvant chemotherapy and radiotherapy, post-operative pathology, post-operative complications, and recurrence rates.

Results

192 patients undergoing a TM procedure were included, 126 (66%) patients had tumours <40mm and 66 (34%) patients had tumours >40mm. The average age of participants was 61 years with a mean follow-up of 31 months. The mean size of tumours >40mm was 56.8mm, of these patients 15% had positive margins, 2 (3%) patients required a further mastectomy and 8 (12%) underwent margin re-excisions. In lesions >40mm there were six episodes (9%) of T-junction delayed wound healing with two requiring surgical management, two episodes (3%) of wound infections requiring antibiotics and four episodes (6%) of seroma with one requiring surgery for an infected seroma. Two patients were found to have metastatic disease and no patients were found to have local recurrence at the most recent follow-up.

Conclusions

Our study demonstrated TM offers a surgical option with suitable cosmetic and oncological outcomes for women with early breast tumours above 40mm. These results warrant further study into the long-term outcomes for patients undergoing TM with tumours >40mm.
1389 Axillary Staging in Ductal Carcinoma in Situ with Microinvasion: A Systematic Review
Authors: Choi B , Jegatheeswaran L , Patel V , Lupi M , Babu E , Nakhoul M , Haria P l
Published: October 2021

Introduction

Ductal carcinoma in situ with microinvasion (DCISM) is a rare subtype of DCIS, with a foci of tumour cells penetrating through the basement membrane. A conundrum for surgeons is that definitive diagnosis is made upon histological examination of the final specimen. In the UK, there are no specific guidelines on the role of axillary staging in the management of DCISM cases.

Method

A systematic review was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, “ductal carcinoma in situ with microinvasion”, sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of lymph node metastases; secondary outcome looked at characteristics of DCISM that may affect node positivity.

Results

2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I2=61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033).

Conclusions

DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management. A conscientious multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.
1443 Comparison of Outcomes Between Immediate Direct-to-Implant Breast Reconstruction versus Two-Stage Implant Breast Reconstruction; a Systematic Review and Meta-analysis
Authors: Kelly O , Balasubramanian I , Cullinane C , Prichard R
Published: October 2021

Background

Direct-to-implant (DTI) breast reconstruction is increasingly performed as the preferred method of immediate breast reconstruction following mastectomy. The proposed advantages of DTI over two-stage tissue expander (TE)/implant reconstruction relate to fewer surgical procedures. This systematic review and meta-analysis aims to evaluate the safety and efficacy of DTI versus conventional TE/implant breast reconstruction.

Method

A systematic review was performed (PubMed, Embase, Scopus) to identify relevant studies that compared outcomes between DTI and TE/Implant reconstructions. Publications up to October 2020 were included. The primary outcome was overall complication rate. Secondary outcomes included infection rate and implant loss.

Results

Nineteen studies, including 32,971 implant-based breast reconstructions, were analysed. Median age was 48 years. Mean BMI was 25.9. There was no statistically significant difference between the two groups. Duration of follow up ranged from 1-60 months. Overall complications were significantly more likely to occur in the DTI group (OR 1.81 [1.17-2.79]). Overall complications refers to all reported complications including seroma, haematoma, would dehiscence, infection, skin necrosis and capsular contracture. Implant loss was also significantly higher in the DTI cohort (OR 1.31 [1.12-1.78]). There was no significant difference in infection rates between the two groups. Subgroup analyses, focusing on high-powered multicentre studies showed that the risks of overall complications were significantly higher in the DTI group (OR 1.51 [1.06-2.14]).

Conclusions

This meta-analysis demonstrates significantly greater risk of complications and implant loss in the DTI breast reconstruction group. These findings serve to aid both patients and clinicians in the decision-making process regarding implant reconstruction following mastectomy
1594 Invasive Ductal Carcinoma with Osteoclast Giant Cells During Pregnancy: A Case Report and A Review of Literature
Authors: Abdulrahman H , Johnston D , Diab S , Skelly B
Published: October 2021

Mammary carcinoma with Osteoclast Giant Cells (OGCs) is a rare tumour. Although several cases were reported, the significance of this histological finding remains incompletely understood. OGCs may occur in several types of breast carcinoma with different epidemiological characteristics but, in association with pregnancy, OGCs has not been reported to date. Here we report a case 37-year-old presenting with a symptomatic breast lump in pregnancy that has been confirmed clinically and radiologically. Microscopic examination of biopsies and surgical specimens showed OGCs accompanying invasive ductal carcinoma with no evidence of axillary metastasis. Immunohistochemical analysis revealed tumour cells to be positive for oestrogen, and progesterone receptors, with human epidermal growth factor negative status (ER6, PR8, HER2 negative).

