Surgical outcomes of total duct excision in the diagnosis and management of nipple discharge

INTRODUCTION

Total duct excision (TDE) is performed for the diagnosis and management of nipple discharge. The Association of Breast Surgery's recent guidelines recommend considering diagnostic surgery for single-duct, blood-stained or clear nipple discharge, and for symptomatic management.

METHODS

We retrospectively reviewed the diagnostic and surgical outcomes of all cases of TDE between January 2013 and November 2019.

RESULTS

In total, 259 TDEs were carried out: 219 for nipple discharge, 29 for recurrent mastitis, 3 for screening abnormalities and 8 for breast lumps. Of the nipple discharge group, 121 had blood-stained discharge. Mean patient age was 52 years (range 19-81). Median follow-up time was 45 months (interquartile range 24-63). The following cases were identified on histopathology: 236 benign breast changes, 10 atypical ductal hyperplasia, 4 lobular carcinoma in situ, 2 low-grade ductal carcinoma in situ (DCIS), 3 intermediate-grade DCIS, 2 high-grade DCIS and 2 invasive ductal carcinomas. In total, 3.5% of patients who underwent TDE had a diagnosis of DCIS or invasive carcinoma. Blood-stained discharge was associated with a significant increase in risk of DCIS or carcinoma compared with other nipple discharge colours (p = 0.043). The most common complications of TDE were infection, poor wound healing and haematoma. Nipple discharge recurred in 14.2% of cases.

CONCLUSIONS

TDE can be considered for the diagnostics and management of nipple discharge. Blood-stained nipple discharge increases the risk of DCIS or malignancy, but the majority of the time TDE reveals benign breast pathology.

Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BACKGROUND

In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.

OBJECTIVES

To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.

MATERIALS AND METHODS

Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.

RESULTS

The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.

CONCLUSION

Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

Analysis of in-person general practice respiratory consultations: assessing translatability to telehealth

BACKGROUND

The COVID-19 pandemic saw many GPs adopt telehealth as a consultation modality to minimise disease transmission. Patients presenting with respiratory ailments were particularly affected by this transition, given the overlap of general respiratory symptoms with those of COVID-19. It is unclear if the rapid transition to telehealth has compromised the ability to conduct certain tasks that were possible during in-person consultations.

AIM

To investigate the extent to which tasks observed during in-person GP consultations are replicable in telehealth, focusing on patients with respiratory concerns.

DESIGN & SETTING

Twenty-six respiratory consultations were extracted from a database of 281 consultations collated from various general practices in the UK.

METHOD

Interactions between GPs and respiratory patients were assessed through in-depth transcript review and de-identified video analysis. Then, tasks performed and physical artefacts used during the consultations were identified and ranked in terms of their translatability to telehealth, using a newly developed scoring system.

RESULTS

Overall, the translatability to telehealth score for these respiratory consultations was 6.7/10, suggesting that many tasks can be replicated over telehealth, but that they might require additional physical artefacts to support this. However, some tasks are not currently amenable to telehealth (for example, auscultation).

CONCLUSION

While many aspects of respiratory consultations are replicable over telehealth, some tasks cannot be replicated at this stage.

Unpaid caregiving for people following hip fracture: longitudinal analysis from the English Longitudinal Study of Ageing

PURPOSE

To determine the provision and its change over time in unpaid care for people following hip fracture.

METHODS

Data were sought from the English Longitudinal Study of Ageing (ELSA) cohort. We identified participants who self-reported experiencing a hip fracture, who had clinical and caregiving data in the previous and subsequent two data collection waves. Demographic and clinical data were collected in addition to data on provision of unpaid care, who provided care and the frequency of needs being met.

RESULTS

The analysed cohort consisted of 246 participants [150 females (61%), mean age 78.9 years (standard deviation: 8.6)]. There was an increase in the number of participants requiring unpaid care between the Pre-Fracture and Fracture Wave (29% vs. 59%), which plateaued in the subsequent two waves (56%; 51%). Although both spouse and daughters provided the most unpaid care to participants over this study period, there was an increase in support provided during the Fracture Wave by both sons and daughters. This increased support offered by spouses continued until Post-Fracture Wave 2 when this plateaued. Support provided by friends increased from 3 to 8% and brothers and sisters increased from 0 and 1% Pre-Fracture to 8% by Post-Fracture Wave 2.

CONCLUSION

These findings provide insights into who, what and how unpaid carers support people following hip fracture over time. Given the level of support unpaid carers offer, and previously reported carer stress and burden, undertaking clinical trials to assess the effectiveness of carer-patient support interventions would be valuable.

Are chronic condition management visits translatable to telehealth? Analysis of in-person consultations in primary care

BACKGROUND

Telehealth was rapidly adopted in primary care during COVID-19. However, there is a lack of research assessing how translatable in-person consultations are to telehealth.

OBJECTIVE

To examine insights from in-person GP-Patient consultations for patients with chronic conditions, including 1/frequency, duration, conditions of physical examinations, and when they occur during consultations, 2/types of physical artefacts used, 3/clinical tasks performed, and 4/translatability of clinical tasks to telehealth.

