Renal mass imaging modalities: does body mass index (BMI) matter?

PURPOSE

Accurate measurement of renal mass size is crucial in the management of renal cancer. With the burdensome cost of imaging yet its need for management, a better understanding of the variability among patients when determining mass size remains of urgent importance. Current guidelines on optimal imaging are limited, especially with respect to body mass index (BMI). The aim of this study is to discern which modalities accurately measure renal mass size and whether BMI influences such accuracy.

METHODS

A multi-institutional chart review was performed for adult patients undergoing partial or radical nephrectomy between 2018 and 2021, with 236 patients ultimately included. Patients were categorized by BMI (BMI 1: 18.5-24.9, BMI 2: 25-29.9, BMI 3: 30-34.9, and BMI 4: ≥ 35). The greatest mass lengths were compared between the pathology report and the following: computerized tomography (CT), renal ultrasound, and magnetic resonance imaging (MRI).

RESULTS

The difference between greatest length on CT with contrast and MRI were significantly different when compared to pathologic measurement. BMI groups 3 and 4 were found to have a significant difference in size estimates compared to BMI 2 for CT with contrast. No difference was found between size estimates by BMI group for any other imaging modality.

CONCLUSION

CT with contrast becomes less accurate at estimating mass size for patients with BMI > 30. While contrast-enhanced CT remains a vital imaging modality for tissue enhancement in the context of unknown renal masses, caution must be used for mass size estimation in the obese population.

Evaluating the forces involved in bubble management in DMEK surgery: mathematical and computational model with clinical implications

PURPOSE

To model postoperative forces involved in Descemet membrane endothelial keratoplasty (DMEK) tissue adherence and bubble management, including the impact of surface tension on graft support, with a view towards clinical applications.

SETTING

Tennent Institute of Ophthalmology, Glasgow, and James Watt School of Engineering, University of Glasgow, Glasgow, United Kingdom.

DESIGN

Mathematical modelling and computer simulation.

METHODS

Theoretical modelling of biphasic flow and interaction of gas, liquid and tissue within the anterior chamber for static horizontal scenario A (adherent DMEK with mobile bubble) and dynamic vertical scenario B (release of bubble due to pupil block following DMEK).

RESULTS

The model assumed incompressibility for both fluids within realistically achievable pressure ranges. Cahn-Hilliard Navier-Stokes equations were discretised through the application of the Finite Element Method. Mathematical modelling and computer simulation showed bubble size, corneal curvature and force intensity influences surface tension support for DMEK tissue in scenario A. Scenario B demonstrated complex, uneven distribution of surface pressure on the DMEK graft during uncontrolled bubble release. Uneven pressure concentration can cause local tissue warping, with air/fluid displacement via capillary waves generated on the fluid-air interface adversely impacting DMEK support.

CONCLUSIONS

We have quantitatively and qualitatively modelled the forces involved in DMEK adherence in normal circumstances. We have shown releasing air/gas can abruptly reduce DMEK tissue support via generation of large pressure gradients at the liquid/bubble/graft interfaces, creating negative local forces. Surgeons should consider these principles to reduce DMEK graft dislocation rates via optimised bubble size to graft size, longer acting bubble support and avoiding rapid decompression where possible.

A Randomised Clinical Feasibility Trial of a Breast Immobilisation Device: The SuPPORT 4 All Bra

AIMS

Despite the breast being a mobile organ, there is currently no standard suitable immobilisation device to optimise radiotherapy for women with larger breasts treated after a wide local excision. The SuPPORT 4 All (S4A) bra was co-designed with patients and radiotherapy professionals. The purpose of this study was to test the feasibility of using the S4A bra in the existing breast cancer radiotherapy pathway.

MATERIALS AND METHODS

A randomised feasibility trial was conducted in a single institution; the primary feasibility endpoint was the recruitment of 50 participants. Efficacy endpoints were also tested, including assessment of skin reactions, dose to organs at risk and patient comfort. Fifty women were randomised to receive either standard radiotherapy with no immobilisation (control) or radiotherapy with the S4A bra (intervention). A separate planning study was undertaken on the cases randomised to receive the S4A bra. Participants in the intervention arm (S4A bra) underwent two planning computed tomography scans, one with the bra on and one without the bra; allowing direct comparison of organs at risk data for S4A bra versus no bra.

RESULTS

All women who started radiotherapy wearing the S4A bra completed treatment with the bra; patient comfort did not change across the 3 weeks of treatment. Positional accuracy using the bra was comparable with existing published accuracy for methods without immobilisation. The mean ipsilateral lung doses showed some improvement when positioning with the S4A bra was compared with the no bra set-up (3.72 Gy versus 4.85 Gy for right-sided cases, 3.23 Gy versus 3.62 Gy for left-sided cases).

CONCLUSIONS

The S4A bra is feasible to use in the radiotherapy pathway with good patient adherence. The S4A bra has potential to reduce dose to organs at risk (specifically ipsilateral lung dose) while maintaining good breast tissue coverage, and improved patient dignity, warranting further investigation on a larger scale.

More than mateship: exploring how Australian male expatriates, longer-term and frequent travellers experience social support

PURPOSE

Those travelling overseas for work or leisure including male expatriates, longer-term and frequent travellers (ELoFTs) may be at heightened risk for a range of health and wellbeing issues. Social support may mediate this risk. However, from a public health perspective, little is written about how ELoFTs access health information and support and the role of their social networks in facilitating health and wellbeing outcomes. This research was part of a study examining social network processes of Australian male ELoFTs travelling, living, or working in Southeast Asia (SEA).

METHODS

Symbolic Interactionism and Grounded Theory were the conceptual framework and methodology supporting semi-structured, in-depth interviews (n = 25) conducted in Australia and Thailand with Australian male ELoFTs to SEA, aged 18 years or older.

RESULTS

Findings highlight supports that assist ELoFT transition and adjustment to country of destination or manage their transnational experience. Influential places, people, and points in the migration journey mediated engagement with social support.

CONCLUSIONS

ELoFT social networks and the support provided within them may provide a mechanism for intervention across a range of public health issues. Findings may support the development of policy and practice across industries charged with supporting successful ELoFT adjustment.