This is the first case of OGCs during pregnancy to be reported, to our best of knowledge, following a search of the literature published in English language.
63 The “Brighton Connector”: A Simple, Reproducible and Cost-Effective Technique for Bilateral Antegrade Cerebral Perfusion During Aortic Arch Surgery
Authors: Holland L , Singh S , Vieira M , Narayana A , Lewis M , Hyde J , Modi A
Published: October 2021

Aim

Surgery of the aortic arch presents significant technical and physiological challenges. Selective antegrade cerebral perfusion (SACP) during arch surgery has been shown to improve mortality and neurological outcomes in these patients. At our centre, we aimed to develop a safe, reliable, and cost-effective technique to provide bilateral antegrade cerebral perfusion without the need of another pump head.

Method

We developed our system using equipment that is included in the accessory packaging for the Sorin Xtra cell saver system, which is readily available in cardiac surgical units nationwide, but often discarded as it is not required. An EOPA arterial return cannula and the TRUE FLOW RDB SACP cannula were joined using our novel connection.

Results

A single surgeon has used the “Brighton Connector” for 6 patients in the last two years. All patients made a satisfactory recovery with a 0% rate of mortality or permanent neurological deficit.

Conclusions

All components in our circuit are already approved for use in cardiac theatres, and the connection tubing would normally be discarded, making our method cost neutral. We demonstrate through a case series that mortality and neurological outcomes are good and comparable with other techniques.
178 Outcomes After Paediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) In A Tertiary Centre
Authors: Ashry A , Harky A , Abousteit A , Smith T , Brady A , Horan M , Nolan S , Lotto A , Guerrero R , Dhannapuneni R
Published: October 2021

Objective

To report our outcomes in utilizing extracorporeal membrane oxygenation (ECMO) institution for cardiac arrest.

Method

Retrospective records of all patients that needed ECPR between January 2015 and July 2020 have been reviewed. Primary outcomes were survival to ECMO decannulation, hospital discharge and one year survival. Secondary outcomes were the need for ECMO re-cannulation and neurology outcome using Paediatric Cerebral Performance Category (PCPC).

Results

A total of 44 consecutive patients were identified. 75 % were post cardiac surgery (n = 33), mean time from arrest to initiation of ECMO was 39.5 mins +/- 17.7 mins. Mean highest lactate prior to ECMO was 12.9 +/- 4.4. 79.6 % of patients received central cannulation. 11.4 % of patients (n = 5) needed more than one run of ECMO. Mean hours on ECMO were 175.4 +/- 212.5 hours and mean PCPC score was 2.14 +/- 1.68. Mean ICU stay was 16.2 +/- 16.9 days and total hospital stay was 47 +/- 68.5 days. Overall Survival to ECMO weaning was 68.4 % (n = 13) vs 92 % (n = 23) in neonates and paediatric patients, respectively. Survival to hospital discharge was 47.4 % (n = 9) vs 72 % (n = 18) and one year survival was 42.1 % (n = 8) vs 72 % (n = 18) in the neonatal and paediatric cohort, respectively.

Conclusions

Our survival rates are encouraging and in line with current published literature and comparable favourably to International ELSO (Extracorporeal life support organisation) registry for neonates and paediatric patients of all cause ECPR. Paediatric patients showed a survival advantage over neonates after ECPR.
354 Thoracic Complex Case Review Meeting (CCRM): A Multidisciplinary Approach to Improving Patient Care and Service Efficiency
Authors: Rozwadowski S , Teh E , West D
Published: October 2021

Objectives

The profile of thoracic patients and the indications for surgery are becoming increasingly complex. A multidisciplinary perioperative approach can optimise patients, improve outcomes and prevent high-risk patients being inappropriately declined surgery. We aim to retrospectively review the first 100 patients discussed at the CCRM in 2016-17 with a primary outcome of number of on-the-day cancellations. Secondary outcomes include unplanned critical care (HDU) admissions, 30 and 90-day morbidity and mortality.