METHODS

Eligible consultations were extracted from a dataset archive named HaRI, which contains 281 in-person GP consultations in de-identified transcript and video format. 38 consultations were included for analysis meeting eligibility criteria in this study. A multi-method approach (using content analysis, visualisation, video and time analysis) was applied to eligible consultations, extracting clinical tasks that involve physical interactions. Finally, an evidence-based scoring system was used on each clinical task, determining the likelihood of whether each task could be translated into telehealth.

RESULTS

Nine chronic conditions were observed across 38 GP-Patient consultations, predominately diabetes (39 %, 15/38). Out of these 38 consultations, 76 % (29/38) featured physical examinations, where 68 % (26/38) were initiated by GPs (e.g., auscultation), and 26 % (10/38) were initiated by patients (e.g., self-palpation). The average percentage of time spent on physical examination(s) during consultations is low (13.6 %, SD = 9.4 %). A total of 24 clinical tasks were observed across these 38 consultations. Out of these 24 tasks, 92 % (22/24) were supported by physical artefacts. The average score of a task being translatable to Telehealth is 7/10 (where Score 1 = Not amenable to being replicated over telehealth at this stage, scoring 10 = Easily translatable over telehealth with almost no additional equipment being required).

CONCLUSION

All tasks observed across chronic condition management visits were deemed translatable/potentially translatable to telehealth. However, physical interactions between GPs and patients are still essential. Future research in telehealth should focus on examining ways to support physical examination, reduce uncertainty, promote safety netting, and facilitate patients' safety at home with effective technology and support.

A Population-Based Assessment of Long-Term Sexual Well-Being and Patient Satisfaction after Breast Reconstruction and Post-Mastectomy Radiation

PURPOSE/OBJECTIVE(S)

In 2016, more than 40% of women who underwent mastectomy for breast cancer went on to have breast reconstruction, but there is little data regarding long-term cosmetic outcomes past 5 years after post-mastectomy radiation (PMRT) and reconstruction. This study aims to evaluate the difference in patient breast satisfaction and sexual well-being over time by receipt of reconstruction and PMRT.

MATERIALS/METHODS

The iCanCare study is a population-based, longitudinal study of women diagnosed with breast cancer in 2014-15 identified in the Los Angeles and Georgia SEER registries. Women were surveyed during initial treatment and again approximately 6 years later in survivorship (2021-2022). Participants were asked about their "Sexual well-being after mastectomy" and "Satisfaction with breasts" using the Breast-Q, which was dichotomized into "high" and "low" scores (using the median), with a high score indicating increased satisfaction. We then evaluated whether satisfaction differed by treatment characteristics, using unadjusted odds ratios (OR) for categorical variables, calculated using the Chi-square test, or the Kruskal-Wallis test for continuous variables. Adjusted odds ratios were found using multivariable logistic regression models adjusting for treatment characteristics, diagnosis, age, BMI, education, and breast cancer stage.

RESULTS

In this preliminary sample of 1191 respondents, 445 underwent mastectomy, of which 272 (61.12%) had reconstruction, and 65 (14.61%) had PMRT. Having breast reconstruction was associated with higher long-term sexual well-being (median score 36.30 vs. 22.20, OR 1.69, 95% confidence interval [CI] 1.09 - 2.64) and breast satisfaction scores (OR 1.53, 95% CI 1.01 - 2.33) compared to not having reconstruction. However, this improvement in sexual well-being was attenuated in women who additionally had PMRT (OR 0.83, CI 0.271 - 2.51). In women who did not have reconstruction after mastectomy, there was no statistically significant difference in sexual well-being scores regardless of the use of PMRT (OR 0.68, CI 0.39 - 1.22). Among respondents in adjusted models who did not receive PMRT, those with reconstruction had higher sexual well-being scores than those with without reconstruction (aOR 2.47, CI 1.34 - 4.56), though there was no statistically significant difference in breast satisfaction scores (p = 0.16) among the groups.

CONCLUSION

Sexual well-being and breast satisfaction are improved with reconstruction 6 years after mastectomy for breast cancer. However, these improvements were attenuated for women who received PMRT. To our knowledge, this is the first study to look at long term outcomes of sexual well-being and treatment satisfaction after breast reconstruction for patients who underwent mastectomy for breast cancer. These data suggest that continued work should be done to optimize patient outcomes when combining PMRT and breast reconstruction.

Translating primary care to telehealth: analysis of in-person consultations on diabetes and cardiovascular disease

BACKGROUND

The COVID-19 pandemic had a considerable impact on primary care, resulting in rapid uptake of telehealth. Patients with chronic conditions, such as type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), relied heavily on telehealth consultations during this period. It is important to assess whether tasks observed during T2DM or CVD in-person consultations are translatable to telehealth.

AIM

To explore the extent to which in-person GP consultations are translatable to telehealth for patients with T2DM or CVD.

DESIGN & SETTING

This study screened 281 GP consultations conducted in 2017 within the UK general practice setting for consultations pertaining to T2DM or CVD. Seventeen in-person consultations (in deidentified video and transcript) were selected for further analysis.

