Factors Influencing Patient Confidence in Screening Mammography

BACKGROUND

We aimed to assess factors associated with patients' confidence in the ability of screening mammography to detect breast cancer.

METHODS

Data were analyzed from a cross-sectional, prospective survey conducted in 2017 of women without a breast cancer history who were undergoing screening mammography at our institution.

RESULTS

In total, 390 women completed the survey questions relevant to this study. Most respondents were 46 years or older (89.7%), White (87.6%), and college-educated (66.1%). Approximately 80% of respondents reported having confidence in the ability of screening mammography to detect breast cancer. Factors significantly associated with lower confidence in screening mammography were higher education (P = .01) and dense breast tissue (P < .001). Age (P = .12), race (P = .64), family history of breast cancer (P = .17), prior abnormal mammogram (P = .07), and mammogram frequency (P = .42) were nonsignificant. Women with a college education or higher were less likely to report confidence in routine mammography than women with less education (odds ratio [OR]= 0.43; 95% CI, 0.20-0.84; P = .02). Compared with women who reported their breast tissue as not dense, women who were aware they had increased breast density (OR = 0.16; 95% CI, 0.04-0.49; P = .004) or were unaware whether they had increased breast density (OR = 0.17; 95% CI, 0.04-0.51; P = .005) reported less confidence in screening mammography.

DISCUSSION

Most respondents were confident in the ability of screening mammography to detect breast cancer. Confidence was inversely associated with education level and self-reported increased breast density.

CONCLUSIONS

These findings highlight the importance of continued patient education about the effectiveness of screening mammography for patients with dense breast tissue.

The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were 'uncommon' (10-100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being 'common' (100-1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent.

Peri-operative cardiac arrest: epidemiology and clinical features of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. Here we report the results of the 12-month registry, from 16 June 2021 to 15 June 2022, focusing on epidemiology and clinical features. We reviewed 881 cases of peri-operative cardiac arrest, giving an incidence of 3 in 10,000 anaesthetics (95%CI 3.0-3.5 per 10,000). Incidence varied with patient and surgical factors. Compared with denominator survey activity, patients with cardiac arrest: included more males (56% vs. 42%); were older (median (IQR) age 60.5 (40.5-80.5) vs. 50.5 (30.5-70.5) y), although the age distribution was bimodal, with infants and patients aged > 66 y overrepresented; and were notably more comorbid (73% ASA physical status 3-5 vs. 27% ASA physical status 1-2). The surgical case-mix included more weekend (14% vs. 11%), out-of-hours (19% vs. 10%), non-elective (65% vs. 30%) and major/complex cases (60% vs. 28%). Cardiac arrest was most prevalent in orthopaedic trauma (12%), lower gastrointestinal surgery (10%), cardiac surgery (9%), vascular surgery (8%) and interventional cardiology (6%). Specialities with the highest proportion of cases relative to denominator activity were: cardiac surgery (9% vs. 1%); cardiology (8% vs. 1%); and vascular surgery (8% vs. 2%). The most common causes of cardiac arrest were: major haemorrhage (17%); bradyarrhythmia (9%); and cardiac ischaemia (7%). Patient factors were judged a key cause of cardiac arrest in 82% of cases, anaesthesia in 40% and surgery in 35%.