Correlation between the Insertion Side of a Transcondylar Screw for the Surgical Management of Humeral Intracondylar Fissures in Dogs and the Incidence of Postoperative Surgical Site Infection

OBJECTIVE

 An increased rate of surgical site infection (SSI) following treatment of canine humeral intracondylar fissure (HIF) with a lateromedially (LM) placed transcondylar screw (TCS) compared with a mediolateral (ML) TCS has been previously postulated. We hypothesized that the direction of insertion of the TCS would not affect the incidence of postoperative SSI.

STUDY DESIGN

 It was single-centre retrospective study. Dogs with HIF confirmed by computerized tomography, treated by TCS placement (between 2008 and 2019) and with a minimum follow-up of 12 weeks, were included. The following data were recorded: signalment, presenting clinical signs, direction of placement and size of the utilized TCS, surgical and anaesthetic times, concurrent surgical procedures, presence of concomitant elbow pathology, perioperative and postoperative antibiotic usage and postoperative complications. Recorded data were analysed with a multinomial logistic regression model with a p-value less than or equal to 0.05.

RESULTS

 Thirty-five dogs (46 elbows) met the inclusion criteria. Median clinical follow-up interval was 52 weeks. Seven of thirty-one elbows with a ML TCS, and 4/15 elbows with a LM TCS developed SSI. Four of nine dogs that underwent bilateral single-surgery TCS placement developed SSI unilaterally.

CONCLUSION

 No significant difference was shown in short-term SSI occurrence between the ML and the LM direction of placement of the TCS.

Treatment of Low-grade Intermediate-risk Nonmuscle-invasive Bladder Cancer With UGN-102 ± Transurethral Resection of Bladder Tumor Compared to Transurethral Resection of Bladder Tumor Monotherapy: A Randomized, Controlled, Phase 3 Trial (ATLAS)

PURPOSE

Low-grade intermediate-risk nonmuscle-invasive bladder cancer is a chronic illness commonly treated by repetitive transurethral resection of bladder tumor. We compared the efficacy and safety of intravesical chemoablation with UGN-102 (a reverse thermal gel containing mitomycin), with or without subsequent transurethral resection of bladder tumor, to transurethral resection of bladder tumor alone in patients with low-grade intermediate-risk nonmuscle-invasive bladder cancer.

MATERIALS AND METHODS

This prospective, randomized, phase 3 trial recruited patients with new or recurrent low-grade intermediate-risk nonmuscle-invasive bladder cancer to receive initial treatment with either UGN-102 once weekly for 6 weeks or transurethral resection of bladder tumor. Patients were followed quarterly by endoscopy, cytology, and for-cause biopsy. The primary end point was disease-free survival. All patients were followed for adverse events.

RESULTS

Trial enrollment was halted by the sponsor to pursue an alternative development strategy after 282 of a planned 632 patients were randomized to UGN-102 ± subsequent transurethral resection of bladder tumor (n=142) or transurethral resection of bladder tumor monotherapy (n=140), rendering the trial underpowered to perform hypothesis testing. Patients were predominantly male and ≥65 years of age. Tumor-free complete response 3 months after initial treatment was achieved by 92 patients (65%) who received UGN-102 and 89 patients (64%) treated by transurethral resection of bladder tumor. The estimated probability of disease-free survival 15 months after randomization was 72% for UGN-102 ± transurethral resection of bladder tumor and 50% for transurethral resection of bladder tumor (hazard ratio 0.45). The most common adverse events (incidence ≥10%) in the UGN-102 group were dysuria, micturition urgency, nocturia, and pollakiuria.

CONCLUSIONS

Primary, nonsurgical chemoablation with UGN-102 for the management of low-grade intermediate-risk nonmuscle-invasive bladder cancer offers a potential therapeutic alternative to immediate transurethral resection of bladder tumor monotherapy and warrants further investigation.

Comparison of prostate-specific antigen response in patients with metastatic castration-sensitive prostate cancer initiated on apalutamide or abiraterone acetate: A retrospective cohort study

BACKGROUND

Deep prostate-specific antigen (PSA) response (≥90% reduction in PSA [PSA90]) is an important early response indicator of radiographic progression-free survival and overall survival in patients with metastatic castration-sensitive prostate cancer (mCSPC). This study compared PSA90 responses by 6 months between patients with mCSPC at first use of apalutamide or abiraterone acetate, both androgen receptor signaling inhibitors.

METHODS

Clinical data from 77 community urology practices in the United States were analyzed. Patients with mCSPC were classified into treatment cohorts based on their first filled prescription (index date) for apalutamide or abiraterone acetate on or after September 17, 2019 (approval date of apalutamide for mCSPC). Patients were followed from the index date until the earliest of index treatment discontinuation, treatment switch, end of clinical activity, or end of data availability (September 17, 2021). Inverse probability of treatment weighting (IPTW) was used to ensure similarity in distribution of baseline characteristics between cohorts. PSA90 was defined as the earliest attainment of ≥90% reduction in PSA relative to baseline (most recent value within 13 weeks pre-index). Time to PSA90 between cohorts was compared by weighted Kaplan-Meier analysis and with Cox proportional hazards models.

RESULTS

A total of 364 patients treated with apalutamide and 147 treated with abiraterone acetate met the study criteria. Patient characteristics were well balanced after IPTW. By 6 months post-index, patients initiated on apalutamide were 53% more likely to achieve PSA90 than those initiated on abiraterone acetate (P = 0.016). Similar results were observed by 9 and 12 months post-index (both P ≤ 0.019). The median time to PSA90 was 3.5 months for the apalutamide cohort and not reached for the abiraterone acetate cohort.

CONCLUSIONS

In real-world patients with mCSPC, significantly more patients achieved PSA90 with apalutamide than with abiraterone acetate, and this response was achieved earlier with apalutamide.

Attainment of early, deep prostate-specific antigen response in metastatic castration-sensitive prostate cancer: A comparison of patients initiated on apalutamide or enzalutamide

BACKGROUND

Deep prostate-specific antigen (PSA) response, defined as a ≥90% decline in PSA (PSA90), is an important early response indicator for achieving radiographic progression-free and overall survival in patients with metastatic castration-sensitive prostate cancer (mCSPC) treated with a next-generation androgen signaling inhibitor (ASI), such as apalutamide or enzalutamide. The objective of this study was to compare deep PSA response among patients with mCSPC newly initiated on apalutamide or enzalutamide.