METHOD

Detailed reporting of tasks, physical artefacts, and physical examinations observed during in-person GP consultations. A new scoring method, applying two key metrics, supporting definitions and examples, was designed to assess translatability of clinical tasks to telehealth.

RESULTS

Across the 17 T2DM or CVD in-person consultations analysed, 23 clinical tasks, 21 physical artefacts, and nine physical examinations were observed. Sixty per cent of tasks analysed were deemed either easily or relatively easily translatable to telehealth. Twenty-six per cent of tasks were rated as 'moderately translatable to telehealth' but may require a patient obtaining their own equipment. Thirteen per cent of tasks were rated as 'potentially translatable to telehealth'. No clinical tasks for these cohorts were rated as untranslatable to telehealth.

CONCLUSION

The majority of tasks observed during T2DM or CVD in-person GP consultations are translatable to telehealth. Further research is warranted to investigate emergent safety concerns from increased uptake of telehealth.

Pediatric Cardiology Fellowship Standards for Training in Exercise Medicine and Curriculum Outline

Over the past 2 decades, fundamentals of exercise medicine, including clinical exercise testing, assessment and promotion of physical activity, exercise prescription, and supervised exercise training/rehabilitation programming have demonstrated considerable clinical value in the management of children and adolescents with congenital and acquired heart disease. Although the principles of exercise medicine have become an integral component in pediatric cardiology, there are no standardized training recommendations for exercise physiology during pediatric cardiology fellowship at this time. Thus, the Pediatric Cardiology Exercise Medicine Curriculum Committee (PCEMCC) was formed to establish core and advanced exercise physiology training recommendations for pediatric cardiology trainees. The PCEMCC includes a diverse group of pediatric cardiologists, exercise physiologists, and fellowship program directors. The expert consensus training recommendations are by no means a mandate and are summarized herein, including suggestions for achieving the minimum knowledge and training needed for general pediatric cardiology practice.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Visit Types in Primary Care With Telehealth Use During the COVID-19 Pandemic: Systematic Review

BACKGROUND

Telehealth was rapidly incorporated into primary care during the COVID-19 pandemic. However, there is limited evidence on which primary care visits used telehealth.

OBJECTIVE

The objective of this study was to conduct a systematic review to assess what visit types in primary care with use of telehealth during the COVID-19 pandemic were reported; for each visit type identified in primary care, under what circumstances telehealth was suitable; and reported benefits and drawbacks of using telehealth in primary care during the COVID-19 pandemic.

METHODS

This study was a systematic review using narrative synthesis. Studies were obtained from four databases (Ovid [MEDLINE], CINAHL Complete, PDQ-Evidence, and ProQuest) and gray literature (NSW Health, Royal Australian College of General Practitioners guidelines, and World Health Organization guidelines). In total, 3 independent reviewers screened studies featuring telehealth use during the COVID-19 pandemic in primary care. Levels of evidence were assessed according to the Grading of Recommendations Assessment, Development, and Evaluation. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. Benefits and drawbacks of telehealth were assessed according to the National Quality Forum Telehealth Framework.

RESULTS

A total of 19 studies, predominately cross-sectional surveys or interviews (13/19, 68%), were included. Seven primary care visit types were identified: chronic condition management (17/19, 89%), existing patients (17/19, 89%), medication management (17/19, 89%), new patients (16/19, 84%), mental health/behavioral management (15/19, 79%), post-test result follow-up (14/19, 74%), and postdischarge follow-up (7/19, 37%). Benefits and drawbacks of telehealth were reported across all visit types, with chronic condition management being one of the visits reporting the greatest use because of a pre-existing patient-provider relationship, established diagnosis, and lack of complex physical examinations. Both patients and clinicians reported benefits of telehealth, including improved convenience, focused discussions, and continuity of care despite social distancing. Reported drawbacks included technical barriers, impersonal interactions, and semi-established reimbursement models.

CONCLUSIONS

Telehealth was used for different visit types during the COVID-19 pandemic in primary care, with most visits for chronic condition management, existing patients, and medication management. Further research is required to validate our findings and explore the long-term impact of hybrid models of care for different visit types in primary care.

TRIAL REGISTRATION

PROSPERO CRD42022312202; https://tinyurl.com/5n82znf4.

807 The Association between Blood Transfusion and Outcome in Hip Fracture Patients

Aim

Hip Fractures are endemic in older adults across Europe, with potential increases in incidence expected as the population ages. Management of blood loss and anaemia is a mainstay of care for these patients, but there is still significant debate regarding balance between benefit and risk of liberal versus restrictive transfusion policies. Understanding the association between providing blood products and adverse healthcare outcomes in hip fracture patients is a key component in the transfusion decision-making process.

Method

This retrospective cohort study uses national audit data from the Scottish Hip Fracture Audit (SHFA) and the Scottish National Blood Transfusion Service (SNBTS) to examine the association between blood transfusion and important hip fracture process of care measures and healthcare outcomes.

Results

A total of 28 461 patient records were included for assessment across 19 acute hospitals. Blood transfusion during admission was associated with a small but statistically significant decrease in survival at both 30 and 60 days. Those receiving blood transfusion during admission were less likely to be mobilised by the end of the 1st post-operative day, less likely to have a length of stay below the average and had far lower probability of discharge.