Peri-operative cardiac arrest: management and outcomes of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12-month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri-operative cardiac arrest, the initial rhythm was non-shockable in 723 (82%) cases, most commonly pulseless electrical activity. There were 665 (75%) patients who survived the initial event and 384 (52%) who survived to hospital discharge. A favourable functional outcome (based on modified Rankin Scale score) was reported for 249 (88%) survivors. Outcomes varied according to arrest rhythm. The highest rates of survival were seen for bradycardic cardiac arrests with 111 (86%) patients surviving the initial event and 77 (60%) patients surviving the hospital episode. The lowest survival rates were seen for patients with pulseless electrical activity, with 312 (68%) surviving the initial episode and 156 (34%) surviving to hospital discharge. Survival to hospital discharge was worse in patients at the extremes of age with 76 (40%) patients aged > 75 y and 9 (45%) neonates surviving. Hospital survival was also associated with surgical priority, with 175 (88%) elective patients and 176 (37%) non-elective patients surviving to discharge. Outcomes varied with the cause of cardiac arrest, with lower initial survival rates for pulmonary embolism (5, 31%) and bone cement implantation syndrome (9, 45%), and hospital survival of < 25% for pulmonary embolism (0), septic shock (13, 24%) and significant hyperkalaemia (1, 20%). Overall care was rated good in 464 (53%) cases, and 18 (2%) cases had overall care rated as poor. Poor care elements were present in a further 245 (28%) cases. Care before cardiac arrest was the phase most frequently rated as poor (92, 11%) with elements of poor care identified in another 186 (21%) cases. These results describe the management and outcomes of peri-operative cardiac arrest in UK practice for the first time.

Artificial intelligence for triaging of breast cancer screening mammograms and workload reduction: A meta-analysis of a deep learning software

OBJECTIVE

Deep learning (DL) has shown promising results for improving mammographic breast cancer diagnosis. However, the impact of artificial intelligence (AI) on the breast cancer screening process has not yet been fully elucidated in terms of potential workload reduction. We aim to assess if AI-based triaging of breast cancer screening mammograms could reduce the radiologist's workload with non-inferior sensitivity.

METHODS

PubMed, EMBASE, Cochrane Central, and Web of Science databases were systematically searched for studies that evaluated AI algorithms on computer-aided triage of breast cancer screening mammograms. We extracted data from homogenous studies and performed a proportion meta-analysis with a random-effects model to examine the radiologist's workload reduction (proportion of low-risk mammograms that could be theoretically ruled out from human's assessment) and the software's sensitivity to breast cancer detection.

RESULTS

Thirteen studies were selected for full review, and three studies that used the same commercially available DL algorithm were included in the meta-analysis. In the 156,852 examinations included, the threshold of 7 was identified as optimal. With these parameters, radiologist workload decreased by 68.3% (95%CI 0.655-0.711, I² = 98.76%, p < 0.001), while achieving a sensitivity of 93.1% (95%CI 0.882-0.979, I² = 83.86%, p = 0.002) and a specificity of 68.7% (95% CI 0.684-0.723, I² = 97.5%, p < 0.01).

CONCLUSIONS

The deployment of DL computer-aided triage of breast cancer screening mammograms reduces the radiology workload while maintaining high sensitivity. Although the implementation of AI remains complex and heterogeneous, it is a promising tool to optimize healthcare resources.

Organisation of UK hospitals and anaesthetic departments in the treatment of peri-operative cardiac arrest: an analysis from the 7th National Audit Project (NAP7) local co-ordinator baseline survey

We report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri-operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paediatric anaesthetic care was provided by 188 (95%) and 165 (84%) hospitals, respectively. There was no paediatric intensive care unit on-site in 144 (87%) hospitals caring for children, meaning transfer of critically ill children is required. Remote site anaesthesia is provided in 182 (92%) departments. There was a departmental resuscitation lead in 113 (58%) departments, wellbeing lead in 106 (54%) and departmental staff wellbeing policy in 81 (42%). A defibrillator was present in every operating theatre suite and in all paediatric anaesthesia locations in 193 (99%) and 149 (97%) departments, respectively. Advanced airway equipment was not available in: every theatre suite in 13 (7%) departments; all remote locations in 103 (57%) departments; and all paediatric anaesthesia locations in 23 (15%) departments. Anaesthetic rooms were the default location for induction of anaesthesia in adults and children in 148 (79%) and 121 (79%) departments, respectively. Annual updates in chest compressions and in defibrillation were available in 149 (76%) and 130 (67%) departments, respectively. Following a peri-operative cardiac arrest, debriefing and peer support programmes were available in 154 (79%) and 57 (29%) departments, respectively. While it is likely many UK hospitals are very well prepared to treat anaesthetic emergencies including cardiac arrest, the survey suggests this is not universal.