METHODS

Clinical data from 69 community urology practices in the United States were evaluated. Patients with mCSPC were classified into cohorts based on their first dispensation (index date) for apalutamide or enzalutamide and were followed until the earliest of treatment discontinuation, initiation of a new next-generation androgen receptor signaling inhibitor, end of clinical activity (including death), or end of data availability (03/05/2021). Inverse probability of treatment weights (IPTW) were used to reduce baseline confounding. PSA90 was defined as the earliest ≥90% PSA decline relative to baseline PSA. The proportion of patients achieving PSA90 and time to PSA90 were reported using weighted Kaplan-Meier analysis and weighted Cox proportional hazards models, respectively.

RESULTS

The apalutamide and enzalutamide cohorts comprised 186 and 165 patients, respectively. Patient characteristics were generally well balanced after IPTW. By 6 months, patients initiated on apalutamide had a 56% greater likelihood of attaining PSA90 than those initiated on enzalutamide (P = 0.014). This result remained significant through the end of the observation period. The median time to achieving PSA90 was 3.1 months with apalutamide and 5.2 months with enzalutamide.

CONCLUSIONS

This real-world study demonstrated that apalutamide initiation is associated with a significantly higher likelihood of achieving ≥90% reduction in PSA as compared to initiation of enzalutamide. Moreover, this deep PSA response was observed to occur earlier with apalutamide treatment than with enzalutamide.

Dual inhibition of EZH2 and G9A/GLP histone methyltransferases by HKMTI-1-005 promotes differentiation of acute myeloid leukemia cells

All-trans-retinoic acid (ATRA)-based differentiation therapy of acute promyelocytic leukemia (APL) represents one of the most clinically effective examples of precision medicine and the first example of targeted oncoprotein degradation. The success of ATRA in APL, however, remains to be translated to non-APL acute myeloid leukemia (AML). We previously showed that aberrant histone modifications, including histone H3 lysine 4 (H3K4) and lysine 27 (H3K27) methylation, were associated with this lack of response and that epigenetic therapy with small molecule inhibitors of the H3K4 demethylase LSD1/KDM1A could reprogram AML cells to respond to ATRA. Serving as the enzymatic component of Polycomb Repressive Complex 2, EZH2/KMT6A methyltransferase plays a critical role in normal hematopoiesis by affecting the balance between self-renewal and differentiation. The canonical function of EZH2 is methylation of H3K27, although important non-canonical roles have recently been described. EZH2 mutation or deregulated expression has been conclusively demonstrated in the pathogenesis of AML and response to treatment, thus making it an attractive therapeutic target. In this study, we therefore investigated whether inhibition of EZH2 might also improve the response of non-APL AML cells to ATRA-based therapy. We focused on GSK-343, a pyridone-containing S-adenosyl-L-methionine cofactor-competitive EZH2 inhibitor that is representative of its class, and HKMTI-1-005, a substrate-competitive dual inhibitor targeting EZH2 and the closely related G9A/GLP H3K9 methyltransferases. We found that treatment with HKMTI-1-005 phenocopied EZH2 knockdown and was more effective in inducing differentiation than GSK-343, despite the efficacy of GSK-343 in terms of abolishing H3K27 trimethylation. Furthermore, transcriptomic analysis revealed that in contrast to treatment with GSK-343, HKMTI-1-005 upregulated the expression of differentiation pathway genes with and without ATRA, while downregulating genes associated with a hematopoietic stem cell phenotype. These results pointed to a non-canonical role for EZH2, which was supported by the finding that EZH2 associates with the master regulator of myeloid differentiation, RARα, in an ATRA-dependent manner that was enhanced by HKMTI-1-005, possibly playing a role in co-regulator complex exchange during transcriptional activation. In summary, our results strongly suggest that addition of HKMTI-1-005 to ATRA is a new therapeutic approach against AML that warrants further investigation.

Chromoblastomycosis treated with posaconazole and adjunctive imiquimod: lending innate immunity a helping hand

Chromoblastomycosis (CBM) is a difficult-to-treat, chronic fungal infection of the skin and subcutaneous tissue. The evidence base for treatment is scarce, with no standardised therapeutic approach. Chronicity of CBM infection is postulated to be due in part to a failure of host cell-mediated immunity to generate a proinflammatory response sufficient for fungal clearance. We present a case of a chronic chromoblastomycosis lesion of the hand present for nearly four decades, previously refractory to itraconazole monotherapy, that was successfully treated with a combination of posaconazole and adjunctive immunotherapy with topical Imiquimod, a toll-like receptor 7 agonist. Serial biopsies and images demonstrate the clinical and histopathological improvement of the lesion. Randomised trials of antifungal therapy with adjunctive imiquimod are warranted to determine whether a combination of antifungal and host-directed therapy improves outcomes for this neglected tropical mycosis.

Dental Public Health in Action: Delivering a domestic violence and abuse screening and identification training programme in North Staffordshire-based dental practices

Domestic violence and abuse (DVA) is a significant public health problem both globally and in the UK. Dental professionals are aptly place to detect the signs of DVA and support patients to disclose DVA. However, dental professionals may lack confidence to identify and refer patients experiencing DVA; training needs in these areas were identified in Staffordshire. Glow DVA charity and the local Dental Public Health teams worked collaboratively to develop DVA training and resources specific to the needs to the dental team; these were provided to participating dental practices in the North-Staffordshire region. Feedback from the training was positive and the training was refined to better meet the needs of the dental team.mKey challenges included obtaining dental team buy in, securing funding for the continuation of the initiative and minimising the disruption to the dental team when attending training sessions or when managing a DVA disclosure. The implementation of the training highlighted the importance of DVA champions within the third sector organisations to develop and evolve the project, within dental practices to support implementation, and within the local Dental Public Health team to facilitate dental team buy-in and sustained engagement. Future plans include developing the patient-facing resources, finding ways to formally accredit dental teams for taking part in the DVA programme, and evaluating the impact of the training programme on DVA screening, identification and referral.