Conclusion

This study found that blood transfusion is associated with poor healthcare outcomes following hip fracture, even when adjusted for potential confounding factors. This likely reflects the potential harm of perioperative anaemia rather than any direct impact from transfusion. Further work to reduce perioperative blood loss is therefore key to improving important hip fracture outcomes.

Self-care Behaviours and Technology utilised during COVID-19: Systematic Review

Background

Self-care behaviors are essential for people living with chronic conditions; however, the outbreak of the COVID-19 pandemic has imposed additional complications on their daily routines. Few studies have analyzed how self-care behaviors have changed during COVID-19 and the role of digital technology, especially among people with chronic conditions.

Objective

This study aims to review how self-care behaviors have changed for people with chronic conditions during the COVID-19 pandemic, and what technology they have adopted to manage their conditions during that period.

Methods

A systematic review was conducted using narrative synthesis. Data were extracted from PubMed, MEDLINE, EMBASE, PsycINFO, CINAHL, and Google Scholar, including articles from December 2019 onward. Eligible studies focused on adults diagnosed with chronic conditions undertaking any self-care tasks in line with the middle-range theory of self-care of chronic illness (ie, self-care maintenance, monitoring, and management). The methodological quality of the included articles was assessed with the McMaster Critical Review Forms for Quantitative or Qualitative Studies.

Results

In total, 36 primary research articles were included. Changes to self-care behaviors during COVID-19 among people with chronic conditions were organized according to the middle-range theory of self-care of chronic illness focusing on self-care maintenance (ie, medication adherence, physical activity, and diet control), self-care monitoring (ie, monitoring signs and symptoms), and self-care management (ie, consultations with health care providers). Positive self-care behaviors observed include the following: individuals trying to maintain good glycemic control during COVID-19 increased their medication adherence in 27% (10/36) of studies; and diet control improved in 50% (18/36) of studies. Negative self-care behaviors observed include the following: decline in physical activities and increased sedentariness were observed in 65% (23/36) of studies; poor diet control was observed in 57% (21/36) of studies; and self-monitoring of health status dropped in 43% (15/36) of studies. The use of technology to support self-care of chronic conditions during COVID-19 was reported in 72% (26/36) of studies. The actual use of telehealth in place of physical consultations during COVID-19 was observed in 50% (18/36) of studies, and other digital technologies (eg, social media apps, smartphone apps, web-based platforms, and web browsing) were used in 50% (18/36) of studies. Telehealth was discussed and recommended as the default technology in delivering future health care services during COVID-19 and beyond in 77% (28/36) of studies.

Conclusions

This review highlighted the necessity to rethink how models of self-care should continue to address the demands of chronic conditions while being responsive to the imminent threats of infectious diseases. Perhaps the silver lining of COVID-19 is that adoption of digital technology (especially telehealth) among a vast cross-section of people with chronic conditions is possible. Future research should investigate effective ways to incorporate evidence-based digital health tools into these new models of self-care that address the challenges of chronic and infectious conditions.

738 DETERMINANTS OF MUSCLE DENSITY IN OLDER PEOPLE: FINDINGS FROM THE HERTFORDSHIRE COHORT STUDY (HCS)

Introduction

Lower calf muscle density (CMD) as assessed by peripheral quantitative computed tomography (pQCT) is associated with greater hip fracture risk, independent of FRAX, falls and bone mineral density. To date, muscle density has been little studied, and its determinants are unknown. In this study, we examine the lifestyle and anthropometric determinants of future muscle density (MD) in the HCS.

Methods

197 men and 178 women, aged 59–70 years, were recruited. A lifestyle questionnaire collected information on physical activity, smoking, alcohol consumption and dietary patterns. Height and weight were measured. pQCT of the radius and tibia was performed a median of 11.5 (IQR 10.9, 12.3) years later. MD was measured at calf and forearm using standard methodology. Baseline characteristics in relation to MD at follow-up were examined separately using linear regression with sex, baseline age and follow-up time included as covariates in all models.

Results

Mean (SD) age at baseline was 64.7 (2.7) years; mean (SD) MD values (mg/cm3) were as follows: forearm [men 79.9 (3.1), women 77.2 (3.2)], calf [men 80.7 (2.6), women 78.5 (2.6)]. Baseline correlates (p < 0.05) of both lower forearm and CMD included female sex, lower weight, and lower BMI. SD difference in CMD for women compared to men, and per SD lower weight and BMI were − 0.84 [95%CI: −1.13, −0.54]), −0.37 [−0.46, −0.27] and − 0.31 [−0.40, −0.23] respectively. Additional correlates of lower CMD included older age and shorter stature. Relationships between MD and age were stronger at the calf (p < 0.001) than the forearm (p = 0.08). Lifestyle measures were not associated with MD.

Conclusion

Female sex, older age, and lower BMI were associated with lower MD in older community-dwelling adults, highlighting the need for sustained muscle conditioning in older individuals. Further studies in larger cohorts are required.