The 7th National Audit Project (NAP7) baseline survey of individual anaesthetists: preparedness for and experiences of peri-operative cardiac arrest

The Royal College of Anaesthetists' 7th National Audit Project baseline survey assessed knowledge, attitudes, practices and experiences of peri-operative cardiac arrests among UK anaesthetists and Anaesthesia Associates. We received 10,746 responses, representing a 71% response rate. In-date training in adult and paediatric advanced life support was reported by 9646 (90%) and 7125 (66%) anaesthetists, respectively. There were 8994 (84%) respondents who were confident in leading a peri-operative cardiac arrest, with males more confident than females, but only 5985 (56%) were confident in leading a debrief and 7340 (68%) communicating with next of kin. In the previous two years, 4806 (46%) respondents had managed at least one peri-operative cardiac arrest, of which 321 (7%) and 189 (4%) of these events involved a child or an obstetric patient, respectively. Respondents estimated the most common causes of peri-operative cardiac arrest to be hypovolaemia, hypoxaemia and cardiac ischaemia, with haemorrhage coming fifth. However, the most common reported causes for the most recently attended peri-operative cardiac arrest were haemorrhage; (927, 20%); anaphylaxis (474, 10%); and cardiac ischaemia (397, 9%). Operating lists or shifts were paused or stopped after 1330 (39%) cardiac arrests and 1693 (38%) respondents attended a debrief, with 'hot' debriefs most common. Informal wellbeing support was relatively common (2458, 56%) and formal support was uncommon (472, 11%). An impact on future care delivery was reported by 196 (4%) anaesthetists, most commonly a negative psychological impact. Management of a peri-operative cardiac arrest during their career was reported by 8654 (85%) respondents. The overall impact on professional life was more often judged positive (2630, 30%) than negative (1961, 23%), but impact on personal life was more often negative.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Case Report: Resolution of high grade anal squamous intraepithelial lesion with antibiotics proposes a new role for syphilitic infection in potentiation of HPV-associated ASCC

Introduction

Human Papillomavirus (HPV) is the primary risk factor for the development of anal intraepithelial neoplasia (AIN) and is a leading risk factor for anogenital squamous cell carcinoma (ASCC). Despite common shared risk factors for both HPV and syphilis, co-infection is not well documented, and the role of syphilitic infection in HPV-associated AIN and ASCC potentiation is not defined.

Case description/methods

A 72-year-old single male presented with complaints of mild rectal pain and intermittent rectal bleeding. A flexible sigmoidoscopy was performed, and a firm 4.5cm x 3cm perianal mass was detected and superficially biopsied. Pathology findings demonstrated evidence of a high grade squamous intraepithelial lesion (HGSIL, AIN II/III/AIS) with viral cytopathic effect, consistent with HPV infection. Much of the biopsied lesion showed acanthotic squamous mucosa with intraepithelial neutrophils and abundant submucosal plasma cells, suggesting possible syphilitic involvement. Subsequent immunohistochemical staining for p16 as a surrogate marker for HPV was positive, as was an immunohistochemical stain for spirochetes, supportive of co-infection with Treponema pallidum pallidum (T. pallidum), the causative agent in venereal syphilis. The patient was referred to an infectious disease specialist for syphilitic infection and was treated with penicillin with surprisingly complete resolution of the lesion. EUAs were performed 2- and 3-months following treatment without lesion recurrence. However, one year following diagnosis, a flexible sigmoidoscopy revealed a 5 mm recurrent HPV-related low-grade AIN 1 lesion at the dentate line.

Discussion

Resolution of the lesion by antibiotic treatment for syphilitic infection suggested that co-infection by T. pallidum may potentiate HPV-associated squamous cell carcinoma based on histological findings. Findings from this case, as well as a review of bacterial involvement and potentiation in various cancers, are reviewed here. Such findings offer new insight regarding the role of STI-associated bacteria and HPV co-infection in the establishment of AIN and may additionally propose new treatment modalities for ASCC.