Atlas of 35 patient reported outcome measures (PROMs) in andrology: a comprehensive overview of literature

INTRODUCTION

Disorders of male sexual health and functioning are complex and can have significant deleterious effects on patients psychological wellbeing and interpersonal relationships. It is well recognised that clinicians have an overall poor understanding of the true effect that disease has on their patients and self-reported patient-reported outcome measures (PROMs) aim to better communicate these issues. PROMs are generally welcomed by patients and their use in this highly sensitive area of clinical practice is well recognised. An atlas of available PROMs for key conditions in andrology is presented in this article.

METHODS

A comprehensive search of world literature was conducted from the inception of databases to June 2022, to identify male-specific PROMs relevant to four key andrological disorders: hypogonadism, erectile dysfunction, penile curvature and disorders of ejaculation. Each tool was evaluated in narrative format.

RESULTS

35 PROMs were identified. 6 were designed for the assessment of hypogonadism, 18 for erectile dysfunction, one for penile curvature and 10 for ejaculatory disorders. In general, PROMs were brief, self-administered and user-friendly. There was sufficient scope and variety in all categories (apart from penile curvature) to give the clinician flexibility in tool selection and find an appropriate tool for different scenarios.

CONCLUSION

A number of PROMs exist within andrology that can be utilised in both research and clinical settings. PROMs enable subjective evaluation of difficult-to-assess aspects of the patient experience.

S9.4c Diverse environmental inputs mediate changes in β-glucan exposure at the Candida albicans cell surface thereby influencing tissue colonisation during systemic infection

S9.4 Free oral presentations (late breaking), September 23, 2022, 4:45 PM - 6:15 PM

 

 

Candida albicans adaptation to host niches affects the exposure of key pathogen-associated molecular patterns (PAMPs) on its cell surface and, consequently, the detection of C. albicans cells by the immune system. Focusing on β-(1,3)-glucan, we screened for host inputs that influence the exposure of this immune-stimulatory PAMP on the C. albicans cell surface. We used a combination of fluorescent microscopy, flow cytometry, and cytokine assays, and then analyzed certain conditions in more detail using transmission electron microscopy and time-lapse video microscopy of C. albicans-phagocyte interactions. We found that some nutrients, micronutrient limitation, stresses, and antifungal drugs trigger β-glucan masking, whereas other inputs, such as nitrogen sources and quorum sensing molecules, exert limited effects on β-glucan exposure. In particular, host- or bacterial-derived L-lactate, hypoxia, or iron limitation induce β-glucan masking, and this leads to attenuation of phagocytic responses [Nature Micro 2, 16 238; mBio 9, e01318-18; Nature Comms 10, 5315]. Lactate signals through Gpr1 to activate Crz1 in a calcineurin-independent manner, whereas hypoxia signals via mitochondrial ROS, and iron limitation signals through Ftr1 and Sef1. β-glucan masking also depends upon downstream signaling via the cAMP-PKA pathway. We conclude that C. albicans has evolved to exploit a range of specific host-derived signals to modulate the exposure of a major PAMP at its cell surface in an attempt to evade phagocytic uptake. Using barcode-sequencing in direct competition assays in vivo, we showed that preadaptation to specific β-glucan masking signals affects the ability of this fungus to colonize particular tissues during systemic infection in a murine model. This reinforces the view that β-glucan masking promotes C. albicans infection.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

EXPRESS: Combining Refutations and Social Norms Increases Belief Change

Misinformed beliefs are difficult to change. Refutations that target false claims typically reduce false beliefs, but tend to be only partially effective. In this study, a social norming approach was explored to test whether provision of peer norms could provide an alternative or complementary approach to refutation. Three experiments investigated whether a descriptive norm-by itself or in combination with a refutation-could reduce the endorsement of worldview-congruent claims. Experiment 1 found that using a single point estimate to communicate a norm affected belief but had less impact than a refutation. Experiment 2 used a verbally-presented distribution of four values to communicate a norm, which was largely ineffective. Experiment 3 used a graphically-presented social norm with 25 values, which was found to be as effective at reducing claim belief as a refutation, with the combination of both interventions being most impactful. These results provide a proof of concept that normative information can aid in the debunking of false or equivocal claims, and suggests that theories of misinformation processing should take social factors into account.

Technology-enhanced AcceleRation of Germline Evaluation for Therapy (TARGET): A randomized controlled trial of a pretest patient-driven webtool vs. genetic counseling for prostate cancer germline testing

BACKGROUND

Germline testing has an increasingly important role in prostate cancer care. However, a relative shortage of genetic counselors necessitates alternate strategies for delivery of pre-test education for germline testing. This study, funded by the Prostate Cancer Foundation, seeks to address the need for novel methods of delivery of pre-test germline education beyond traditional germline counseling to facilitate informed patient decision-making for germline testing.

METHODS

This is a two-armed randomized controlled trial (RCT) with a target enrollment of 173 participants with prostate cancer per study arm (total anticipated n = 346). Patients who meet criteria for germline testing based on tumor features, family history or Ashkenazi Jewish ancestry are being recruited from 5 US sites including academic, private practice and Veterans healthcare settings. Consenting participants are randomized to the interactive pretest webtool or germline counseling with assessment of key patient-reported outcomes involved in informed decision-making for germline germline testing.

RESULTS

Participants complete surveys at baseline, after pretest education/counseling, and following disclosure of germline germline results. The primary outcome of the study is decisional conflict for germline testing. Secondary outcomes include germline knowledge, satisfaction, uptake of germline testing, and understanding of results.

CONCLUSION

Our hypothesis is that the web-based germline education tool is non-inferior to traditional germline counseling regarding key patient-reported outcomes involved in informed decision-making for germline testing. If proven, the results would support deploying the webtool across various practice settings to facilitate pre-test germlines education for individuals with prostate cancer and developing collaborative care strategies with germline counseling.

CLINICALTRIALS

gov Identifier: NCT04447703.