New Zealand women's experiences of managing gestational diabetes through diet: a qualitative study

Background

For women with gestational diabetes mellitus (GDM) poor dietary choices can have deleterious consequences for both themselves and their baby. Diet is a well-recognised primary strategy for the management of GDM. Women who develop GDM may receive dietary recommendations from a range of sources that may be inconsistent and are often faced with needing to make several dietary adaptations in a short period of time to achieve glycaemic control. The aim of this study was to explore how women diagnosed with GDM perceive dietary recommendations and how this information influences their dietary decisions during pregnancy and beyond.

Methods

Women diagnosed with GDM before 30 weeks’ gestation were purposively recruited from two GDM clinics in Auckland, New Zealand. Data were generated using semi-structured interviews and thematic analysed to identify themes describing women’s perceptions and experiences of dietary recommendations for the management of GDM.

Results

Eighteen women from a diverse range of sociodemographic backgrounds participated in the study. Three interconnected themes described women’s perceptions of dietary recommendations and experiences in managing their GDM through diet: managing GDM is a balancing act; using the numbers as evidence, and the GDM timeframe. The primary objective of dietary advice was perceived to be to control blood glucose levels and this was central to each theme. Women faced a number of challenges in adhering to dietary recommendations. Their relationships with healthcare professionals played a significant role in their perception of advice and motivation to adhere to recommendations. Many women perceived the need to follow dietary recommendations to be temporary, with few planning to continue dietary adaptations long-term.

Conclusions

The value of empathetic, individually tailored advice was highlighted in this study. A greater emphasis on establishing healthy dietary habits not just during pregnancy but for the long-term health of both mother and baby is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04297-0.

A pilot of modified Conversation Analytic Role-play Method for one-to-one clinical communication training

OBJECTIVE

It can be difficult to identify specific skills to improve communication, particularly if feedback is generalised or vague. With the aim of providing specific feedback for improved doctor-patient communication, we piloted a modified Conversation Analytic Roleplay Method (CARM) for one-to-one training.

METHODS

We recorded one surgical registrar during ward rounds in a hospital. These seven consultations were then analysed and an individualised CARM workshop, utilising the findings and related published evidence, was developed and delivered. One month after this workshop, another nine consultations were recorded and analysed.

RESULTS

There were three "trainables" identified in the initial analysis that formed the basis of the personalised workshop. Analysis of the post-training recordings showed that the verbal behaviours were mostly modified but the non-verbal behaviour generally was not.

CONCLUSION

By facilitating reflection on and close analysis of his own interaction using CARM, we were able to assist this doctor in modifying some of his communication behaviours.

PRACTICE IMPLICATIONS

Personalised video-based training enables the identification of an individual's practice, allowing for specific feedback and engaging participants with the analysis of their own talk. This makes it potentially an ideal method for helping those struggling to improve with other training methods.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Adiposity and bone microarchitecture in the GLOW study

Low body mass index (BMI) is an established risk factor for fractures in postmenopausal women but the interaction of obesity with bone microarchitecture is not fully understood. In this study, obesity was associated with more favourable bone microarchitecture parameters but not after parameters were normalised for body weight.

INTRODUCTION

To examine bone microarchitecture in relation to fat mass and examine both areal bone mineral density (aBMD) and microarchitecture in relation to BMI categories in the UK arm of the Global Longitudinal Study of Osteoporosis in Women.

METHODS

Four hundred and ninety-one women completed questionnaires detailing medical history; underwent anthropometric assessment; high-resolution peripheral quantitative computed tomography (HRpQCT) scans of the radius and tibia and DXA scans of whole body, proximal femur and lumbar spine. Fat mass index (FMI) residuals (independent of lean mass index) were derived. Linear regression was used to examine HRpQCT and DXA aBMD parameters according to BMI category (unadjusted) and HRpQCT parameters in relation to FMI residuals (with and without adjustment for anthropometric, demographic and lifestyle covariates).

RESULTS

Mean (SD) age was 70.9 (5.4) years; 35.0% were overweight, 14.5% class 1 obese and 7.7% class 2/3 obese. There were significant increasing trends according to BMI category in aBMD of whole body, hip, femoral neck and lumbar spine (p ≤ 0.001); cortical area (p < 0.001), thickness (p < 0.001) and volumetric density (p < 0.03), and trabecular number (p < 0.001), volumetric density (p < 0.04) and separation (p < 0.001 for decreasing trend) at the radius and tibia. When normalised for body weight, all HRpQCT and DXA aBMD parameters decreased as BMI increased (p < 0.001). FMI residuals were associated with bone size and trabecular architecture at the radius and tibia, and tibial cortical microarchitecture.

CONCLUSION

Significant trends in HRpQCT parameters suggested favourable bone microarchitecture at the radius and tibia with increasing BMI but these were not proportionate to increased weight.

Abstract PD4-03: MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL

Background: Detecting residual disease accurately using MRI after NAC to identify both responders and non-responders is essential for de-escalating therapy or redirecting patients to more effective treatment. The purpose of this study is to determine if the combination of longest diameter (LD) and functional tumor volume (FTV) from dynamic contrast enhanced (DCE-) MRI is superior to FTV alone or LD alone for assessing treatment response after neoadjuvant therapy in breast cancer patients.