Natural killer cells have an activated profile in early Parkinson's disease

Immune dysregulation is heavily implicated in Parkinson's disease (PD) but the role of Natural Killer (NK) cells has not been well characterised. Accumulating evidence indicates the immune response peaks early in the disease, hence this study focused on characterising NK cells in recently diagnosed PD. PBMCs were obtained from PD cases (< 2 years duration) and age-matched controls and immunophenotyped using flow cytometry. We found an increased proportion and number of NK cells (CD3-CD56+), mature cytotoxic NK cells (CD3-CD16 + CD56dim), and NK cells expressing the activation marker, NKG2D. This implies NK cells are activated in the earliest stages of PD.

Neurological update: non-motor symptoms in atypical parkinsonian syndromes

Among people with Parkinson's disease (PD), non-motor symptoms (NMS) are a well-recognised cause of significant morbidity and poor quality of life. Yet, it is only more recently that NMS have been recognised to affect the lives of patients with atypical parkinsonian syndromes in a similar fashion. The aim of this article is to highlight and compare the relative prevalence of NMS among patients with atypical parkinsonian syndromes in the published literature, which largely remain underreported and unaddressed in routine clinical practice. All NMS that are recognised to occur in PD are also found to commonly occur in atypical parkinsonian syndromes. In particular, excessive daytime sleepiness is more prevalent among atypical parkinsonian syndromes (94.3%) compared to PD (33.9%) or normal controls (10.5%) (p < 0.001). Urinary dysfunction (not limited to urinary incontinence) is not only found to occur in MSA (79.7%) and PD (79.9%), but has also been reported in nearly half of the patients with PSP (49.3%), DLB (42%) and CBD (53.8%) (p < 0.001). Apathy is significantly more common among the atypical parkinsonian syndromes [PSP (56%), MSA (48%), DLB (44%), CBD (43%)] compared to PD (35%) (p = 0.029). Early recognition and addressing of NMS among atypical parkinsonian syndromes may help improve the holistic patient care provided and may encompass a range of conservative and pharmacotherapeutic treatments to address these symptoms.

How to Recognize and Correct Artifacts on Contrast-Enhanced Mammography

Contrast-enhanced mammography (CEM) has emerged as an important new technology in breast imaging. It can demonstrate a number of imaging artifacts that have the potential to limit interpretation by either obscuring or potentially mimicking disease. Commonly encountered artifacts on CEM include patient motion artifacts (ripple and misregistration), pectoral highlighting artifact, breast implant artifact, halo artifact, corrugation artifact, cloudy fat artifact, contrast artifacts (retention and contamination), skin artifacts (skin line enhancement and skin overexposure), and skin lesions. Skin lesions may demonstrate a variety of imaging appearances and have both benign and malignant etiologies. It is important that the technologist, radiologist, and physicist be aware of potential artifacts and skin enhancement on CEM that may affect interpretation and understand their causes and potential solutions.

Abstract 6666: Multispectral imaging to detect immune phenotypes in pre and post therapy breast cancer patient specimens

The immune microenvironment is an important component in cancer therapy. Immune cells can encourage tumor growth, leading to disease progression. A high number of immune cells may be predictive of disease prognosis and response to therapies. Therefore, understanding the immune cell phenotypes present within cancerous tissue can be valuable in developing strategies that aid in the treatment of cancer. In this study, we analyzed pre-and post-therapy samples from breast cancer patients, treated with neoadjuvant chemotherapy, using a 6-plex immunofluorescence assay which included clinically relevant immuno-oncology biomarkers (FoxP3, PD-L1, PanCK, CD4, CD8 and CD163). This assay was developed and optimized in-house prior to testing the cohort. Endpoints for this analysis were characterization of the tumor microenvironment and analysis of the individual immune cell subsets pre and post treatment. Staining was completed on the Leica Bond RX autostainer (Leica Biosystems) and slides were scanned using the PhenoImager™ Fusion (Akoya Biosciences). Using Visiopharm® software, the multiplex phenotyping module was used to analyze the high dimensional human tissue and cell phenotypes were detected using artificial intelligence. Qualitative and quantitative results revealed a change in immune cell phenotypes between pre- and post-therapy samples. These included an increase in intra-tumoral and stromal T cells, no significant difference in PD-L1 positive cells, and an increase in the FOXP3 positive T cells in post-treatment samples. Our data provides insights into the development and application of multispectral imaging for characterization of tumor microenvironment and its dynamics before and after treatment in breast cancer. This can be applied to other cancer types and can aid in making treatment decisions.