Spatial mapping of immunological epitopes in the Candida cell wall using C-type lectin probes

The primary recognition event between a fungal pathogen and the immune system normally involves the engagement of a pattern recognition receptor with specific components of the cell wall. However, the cell wall is a complex three dimensional structure whose composition changes rapidly in accordance with environmental stimuli. Therefore it is important to know what is the precise nature of the primary recognition event, how many events occur to activate the immune response and how these recognition events are affected by changes in cell wall architecture, cellular morphogenesis and physiological adaptation of the pathogen to specific niches in the human body. We address this fundamental question using four soluble immune C-Type lectin receptor-probes which recognize specific mannans and β-1,3 glucan in the cell wall. We use these C-type lectin probes to demonstrate that mannan epitopes are differentially distributed in the inner and outer layers of fungal cell wall in a clustered or diffuse manner. Immune reactivity of fungal cell surfaces did not correlate with relatedness of different fungal species, and mannan-detecting receptor-probes discriminated between cell surface mannans generated by the same fungus growing under different conditions. These studies demonstrate that mannan-epitopes within fungal cell walls are differentially distributed and dynamically expressed as the fungus adapted to microenvironments that would be encountered in vivo.

531 An Admission Proforma to Improve Clerking Documentation in the ENT Department During the Covid-19 Pandemic: A Full Cycle Audit

Aim

Good Surgical Practice states that surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained for all their interactions with patients. It is therefore critical that the clerking document, as the initial record of an admission, meets this standard. During the Covid-19 pandemic, an emergency rota meant that cross-covering of ENT at junior level was increasingly required in our hospital. Understandably, these trainees were less familiar with admitting ENT patients and of departmental standards. Our aim was to evaluate the quality of clerking documentation in our department during this period and investigate whether a standardised admission proforma could improve this.

Method

Clerking documents for all patients admitted in April 2020 were checked for completion of venous thromboembolism (VTE) risk assessment and inclusion of ten key pieces of information as outlined by the Surgical Tool for Auditing Records score. As was standard at this time, all clerking documentation had been completed on blank hospital continuation paper. A departmental admission proforma was introduced before admissions in June 2020 were then assessed identically.

Results

Improvement was noted in all measured parameters with no adverse effects. There was particular improvement in documentation of referral source (28% to 97%), consultant in charge (35% to 90%), name/grade/bleep (25% to 94%) and VTE risk assessment (14% to 78%). Trainee response was positive.

Conclusions

A simple admission proforma can markedly improve the standard of clerking documentation and therefore increase patient safety during a turbulent time. We would encourage other departments to consider developing their own.

1423 Quality and Efficacy of Multidisciplinary Team (MDT) Discussion Quality Assessment Tools and Checklists: A Systematic Review

Aim

MDT discussion is the gold standard for cancer care in the UK. With the cancer incidence and complexity of treatments both increasing, demand for MDT discussion is growing. The need for efficiency, whilst maintaining high standards, is therefore clear. Paper-based MDT quality assessment tools and discussion checklists may represent a practical method of monitoring and improving MDT practice. This review aims to describe and appraise these tools, as well as consider their value to quality improvement.

Method

MEDLINE, Embase and PsycInfo were searched using pre-defined terms. PRISMA methodology was followed throughout. Studies were included if they described the development of a relevant tool/checklist, or if an element of the methodology further informed tool quality assessment. To investigate efficacy, studies using a tool as a method of quality improvement in MDT practice were also included. Study quality was appraised using the COSMIN risk of bias checklist or the Newcastle-Ottawa scale, depending on study type.

Results

The search returned 6888 results. 17 studies were included, and 6 different tools were identified. Overall, methodological quality in tool development was adequate to very good for assessed aspects of validity and reliability. Clinician feedback was positive. In one study, the introduction of a discussion checklist improved MDT ability to reach a decision from 82.2% to 92.7%. Improvement was also noted in the quality of information presented and the quality of teamwork.

Conclusions

Several tools for assessing and guiding MDT discussions are available. Although limited, current evidence indicates sufficient rigour in their development and their potential for quality improvement.

Predicting high-grade prostate cancer at initial biopsy: clinical performance of the ExoDx (EPI) Prostate Intelliscore test in three independent prospective studies

Background

The ability to discriminate indolent from clinically significant prostate cancer (PC) at the initial biopsy remains a challenge. The ExoDx Prostate (IntelliScore) (EPI) test is a noninvasive liquid biopsy that quantifies three RNA targets in urine exosomes. The EPI test stratifies patients for risk of high-grade prostate cancer (HGPC; ≥ Grade Group 2 [GG] PC) in men ≥ 50 years with equivocal prostate-specific antigen (PSA) (2–10 ng/mL). Here, we present a pooled meta-analysis from three independent prospective-validation studies in men presenting for initial biopsy decision.

Methods

Pooled data from two prospective multi-site validation studies and the control arm of a clinical utility study were analyzed. Performance was evaluated using the area under the receiver-operating characteristic curve (AUC), negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity for discriminating ≥ GG2 from GG1 and benign pathology.

Results

The combined cohort (n = 1212) of initial-biopsy subjects had a median age of 63 years and median PSA of 5.2 ng/mL. The EPI AUC (0.70) was superior to PSA (0.56), Prostate Cancer Prevention Trial Risk Calculator (PCPT-RC) (0.62), and The European Randomized Study of Screening for Prostate Cancer (ERSPC) (0.59), (all p-values <0.001) for discriminating GG2 from GG1 and benign histology. The validated cutoff of 15.6 would avoid 23% of all prostate biopsies and 30% of “unnecessary” (benign or Gleason 6/GG1) biopsies, with an NPV of 90%.

Conclusions

EPI is a noninvasive, easy-to-use, urine exosome–RNA assay that has been validated across 3 independent prospective multicenter clinical trials with 1212 subjects. The test can discriminate high-grade (≥GG2) from low-grade (GG1) cancer and benign disease. EPI effectively guides the biopsy-decision process independent of PSA and other standard-of-care factors.