Methods: Data from patients in the graduated drug arms of the I-SPY 2 trial were included in the analysis. Both LD and FTV were assessed using DCE-MRI after neoadjuvant therapy. LD was measured by the site radiologist as the longest dimension of the enhanced area on early post-contrast images. Functional tumor volume (FTV) was assessed as the sum of voxels with enhancement above specific thresholds within the pre-defined region-of-interest (ROI). A linearized variable was derived to represent the combination of FTV and LD. The area under the receiver operating characteristic curve (AUC) was used to evaluate the assessment of treatment response, pathologic complete response (pCR), defined as no invasive disease in the breast and lymph nodes, and in-breast pCR, defined as no invasive disease in the breast only. The analysis was performed in the full cohort and in breast cancer subtype defined by hormone receptor status and HER2 status.

Results: Among the patient cohort of N=675 with FTV and LD, 247 (37%) did and 428 (41%) did not achieve pCR after neoadjuvant therapy. pCR rates varied among HR/HER2 subtypes (HR+/HER2-: 19%; HR+/HER2+: 38%; HR-/HER2+: 71%; HR-/HER2- (triple negative, TN): 43%). In-breast pathologic complete response rates were slightly higher in each group (full: 41%; HR+/HER2-: 23%; HR+/HER2+: 43%; HR-/HER2+: 72%; HR-/HER2-: 49%). Table 1 shows AUCs for assessing pCR using FTV alone, LD alone, and the variable combining FTV and LD. Higher AUCs were observed in all patient groups using the combined variable. AUC of 0.79 (95% CI: 0.77, 0.81) was observed for the combined variable to assess pCR in the full cohort. AUCs varied from 0.69 to 0.86 among HR/HER2 subgroups (HR+/HER2-: 0.69; HR+/HER2+: 0.74; HR-/HER2+: 0.86; HR-/HER2-: 0.80), with no difference in assessing pCR or in-breast pCR. The performance is best for the HR- subtypes.

Conclusions: Both FTV and LD can be used in the assessment of invasive disease residual after neoadjuvant therapy. The combined variable of FTV and LD achieved highest AUCs, compared to using individual variable alone. Tools to improve performance in the HR+ subsets are underway.

AUCs of MR measurements for identifying pCR  FTV alone (95% CI)LD alone (95% CI)Combined (95% CI)FullWith subtype adj.0.73 (0.71, 0.75)0.77 (0.74, 0.79)0.79 (0.77, 0.81)FullWithout subtype adj0.69 (0.65, 0.73)0.72 (0.68, 0.76)0.75 (0.71, 0.79)HR+/HER2- 0.68 (0.60, 0.77)0.68 (0.59, 0.77)0.69 (0.61, 0.77)HR+/HER2+ 0.65 (0.56, 0.75)0.72 (0.64, 0.80)0.74 (0.66, 0.82)HR-/HER2+ 0.69 (0.55, 0.83)0.82 (0.71, 0.92)0.86 (0.77, 0.95)HR-/HER2- (TN) 0.72 (0.66, 0.79)0.73 (0.67, 0.80)0.80 (0.74, 0.85)

Citation Format: Li W, Newitt D, Yun BL, Kornak J, Joe B, Yau C, Abe H, Wolverton D, Crane E, Ward K, Nelson M, Niell B, Drukteinis J, Oh K, Brandt K, Bang DH, Ojeda H, Eghtedari M, Sheth P, Bernreuter W, Umphrey H, Rosen M, Dogan B, Yang W, Esserman L, Hylton N. MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-03.

Abstract P2-08-32: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Perimbeti SP, Shrivastav R, Ward K, Styler M. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-32.

Essential TNM: A Means to Collect Stage Data in Population-Based Registries in Low- and Middle-Income Countries

Background and context: Cancer control requires knowledge of cancer incidence. Information on anatomic extent of disease (stage) at presentation significantly enhances incidence and mortality data in understanding the cancer burden. The most frequently used staging classification of cancer disease extent is the tumor, node, metastases (TNM). Population-based registries (PBCR) in low- and middle-income countries (LMIC) frequently have insufficient information to derive complete TNM data, either because of inability to perform the necessary evaluations or because of a lack of recorded information. Aim: To develop a simplified system of recording extent of disease to facilitate the collection of stage data by PBCR and enhance the utility of data to facilitate cancer control in LMICs. Strategy/Tactics: A working group with representatives from the UICC (Union for International Cancer Control), the IARC (International Agency for Cancer Research), IACR (International Association of Cancer Registries) and the NCI (National Cancer Institute) was formed and Essential TNM was developed. When the T, N, and M categories have not been recorded in the clinical records or if the complete data to determine the categories is unavailable, the cancer registrar can code extent of disease according to the Essential TNM scheme. Once a cancer registrar had identifies the presence of metastatic disease (M1) this is recorded and additional information is unnecessary to establish that stage of disease. If there is no metastatic disease the extent of nodal disease is recorded. In turn if there is no nodal disease the extent/size of the primary carcinoma is recorded. The extent of disease can be summarized in the following order: M, N and T. Program/Policy process: Diagrams and rules for combining Essential TNM elements into stage groups (I-IV) or to be expressed as “distant”, “regional” or “localized” if only the most limited data were available, were developed for breast, cervix, prostate and colon cancers and will be demonstrated. Once the schema were developed they were verified in Georgia (USA) and field tested in Ecuador, Malawi, Cote d'Ivoire and Zimbabwe. Outcomes: There was good agreement between the stage identified through Essential TNM and that within the Georgia State Registry. The field tests however identified three key issues: the underidentification of distant metastases, inaccurate the collection of lymph node data and improved training needs. In particular there was uncertainty in the identification of when lymph node involvement was considered to be distant metastatic or regional. In view of this, refinements to the schemas have been made to simplify the collection of nodal data. The schema have been updated to ensure compatibility with the 8th edition of TNM. Training programs are being developed and Essential TNM is being expanded. What was learned: Essential TNM can be used by LMIC PBCR to facilitate the collection of stage data. Further refinements and training are needed and are underway.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Abstract P4-10-21: Disparities in the risk of mortality in breast cancer based on health insurance status