Citation Format: Bhavika Patel, Stephanie Allen, Brenna Dennison, Jacob Stapleton, Roni Archuleta, Mary Lou Rath, Navi Mehra, Sameer S. Talwalkar. Multispectral imaging to detect immune phenotypes in pre and post therapy breast cancer patient specimens [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6666.

MRI phenotypes associated with breast cancer predisposing genetic variants, a multisite review

PURPOSE

Examine MRI phenotypes of breast cancers arising in patients with various pathogenic variants, to assess for imaging trends and associations.

METHOD

Multisite retrospective review evaluated 410 patients from 2001 to 2020 with breast cancer and a predisposing pathogenic variant who underwent breast MRI at time of cancer diagnosis. Dominant malignant lesion features were reported, including lesion type (mass versus non-mass enhancement), size, shape, margin, internal enhancement pattern, plus other features. Kruskal-Wallis test, Fisher's exact test, and pairwise comparisons performed comparing imaging manifestations for the most frequent genetic results.

RESULTS

BRCA1 (29.5 %) and BRCA2 (25.9 %) variants were most common, followed by CHEK2 (16.6 %), ATM (8.0 %), and PALB2 (6.3 %), with significant associated differences in race/ethnicity (p = 0.040), age at cancer diagnosis (p = 0.005), tumor shapes (p = 0.001), margins (p < 0.001), grade (p < 0.001), internal enhancement pattern (rim enhancement) (p < 0.001), kinetics (washout) (p < 0.001), and presence of necrosis (p < 0.001). CHEK2 and ATM tumors were often lower grade with spiculated margins (CHEK2: 47.1 %, ATM: 45.5 %), rarely exhibiting washout or tumor necrosis (p < 0.001), and were mostly comprised of luminal molecular subtypes (CHEK2: 88.2 %, ATM: 90.9 %). BRCA1 tumors had the highest proportions with round shape (31.4 %), circumscribed margins (24.0 %), rim enhancement (24.0 %), washout (58.7 %), and necrosis (19.8 %), with 47.9 % comprised of triple negative subtype. Bilateral mastectomy was performed in higher proportions of patients with BRCA1 (84.3 %) and BRCA2 (75.5 %) variants compared to others.

CONCLUSIONS

Genetic and molecular profiles of breast cancers demonstrate reproducible MRI phenotypes.

Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey

Detailed contemporary knowledge of the characteristics of the surgical population, national anaesthetic workload, anaesthetic techniques and behaviours are essential to monitor productivity, inform policy and direct research themes. Every 3-4 years, the Royal College of Anaesthetists, as part of its National Audit Projects (NAP), performs a snapshot activity survey in all UK hospitals delivering anaesthesia, collecting patient-level encounter data from all cases under the care of an anaesthetist. During November 2021, as part of NAP7, anaesthetists recorded details of all cases undertaken over 4 days at their site through an online survey capturing anonymous patient characteristics and anaesthetic details. Of 416 hospital sites invited to participate, 352 (85%) completed the activity survey. From these, 24,177 reports were returned, of which 24,172 (99%) were included in the final dataset. The work patterns by day of the week, time of day and surgical specialty were similar to previous NAP activity surveys. However, in non-obstetric patients, between NAP5 (2013) and NAP7 (2021) activity surveys, the estimated median age of patients increased by 2.3 years from median (IQR) of 50.5 (28.4-69.1) to 52.8 (32.1-69.2) years. The median (IQR) BMI increased from 24.9 (21.5-29.5) to 26.7 (22.3-31.7) kg.m^-2 . The proportion of patients who scored as ASA physical status 1 decreased from 37% in NAP5 to 24% in NAP7. The use of total intravenous anaesthesia increased from 8% of general anaesthesia cases to 26% between NAP5 and NAP7. Some changes may reflect the impact of the COVID-19 pandemic on the anaesthetic population, though patients with confirmed COVID-19 accounted for only 149 (1%) cases. These data show a rising burden of age, obesity and comorbidity in patients requiring anaesthesia care, likely to impact UK peri-operative services significantly.