Cystitis Cystica Et Glandularis Causing Lower Urinary Tract Symptoms in a 29-Year-Old Male

We present the case of a 29-year-old male who presented to the office with three years of persistent lower urinary tract symptoms and hematuria. On workup, the patient was determined to have an atypical condition contributing to his symptoms. There are numerous causes of lower urinary tract symptoms that can occur in young men. These symptoms, including frequency, urgency, dysuria, and hematuria, are typically caused by common benign conditions such as urethritis, urolithiasis, and urinary tract infections. Prostatic pathology does not typically manifest in this population. Likewise, a more serious condition such as a mass or carcinoma may contribute to persistent lower urinary tract symptoms and hematuria less often in young men. In our patient, a benign mass later identified as cystitis cystica et glandularis was discovered to be contributing to his reported discomfort.

Interobserver variation in the classification of tumor deposits in rectal cancer-is the use of histopathological characteristics the way to go?

The focus on lymph node metastases (LNM) as the most important prognostic marker in colorectal cancer (CRC) has been challenged by the finding that other types of locoregional spread, including tumor deposits (TDs), extramural venous invasion (EMVI), and perineural invasion (PNI), also have significant impact. However, there are concerns about interobserver variation when differentiating between these features. Therefore, this study analyzed interobserver agreement between pathologists when assessing routine tumor nodules based on TNM 8. Electronic slides of 50 tumor nodules that were not treated with neoadjuvant therapy were reviewed by 8 gastrointestinal pathologists. They were asked to classify each nodule as TD, LNM, EMVI, or PNI, and to list which histological discriminatory features were present. There was overall agreement of 73.5% (κ 0.38, 95%-CI 0.33–0.43) if a nodal versus non-nodal classification was used, and 52.2% (κ 0.27, 95%-CI 0.23–0.31) if EMVI and PNI were classified separately. The interobserver agreement varied significantly between discriminatory features from κ 0.64 (95%-CI 0.58–0.70) for roundness to κ 0.26 (95%-CI 0.12–0.41) for a lone arteriole sign, and the presence of discriminatory features did not always correlate with the final classification. Since extranodal pathways of spread are prognostically relevant, classification of tumor nodules is important. There is currently no evidence for the prognostic relevance of the origin of TD, and although some histopathological characteristics showed good interobserver agreement, these are often non-specific. To optimize interobserver agreement, we recommend a binary classification of nodal versus extranodal tumor nodules which is based on prognostic evidence and yields good overall agreement.

Trialling a novel socially-distanced teaching approach for OMFS dental core trainees: case-based discussions through WhatsApp©

In our tertiary level centre, the oral and maxillofacial (OMFS) rotas often change at short- notice due to service requirements and the development of guidance relating to the COVID-19 pandemic. Consequently, we have developed a novel teaching method for our dental core trainees (DCTs) to accommodate hectic schedules and conflicting availability between junior and senior staff. Here, we describe the innovative teaching approach we have established using case-based discussions via WhatsApp©. Feedback has been excellent. Respondents have stated that the most useful aspect is flexibility to participate in between tasks and across multiple sites, and 87% stated that they use the searchable summaries when managing patients. This teaching method is highly beneficial for OMFS DCTs. It allows flexibility for fluctuating schedules, is interactive, and provides an easily accessible resource whilst on call. We believe that other teams may benefit from the method if scheduling the time for regular didactic teaching is difficult, or they wish to supplement existing practices.

Systematic review of classification systems for locally recurrent rectal cancer

Background

Classification of pelvic local recurrence (LR) after surgery for primary rectal cancer is not currently standardized and optimal imaging is required to categorize anatomical site and plan treatment in patients with LR. The aim of this review was to evaluate the systems used to classify locally recurrent rectal cancer (LRRC) and the relevant published outcomes.

Methods

A systematic review of the literature prior to April 2020 was performed through electronic searches of the Science Citation Index Expanded, EMBASE, MEDLINE and CENTRAL databases. The primary outcome was to review the classifications currently in use; the secondary outcome was the extraction of relevant information provided by these classification systems including prognosis, anatomy and prediction of R0 after surgery.

Results

A total of 21 out of 58 eligible studies, classifying LR in 2086 patients, were reviewed. Studies used at least one of the following eight classification systems proposed by institutions or institutional groups (Mayo Clinic, Memorial Sloan-Kettering – original and modified, Royal Marsden and Leeds) or authors (Yamada, Hruby and Kusters). Negative survival outcomes were associated with increased pelvic fixity, associated symptoms of LR, lateral compared with central LR and involvement of three or more pelvic compartments. A total of seven studies used MRI with specifically defined anatomical compartments to classify LR.

Conclusion

This review highlights the various imaging systems in use to classify LRRC and some of the prognostic indicators for survival and oncological clearance based on these systems. Implementation of an agreed classification system to document pelvic LR consistently should provide more detailed information on anatomical site of recurrence, burden of disease and standards for comparative outcome assessment.

Intravesical nadofaragene firadenovec gene therapy for BCG-unresponsive non-muscle-invasive bladder cancer: a single-arm, open-label, repeat-dose clinical trial

BACKGROUND

BCG is the most effective therapy for high-risk non-muscle-invasive bladder cancer. Nadofaragene firadenovec (also known as rAd-IFNa/Syn3) is a replication-deficient recombinant adenovirus that delivers human interferon alfa-2b cDNA into the bladder epithelium, and a novel intravesical therapy for BCG-unresponsive non-muscle-invasive bladder cancer. We aimed to evaluate its efficacy in patients with BCG-unresponsive non-muscle-invasive bladder cancer.

METHODS

In this phase 3, multicentre, open-label, repeat-dose study done in 33 centres (hospitals and clinics) in the USA, we recruited patients aged 18 years or older, with BCG-unresponsive non-muscle-invasive bladder cancer and an Eastern Cooperative Oncology Group status of 2 or less. Patients were excluded if they had upper urinary tract disease, urothelial carcinoma within the prostatic urethra, lymphovascular invasion, micropapillary disease, or hydronephrosis. Eligible patients received a single intravesical 75 mL dose of nadofaragene firadenovec (3 × 1011 viral particles per mL). Repeat dosing at months 3, 6, and 9 was done in the absence of high-grade recurrence. The primary endpoint was complete response at any time in patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour). The null hypothesis specified a complete response rate of less than 27% in this cohort. Efficacy analyses were done on the per-protocol population, to include only patients strictly meeting the BCG-unresponsive definition. Safety analyses were done in all patients who received at least one dose of treatment. The study is ongoing, with a planned 4-year treatment and monitoring phase. This study is registered with ClinicalTrials.gov, NCT02773849.