In 2007 Foley et al showed that low-income Canadian residents had a survival advantage over low-income US residents, which was attributed to the equal access to medical care in Canada's universal health care system. Niu et al. found that uninsured and Medicaid insured patients with breast, cervical, colorectal, head and neck, lung, prostate or uterine cancer have higher mortality rates compared to patients with private insurance or Medicare. As substantial proportions of the US population are uninsured or enrolled in Medicaid, we examined the association between in-hospital mortality and different primary payers in patients with breast cancer.

Methods

Adult female admissions (adm) with a primary diagnosis of breast cancer between 1999 and 2014 were extracted from the National Inpatient Sample database using the ICD-9 code 174.9 (N=98631, for a weighted N=484859). The sample was weighted to approximate the full inpatient population of the US over the time period. To minimize the effect of changes in mortality rates based on insurance status over the time interval studied, we grouped the adm into three categories: Group 1 for adm from 1999 to 2003, Group 2 2004 to 2008, and Group 3 2009 to 2014. Chi-Square analysis was done to determine the in-hospital mortality rates by payer group and Cox Proportional Hazard regression was used to determine the hazard of death (HR) within 30 days of adm by payer.

Results

In-hospital Mortality (%) by primary payerYear GroupMedicareMedicaidPrivate InsuranceSelfpay/UninsuredP value13.836.773.4310.140.000124.587.554.9590.000132.843.463.0210.260.0001

Hazard ratio of death within the hospitalizationYear GroupMedicaid vs MedicareP valueUninsured vs MedicareP value12.03 (1.49, 2.76)0.00013.2 (2.49, 4.22)0.000121.56 (1.19, 2.46)0.00012.9 (2.20, 3.80)0.000132.55 (1.99, 3.27)0.00017.76 (1.99, 3.27)0.0001

The number of adm with Medicare or Private insurance were higher than those with Medicaid or Selfpay/uninsured. The in-hospital mortality was highest for Selfpay/uninsured, followed by admissions with Medicaid. After controlling for age, race, median income and comorbidities, the HR was significantly higher in the Medicaid and selfpay/uninsured admissions compared to Medicare admissions. In Group 1, compared to Medicare adm the HR was 103% higher for Medicaid and 220% higher for uninsured. In Group 2, the HR was 56% higher for Medicaid and 196% higher for uninsured. In Group 3, it was 155% higher for Medicaid and 676% higher in uninsured.

Conclusion

Even after controlling for other factors which are implicated in the mortality, the HR is significantly higher in Medicaid and uninsured admissions when compared with Medicare enrolled admissions with breast cancer. Equitable distribution of health was one of the “Aims for Improvement” in the Institute of Medicine's 2001 report, but our results suggests that this has not yet been achieved. Insurance status still appears to play a crucial role in patient outcomes and should be considered as a metric of equitable care. More scientific research is needed in the area of differential receipt of standard therapy in cancer patients considering the limitations of our study.

Citation Format: Perimbeti S, Chakunta H, Liu L, Ward K, Jain M, Styler M. Disparities in the risk of mortality in breast cancer based on health insurance status [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-21.

Mild cognitive impairment is associated with poor physical function but not bone structure or density in late adulthood: findings from the Hertfordshire cohort study

This study investigated the association between mild cognitive impairment (MCI) and physical function and bone health in older adults. MCI was associated with poor physical performance but not bone mineral density or bone microarchitecture.

PURPOSE

Cross-sectional study to investigate the association between mild cognitive impairment (MCI) and physical performance, and bone health, in a community-dwelling cohort of older adults.

METHODS

Cognitive function of 222 men and 221 women (mean age 75.5 and 75.8 years in men and women, respectively) was assessed by the Strawbridge questionnaire and Mini Mental State Exam (MMSE). Participants underwent dual-energy X-ray absorptiometry (DXA), peripheral-quantitative computed tomography (pQCT) and high-resolution peripheral-quantitative computed tomography (HR-pQCT) scans to assess their bone density, strength and microarchitecture. Their physical function was assessed and a physical performance (PP) score was recorded.