A one-stop shoulder clinic to save time and resources

There is now a need more than ever to streamline services. A one-stop shoulder clinic was introduced during the COVID-19 pandemic. A total of 861 patients were seen, saving 794 future appointments. 111 patients had an ultrasound scan and 285 patients had an ultrasound-guided procedure, saving an average waiting time of 134 days. 327 patients had physiotherapy, and the average Oxford Shoulder Score improved by 8.56 at 1 year.

Methods of the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists: peri-operative cardiac arrest

Cardiac arrest in the peri-operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri-operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, and anaesthetists may not be involved in such cases for years. Therefore, a large-scale prospective cohort is needed to gain a deep understanding of events leading up to cardiac arrest, management of the arrest itself and patient outcomes. Consequently, the Royal College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents' prior peri-operative cardiac arrest experience, resuscitation training and local departmental preparedness. Second, an activity survey to record anonymised details of all anaesthetic activity in each site over 4 days, enabling national estimates of annual anaesthetic activity, complexity and complication rates. Third, a case registry of all instances of peri-operative cardiac arrest in the UK, reported confidentially and anonymously, over 1 year starting 16 June 2021, followed by expert review using a structured process to minimise bias. The definition of peri-operative cardiac arrest was the delivery of five or more chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist. The peri-operative period began with the World Health Organization 'sign-in' checklist or first hands-on contact with the patient and ended either 24 h after the patient handover (e.g. to the recovery room or intensive care unit) or at discharge if this occured earlier than 24 h. These components described the epidemiology of peri-operative cardiac arrest in the UK and provide a basis for developing guidelines and interventional studies.

The value of disease-free survival (DFS) and osimertinib in adjuvant non-small-cell lung cancer (NSCLC): an international Delphi consensus report

Background

Rates of disease recurrence and death following surgery remain high in early-stage non-small-cell lung cancer (NSCLC), despite adjuvant treatment and curative intent. Recently, osimertinib showed overwhelming evidence for disease-free survival (DFS), as demonstrated by an overall reduction in the risk of disease recurrence or death in the adjuvant setting of 80% versus control in the ADAURA study (stage IB-IIIA; hazard ratio 0.20; 99.12% confidence interval 0.14-0.30; P < 0.001). However, due to the early unblinding of ADAURA and lack of mature overall survival data, there is a need to qualitatively confirm consensus on the clinical and patient relevance of DFS.

Materials and methods

We conducted a modified Delphi panel study consisting of two rounds of surveys, followed by a consensus meeting. An international panel of experts in the field of NSCLC and epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) (n = 13) was asked to rate agreement and comment on a list of pre-defined statements covering key consensus gaps. Statements were eliminated or updated between surveys, depending on the level of agreement. A final list of agreed-upon statements was drafted in the consensus meeting.

Results

Consensus was reached on 32 qualitative statements, with topics including unmet needs in early-stage NSCLC, the value of DFS, and the value of osimertinib. Crucially, DFS was agreed to be a clinically and patient-relevant endpoint in adjuvant NSCLC. The relevance of DFS was found to relate to the ability of an adjuvant therapy, such as osimertinib, to keep patients in the clinically valuable curative intent setting, while preventing the burden associated with distant and locoregional recurrence, and progressive disease.

Conclusions

Addressing the need for measures that reflect clinical benefit is essential to continue improving outcomes for NSCLC patients. To that end, this work provides a qualitative framework for clinicians to consider the clinical and patient relevance of DFS in adjuvant NSCLC and the benefit demonstrated in ADAURA thus far.

•

There is a need for qualitative consensus assessment of the clinical and patient relevance of DFS in the adjuvant setting.