FINDINGS

Between Sept 19, 2016, and May 24, 2019, 198 patients were assessed for eligibility. 41 patients were excluded, and 157 were enrolled and received at least one dose of the study drug. Six patients did not meet the definition of BCG-unresponsive non-muscle-invasive bladder cancer and were therefore excluded from efficacy analyses; the remaining 151 patients were included in the per-protocol efficacy analyses. 55 (53·4%) of 103 patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour) had a complete response within 3 months of the first dose and this response was maintained in 25 (45·5%) of 55 patients at 12 months. Micturition urgency was the most common grade 3-4 study drug-related adverse event (two [1%] of 157 patients, both grade 3), and there were no treatment-related deaths.

INTERPRETATION

Intravesical nadofaragene firadenovec was efficacious, with a favourable benefit:risk ratio, in patients with BCG-unresponsive non-muscle-invasive bladder cancer. This represents a novel treatment option in a therapeutically challenging disease state.

FUNDING

FKD Therapies Oy.

Change in EEG Activity is Associated with a Decrease in Tinnitus Awareness after rTMS

OBJECTIVE

To examine how 1Hz and 10Hz rTMS temporarily influence ratings of tinnitus loudness, annoyance, and awareness. The thalamocortical dysrhythmia (TCD) model of tinnitus was tested by examining changes in spectral power and coherence of resting state EEGs from baseline to each phase of treatment and correlating these data with change in tinnitus.

METHODS

Nineteen participants completed a double-blind, placebo (sham rTMS) controlled, within-subjects study with crossover between the two active rTMS treatment conditions. An imposed order effect, sham rTMS first, eliminated drift of active treatment into the placebo condition. The primary outcome measures were analogue ratings of tinnitus loudness, annoyance, and awareness, assessed repeatedly at baseline and during treatment, and 64 channel, resting state EEGs collected at baseline and the end of each treatment phase. Active rTMS consisted of 1800 pulses at 110% of motor threshold over temporal cortex delivered at 1Hz and 10Hz over four days. The research design also examined the effect of rTMS immediately following stimulation, regression to the mean in tinnitus ratings made over multiple days, and differences between treatment responders and non-responders.

RESULTS

There was no immediate effect of rTMS on tinnitus during a single rTMS session. Regression to the mean in tinnitus ratings occurred over three days of baseline and four days of treatment (both sham and active rTMS). After accounting for regression to the mean in the statistical model, 1Hz rTMS led to a significant decrease in tinnitus awareness from baseline and 10Hz rTMS trended in the same direction, whereas sham rTMS showed little change from baseline other than regression to the mean. Changes from baseline in spectral power of the resting state EEG provided partial support for predictions based on TCD model of tinnitus for active 1 and 10Hz rTMS but not sham rTMS. However, only an increase in beta coherence correlated significantly with a decrease in tinnitus awareness. Changes in the EEG were robust in treatment responders but absent among non-responders and during sham rTMS.

CONCLUSIONS

A positive response to rTMS for tinnitus is associated with an rTMS-induced change in beta coherence of the EEG. Increased beta coherence may be a biomarker of the rTMS effect; a "top-down" modulation of the EEG that promotes habituation to tinnitus. Participants whose tinnitus did not improve after rTMS did not show any changes in the EEG.

International cooperation during the COVID-19 pandemic

This paper explores the concept of ‘global public goods’ (GPGs) in the context of the ongoing COVID-19 pandemic. It argues that many of the tasks involved in public health, and in particular those involved in the control of an infectious disease like COVID-19, ought to be treated as GPGs that can only be effectively delivered through international cooperation. It sets out what a cooperative response to the COVID-19 pandemic should look like and introduces ideas for further discussion about how it might be financed.

Frozen section analysis for organ-conserving surgery in penile cancer: Assessing oncological outcomes and trends of local recurrence

Introduction and objectives:

The local recurrence rate of penile cancer following surgical excision is reported in many series to be between 6 and 29%. Intra-operative frozen section (FS) is a useful tool to ensure safe microscopic margins in organ-sparing procedures in penile cancer. In this series, we assessed the rates of positive margins and patterns of local recurrence in a multicentre cohort of patients undergoing penile-preserving surgery assisted by intra-operative FS analysis.

Materials and methods:

We reviewed all those patients for whom intra-operative FS was employed during penile-preserving surgery in three tertiary referral centres between 2003 and 2016. We assessed whether the use of FS altered the surgical technique and what affect it had on positive margins and recurrence rates.

Results:

A total of 169 patients were identified. Of these, intra-operative FS examination of the surgical margin was positive in 21 (12%) cases. Final histological examination confirmed cancer-free margins in all but one patient (99.4%). Overall, 9 patients developed local recurrence (5.3%).

Conclusions:

In this series, intra-operative FS contributed to a very low rate (5.3%) of local recurrence. We noted an extremely low positive margin rate (0.6%) which highlights the benefit of incorporating FS analysis into organ-preserving surgery for penile cancer.

Level of evidence:

Not applicable for this multicentre audit.

Ex vivo specimen MRI and pathology confirm a rectosigmoid mesenteric waist at the junction of the mesorectum and mesocolon

AIM

Continuity of the mesentery has recently been established and may provide an anatomical basis for optimal colorectal resectional surgery. Preliminary data from operative specimen measurements suggest there is a tapering in the mesentery of the distal sigmoid. A mesenteric waist in this area may be a risk factor for local recurrence of colorectal cancer. This study aimed to investigate the anatomical characteristics of the mesentery at the colorectal junction.

METHOD

In this cross-sectional study, 20 patients were recruited. After planned colorectal resection, the surgical specimens were scanned in a MRI system and subsequently dissected and photographed as per national pathology guidelines. Mesenteric surface area and linear measurements were compared between MRI and pathology to establish the presence and location of a mesenteric waist.