Method

Data was collected retrospectively for demographics, co-morbidities, lung-function and dynamic testing, diagnosis and proposed surgical approach. CCRM outcomes included need for HDU, requiring further optimisation, change in surgical strategy or patient deemed too high risk.

Results

Average age was 69 years (IQR 12.5) (65 M: 35 F). American Society of Anaesthesiologists’ classification of 3 with predicted of mortality of 2 % (IQR 0.8). Maximal oxygen uptake (VO2 max) was 18.6ml/kg/min (SD ± 4.2). 24 patients were recommended for optimisation and 34 to proceed with HDU. 14 were deemed too high-risk and 30 had a change in surgical strategy. Only 1 patient was cancelled on-the-day due to a recent deterioration in health. 30 and 90-day mortality rates were 1% and 2% respectively, and 2 patients required unplanned HDU.

Conclusions

CCRM is a simple approach to optimise high-risk patients and minimise unplanned HDU. No patients were cancelled on-the-day due to inadequate optimisation or unexpected need for HDU. Mortality was acceptable and lower than predicted. Our study established CCRM as a safe and effective way of selecting high-risk patients for further optimisation and appropriate perioperative care.
401 Conventional Aortic Valves Versus Rapidly Deployed Valves in The Elderly Population. A Comparative Study in A Single Centre Experience
Authors: Moawad N , McCrorie A , Aljanadi F , Jones M
Published: October 2021

Aim

Current recommendations favour TAVI over Surgical Aortic valve replacement (SAVR) for patients aged>75 years. However, in current practice a significant proportion of patients in this group are offered SAVR. Rapidly deployed valves are of increasing popularity among surgeons as they shorten the procedure time, but their benefits are yet to be investigated.

Method

Patients aged >75 years undergoing Aortic valve replacement with or without any concomitant procedure were included between January 2014 and January 2020 (total: 597). Patients were divided into two groups: Group A (495 patients) conventional Aortic valve and Group2 (102 patients) rapidly deployed valve.

Results

Preoperative variables including mean age, EuroScore II, and body mass index were of no statistical significance between the two groups. More females and Octogenarians were in the rapidly deployed valve group versus the conventional valve group, respectively. Bypass time and Cross-clamp times were shorter in rapidly deployed group. However, the length of ICU and hospital stay was not significant between the two groups. Early post-operative pacemaker implantation (Conventional 2% Vs RDV 7%) (P < 0.05) differed significantly between groups. At follow up echocardiography, pressure gradients were comparable between groups. Thirty-day mortality and valve-related complications were insignificant.

Conclusions

RDVs show comparable early and medium-term outcomes and valve hemodynamics. RDVs are associated with shortened operative time and cross-clamp time but may carry an increased risk of need for permanent pacing.
403 Sutureless Sorin Perceval Versus Rapidly Deployed Edwards Intuity Elite: Short- And Medium-Term Outcomes Comparison in A Single Centre Experience
Authors: Moawad N , Aljanadi F , Jones M
Published: October 2021

Aim

Rapid deployment aortic valves (RDAV) are an alternative to conventional aortic valve replacement. This single-centre study compares surgical outcomes, and hemodynamic performance between the rapid deployment valves.

Method

A total of 120 consecutive patients receiving either a Sorin Perceval S (N = 61) or an Edwards INTUITY valve (N = 59) between January 2016 and September 2019 were included. Retrospective analysis of prospectively collected data from all patients undergoing isolated Aortic valve replacement or with any concomitant procedure were included. This study compared Preoperative characteristics, valve-related adverse events, post-operative complications, trans-valvular gradients and survival rates.

Results

Mean age, EuroSCORE II 2.78, body mass index and gender distribution were similar between the two studied groups. More Octogenarians received a Perceval valve than an Intuity valve (31 vs 9 P > 0.05). Thirty-day mortality and valve-related complications including need for insertion of permanent pacemaker were comparable. At follow up echocardiography, peak or mean pressure gradients were comparable between groups. However, higher peak gradient was recorded when Perceval size S is compared to Intuity 21 (P < 0.05) and Perceval size L is compared to Intuity 25 (P,0.05)

Conclusions

Both Perceval and Intuity rapid deployment valves had good early and medium-term surgical outcomes and valve hemodynamics, with relatively low valve-related complication rates. More Perceval valves were deployed through Mini-sternotomy incision but Intuity valves were used more often with double valve procedures. Intuity valves were associated with lower pressure gradients when compared with size matched Perceval valves.