•

An international panel of experts viewed DFS as a clinically and patient-relevant endpoint in adjuvant NSCLC.

•

DFS relevance in adjuvant therapy, e.g. osimertinib, relates to keeping early-stage patients in a curative intent setting.

•

Curative intent prevents or significantly delays locoregional and distant (CNS) recurrence burden and progressive disease.

409 Evaluation of Advanced Bimanual Skills in Novices Using the Wrist-Like FlexDex™ Articulating Laparoscopic Needle Holder in 2D and 3D Vision: A Randomised Trial

Aim

The aim of this study was to evaluate the novice performance of advanced bimanual laparoscopic skills using the articulating FlexDex™ laparoscopic needle holder in two-dimensional (2D) and three-dimensional (3D) visual systems.

Method

In this prospective randomised trial, novices (n=40) without laparoscopic experience were recruited from a university cohort and randomised into two groups, which used the FlexDex™ and 2D or the FlexDex™ and 3D. Both groups performed 10 repetitions of a validated assessment task. Times taken and error rates were measured, and assessments were made based on completion times, error rates and learning curves.

Results

The intervention group that used FlexDex™ and 3D visual output completed 10 attempts of the standardised laparoscopic task quicker than the control group that used FlexDex™ with standard 2D visual output (268 seconds vs 415 seconds taken for the first three attempts and 176 seconds vs 283 seconds taken for the last three attempts, respectively). Moreover, each attempt was completed faster by the intervention group compared to the control group. The difference in average time for the first three and last three attempts reached statistical significance (P &lt; 0.001).

Conclusion

Combination of 3D visual systems and the FlexDex™ laparoscopic needle holder resulted in superior task performance speed, leading to shorter completion times and quicker learning effect. Although the 3D group demonstrated lower mean error rates, it did not reach statistical significance.

84 An Analysis into the Prevalence of Work-Related Musculoskeletal Disorders Affecting Surgeons: A Systematic Review

Aim

This review sought to answer 3 primary questions- (1) What is the global career prevalence rate of work-related musculoskeletal disorders (WRMSDs) among the surgeon population? (2) What is the prevalence rate of WRMSDs between surgical specialties? and (3) Which anatomical locations are most affected in surgeons with WRMSDs?

Method

A qualitative systematic review of publications was conducted across 4 medical indices, 3 clinical trial registries, and 2 specialised search engines for relevant records published from inception until the 31st of December 2020. The JBI checklist and ROBINS-I tool were used for quality and risk assessment among included studies.

Results

In total, 56 articles met the inclusion criteria set for this review. This gave a pooled total of 13,628 surgeons. From this population, the calculated career prevalence rate of WRMSDs was found to be 71.1%, and the specialties with the highest incidences of WRMSDs were- Dermatology surgery (90.1%), Obstetrics and Gynaecology surgery (81.4%), and Vascular surgery (80.0%). When analysing body regions most frequently affected by WRMSDs, 91.3% of injuries were reported above the waist. More specifically, the most frequently reported injuries were to the back (30.4%), neck (26.2%), and shoulders (16.0%).

Conclusions

Overall, this review found high career prevalence rates of WRMSDs across all analysed surgical specialties. Furthermore, these injuries were most frequently reported in the upper limb and torso of the surgeon. With these findings, it is hoped future interventional studies would aim to target specific ergonomic deficits in specialties at high risk of developing WRMSDs.

Geographic Variations in Growth of Radiologists and Medicare Enrollees From 2012 to 2019

OBJECTIVE

Analyze changes in the number of Medicare-serving radiologists and Medicare enrollees nationwide and by geographic region and state from 2012 to 2019 to understand variations in allocation of imaging health care services over the past decade.

METHODS

The number of radiologists submitting claims to Medicare was extracted from the CMS Physician and Other Supplier Public Use File Database. The number of Medicare enrollees by state was obtained from the Kaiser Family Foundation. National-, regional-, and state-level changes in rates of growth of radiologists, Medicare enrollees, and radiologists per 100,000 Medicare enrollees from 2012 to 2019 were tabulated.