RESULTS

Specimen analysis confirmed that a narrowing in the mesenteric surface area was consistently apparent at the rectosigmoid junction. Above the anterior peritoneal reflection, the surface area and posterior distance of the mesentery of the upper rectum initially decreased before increasing as the mesentery of the sigmoid colon. These anatomical properties created the appearance of a mesenteric 'waist' at the rectosigmoid junction. Using the anterior reflection as a reference landmark, the rectosigmoid waist occurred at a mean height of 23.6 and 21.7 mm on MRI and pathology, respectively.

CONCLUSION

A rectosigmoid waist occurs at the junction of the mesorectum and mesocolon, and is a mesenteric landmark for the rectum that is present on both radiology and pathology.

Expression, purification and metal utilization of recombinant SodA from Borrelia burgdorferi

Borrelia are microaerophilic spirochetes capable of causing multisystemic diseases such as Lyme disease and Relapsing Fever. The ubiquitous Fe/Mn-dependent superoxide dismutase (SOD) provides essential protection from oxidative damage by the superoxide anion. Borrelia possess a single SOD enzyme - SodA that is essential for virulence, providing protection against host-derived reactive oxygen species (ROS). Here we present a method for recombinant expression and purification of Borrelia burgdorferi SodA in E. coli. Metal exchange or insertion into the Fe/Mn-SOD is inhibited in the folded state. We therefore present a method whereby the recombinant Borrelia SodA binds to Mn under denaturing conditions and is subsequently refolded by a reduction in denaturant. SodA purified by metal affinity chromatography and size exclusion chromatography reveals a single band on SDS-PAGE. Protein folding is confirmed by circular dichroism. A coupled enzyme assay demonstrates SOD activity in the presence of Mn, but not Fe. The apparent molecular weight determined by size exclusion corresponds to a dimer of SodA; a homology model of dimeric SodA is presented revealing a surface Cys distal to the dimer interface. The method presented of acquiring a target metal under denaturing conditions may be applicable to the refolding of other metal-binding proteins.

Time-intensive behavioural activation for depression: A multiple baseline study

BACKGROUND AND OBJECTIVES

Depression is the second leading cause of disability, worldwide, and increasing access to its effective/preferred treatment requires more attention. Behavioural activation and time-intensive treatment delivery both show promise in this regard, yet research into their combination is limited. This study aimed to investigate the feasibility, effectiveness, and acceptability of time-intensive behavioural activation (BA) for depression METHODS: Eight adults with major depressive disorder were recruited from three outpatient IAPT services in London. The study employed a single case experimental design with multiple baselines. All participants completed time-intensive BA, consisting of up to seven twice weekly sessions with daily prompting in-between and three optional booster sessions. Idiographic, standardised and process measures of depression symptomatology were collected.

RESULTS

Treatment recruitment and retention indicated that the intervention was feasible. Visual and statistical analyses showed that relative to baseline, 6 out of 8 participants made significant improvements in all idiographic symptoms of depression following the intervention. According to standardised measures of depression, four out of eight participants were considered treatment responders. Five participants completed follow-up measures and the majority of progress was maintained after the withdrawal of the intervention. The intervention was also considered highly acceptable by participants and therapists.

LIMITATIONS

Conclusions cannot be drawn about the generalizability or the long-term durability of the findings CONCLUSIONS: Overall this study provides new, but tentative evidence highlighting the potential of time-intensive BA as a feasible, effective and acceptable treatment for some adult outpatients with depression. The findings now warrant further, more rigorous evaluation of the treatment.

Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

  Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT). Patients and Methods: Rectal cancer patients with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied in a post hoc, explorative analysis of two previously reported clinical trials. MRI was performed at Weeks 9 and 14 post-NACRT, with surgery at Week 15. Patients undertook a 6-week preoperative exercise-training programme. Oxygen uptake (VO2) at anaerobic threshold (AT) wasmeasured at baseline (pre-NACRT), after completion of NACRT and at week 6 (post-NACRT). Tumour related outcome variables: MRI tumour regression grading (ymrTRG) at Week 9 and 14; histopathological T-stage (ypT); and tumour regression grading (ypTRG)) were compared. Results: 35 patients (26 males) were recruited. 26 patients undertook tailored exercise-training with 9 unmatched controls. NACRT resulted in a fall in VO2 at AT -2.0 ml/kg^-1/min^-1(-1.3,-2.6), p < 0.001. Exercise was shown to reverse this effect. VO2 at AT increased between groups, (post-NACRT vs. week 6) by +1.9 ml/kg^-1/min^-1(0.6, 3.2), p = 0.007. A significantly greater ypTRG in the exercise group at the time of surgery was found (p = 0.02). Conclusion: Following completion of NACRT, exercise resulted in significant improvements in fitness and augmented pathological tumour regression.

A temperature-controlled single-crystal growth cell for the in situ measurement and analysis of face-specific growth rates

The design and construction of a growth cell for the precision measurement of face-specific single-crystal growth rates are presented. Accurate mechanical drawings in SolidWorks of the cell and individual components are provided, together with relevant construction models. A general methodology for its use in the measurement of single-crystal growth rates and their underpinning growth mechanism is presented and illustrated with representative data provided for the crystal growth of the {011} and {001} faces of RS-ibuprofen single crystals grown in ethanolic solutions. Analysis of these data highlights the utility of the methodology in morphological model development and crystallization process design.

The MRI assessment of SPECC (significant polyps and early colorectal cancer) lesions

The development of high-resolution magnetic resonance imaging (MRI) has resulted in the ability to clearly depict the finer details of rectal wall anatomy. Careful specialist assessment of images obtained in patients with significant polyps and early rectal cancer lesions enables the identification of lesions that are confined to the bowel wall and amenable to organ preserving local excision. Currently, one-third of screen detected rectal cancers are limited to the bowel wall without nodal spread yet more than 90% undergo major excision surgery resulting in significant loss of bowel function, quality of life and at high economic cost. The SPECC initiative has highlighted the need for specialist training and accreditation of radiology specialists in precision assessment of significant polyps and early rectal cancer. The detailed assessment will enable provision of detailed roadmaps for surgeons and gastroenterologists to facilitate definitive excision of more lesions using minimally invasive endoscopic technique. Finally, the use of high resolution MRI in surveillance will enable the close monitoring of such patients where the preservation of the rectum has been achieved.