RESULTS

In the study, 11.8% of women and 8.1% of men were cognitively impaired on the MMSE (score < 24). On the Strawbridge questionnaire, 24% of women were deemed cognitively impaired compared to 22.3% of men. Cognitive impairment on the Strawbridge questionnaire was associated with poorer physical performance score in men but not in women in the unadjusted analysis. MMSE < 24 was strongly associated with the risk of low physical performance in men (OR 12.9, 95% CI 1.67, 99.8, p = 0.01). Higher MMSE score was associated with better physical performance in both sexes. Poorer cognitive function, whether assessed by the Strawbridge questionnaire, or by MMSE score, was not associated with bone density, shape or microarchitecture, in either sex.

CONCLUSION

MCI in older adults was associated with poor physical performance, but not bone density, shape or microarchitecture.

Hardware image assessment for wireless endoscopy capsules

Wireless capsule endoscopy is a new technology in the realm of telemedicine that has many advantages over the traditional endoscopy systems. Transmitted images should help diagnosis of diseases of the gastrointestinal tract. Two important technical challenges for the manufacturers of these capsules are power consumption and size of the circuitry. Also, the system must be fast enough for real-time processing of image or video data. To solve this problem, many hardware designs have been proposed for implementation of the image processing unit. In this paper we propose an architecture that could be used for the assessment of endoscopy images. The assessment allows avoidance of transmission of medically useless images. Hence, volume of data is reduced for more efficient transmission of images by the endoscopy capsule. This is done by color space conversion and moment calculation of images captured by the capsule. The inputs of the proposed architecture are RGB image frames and the outputs are images with converted colors and calculated image moments. Experimental results indicate that the proposed architecture has low complexity and is appropriate for a real-time application.

Vessel extraction in X-ray angiograms using deep learning

Coronary artery disease (CAD) is the most common type of heart disease which is the leading cause of death all over the world. X-ray angiography is currently the gold standard imaging technique for CAD diagnosis. These images usually suffer from low quality and presence of noise. Therefore, vessel enhancement and vessel segmentation play important roles in CAD diagnosis. In this paper a deep learning approach using convolutional neural networks (CNN) is proposed for detecting vessel regions in angiography images. Initially, an input angiogram is preprocessed to enhance its contrast. Afterward, the image is evaluated using patches of pixels and the network determines the vessel and background regions. A set of 1,040,000 patches is used in order to train the deep CNN. Experimental results on angiography images of a dataset show that our proposed method has a superior performance in extraction of vessel regions.

Robust watermarking in non-ROI of medical images based on DCT-DWT

Increasing demand and utilization of telemedicine require transmission of medical information and images over internet. Since authenticity of received images is crucial and patient's information should be included with minimum changes in images, robust watermarking schemes are needed. In this paper, we propose a robust watermark method that embeds patient's information outside the region of interest (ROI) in medical image. In order to find appropriate regions for embedding, we use saliency as a means of measuring importance of regions and find blocks having minimum overlap with the ROI. The algorithm employs wavelet transform and also discrete cosine transform (DCT) domains in the embedding stage and redundantly embeds watermark to increase robustness against possible alterations. Moreover, voting is utilized in the extraction phase. Experimental results show the efficiency of the proposed method and better results are obtained as compared to comparable methods with same size of the watermarked data.

Safety and efficacy of imiquimod 5% cream in the treatment of penile genital warts in uncircumcised men when applied three times weekly or once per day

This dose-escalation study was performed to evaluate safety and efficacy of imiquimod 5% cream in the treatment of uncircumcised men with penile warts associated with the foreskin. The cream was applied 3 times/week (n=34) or once per day (n=30) over 8 ± 2h. Imiquimod 5% cream was safe in both treatment groups. However, the 3 times/week regimen was better tolerated with a lower incidence of local skin reactions. In both groups, the 2 most frequently reported local skin reactions were erythema and erosion; they were more severe with the once-daily dosing. The most frequently reported application site reactions were burning, pruritus and irritation or pain (once-daily patients only). Total clearance was achieved in 62% of the patients in the 3 times/week group and by 57% in the once-daily group. Thus, imiquimod 5% cream administered 3 times/week was the optimal dosing regimen in the treatment of penile warts in uncircumcised men.

Automatic segmentation of multimodal brain tumor images based on classification of super-voxels

Despite the rapid growth in brain tumor segmentation approaches, there are still many challenges in this field. Automatic segmentation of brain images has a critical role in decreasing the burden of manual labeling and increasing robustness of brain tumor diagnosis. We consider segmentation of glioma tumors, which have a wide variation in size, shape and appearance properties. In this paper images are enhanced and normalized to same scale in a preprocessing step. The enhanced images are then segmented based on their intensities using 3D super-voxels. Usually in images a tumor region can be regarded as a salient object. Inspired by this observation, we propose a new feature which uses a saliency detection algorithm. An edge-aware filtering technique is employed to align edges of the original image to the saliency map which enhances the boundaries of the tumor. Then, for classification of tumors in brain images, a set of robust texture features are extracted from super-voxels. Experimental results indicate that our proposed method outperforms a comparable state-of-the-art algorithm in term of dice score.