RESULTS

The overall number of radiologists per 100,000 Medicare enrollees was 79.7 in 2012, increasing to 79.9 in 2019. In 2012, the number of radiologists per 100,000 enrollees was lower than the national average in the South (66.9; 16% lower) and Midwest (79.1; 0.7% lower) and higher in the Northeast (98.3; 23% higher) and West (88.8; 11% higher). In 2019, the number of radiologists per 100,000 enrollees was lower than the national average in the South (69.8; 12% lower) only and was higher in the Midwest (81.4; 1.9% higher), Northeast (99.3; 24% higher), and West (80.2; 0.4% higher). By state, there was a 4.2-fold variation in the number of radiologists per 100,000 Medicare enrollees, ranging from 38.8 in Wyoming to 161.4 in Minnesota (200.5 in Washington, DC).

DISCUSSION

The growth of Medicare-serving radiologists and Medicare enrollees was stable nationally and demonstrated tremendous variations by US region and state. These variations bring to light potential implications for patient access to care and distribution of health care resources.

EP-235 Improving working conditions of junior surgeons

Aims

Significant exception reporting is reflective of difficult working conditions though well-recognised barriers exist to reporting which may reflect the culture within a unit. This study used exception reporting data to understand and improve the working conditions of juniors.

Methods

Junior surgeons were surveyed in December 2019 to evaluate additional hours worked, reasons for this work and whether exception reports were completed; where they were not, doctors were asked why.

After data analysis, rota structures and surgical teams were changed and formal education about exception reporting given at departmental induction. The main changes involved greater opportunities to take leave and enhanced staffing on evenings and weekends.

Surgical juniors were re-surveyed in September 2021.

Results

In December 2019, 49.2 additional hours were worked between 18 juniors. No exception reports were completed with the main reasons being a personal decision to stay late (for training opportunities), lack of understanding on how to report and cultural issues that made juniors unsure about how exception reports would be viewed.

In September 2021, only 30 additional hours were worked between 17 respondents. Again, no exception reports were completed with over 95% of respondents citing a personal decision to stay late. Cultural issues within the department were no longer cited and knowledge of how to exception report was greatly increased.

Conclusions

A positive and open culture, where consultants and surgical leaders engage with juniors about rotas and working conditions can lead to a reduction in additional hours and improve the understanding of exception reporting.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

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.

Abstract 2768: Whole-slide multispectral imaging reveals the immune subtypes of melanoma associated with the tumor microenvironment

Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the advancement of treatments to enhance a patient’s immune system. Akoya’s MOTiF™ PD-1/PD-L1 Auto Melanoma Kit is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial biomarkers: FoxP3, PD-L1, Sox10/S100, PD-1, CD8 and CD68. In this study, the MOTiF™ PD-1/PD-L1 panel was used to analyze the tumor microenvironment and specifically assess immune phenotypes within melanoma samples from 3 patients. This study demonstrates a fully optimized and end-to-end workflow solution for biomarker discovery in melanoma. We demonstrate the utility of Akoya’s MOTiF™ PD-1/PD-L1 Melanoma panel kit in studying the cellular diversity while retaining spatial context. Stained slides were analyzed using the InForm® and PhenoptrReports image analysis platforms to identify phenotypes and better understand spatial relationships between cell phenotypes. The MOTiF™ PD-1/PD-L1 panel kit provides reproducibility across different patient samples. This data provides insight into the innate and adaptive immune landscape for targeted design of new immunotherapies as well as improved efficacy and reduced toxicity in the treatment of melanoma.

Citation Format: Bhavika Patel, Stephanie Allen, Brittney Boldt, Najiba Mammadova, Agnes Haggerty, Navi Mehra. Whole-slide multispectral imaging reveals the immune subtypes of melanoma associated with the tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2768.

Abstract 4144: An AI-based, automated workflow for identification and scoring of invasive tumors in Ki-67 stained breast cancer specimens

Understanding the rate of tumor cell growth in breast cancer specimens may be indicative of disease aggressiveness, a tumor characteristic which can be used to make an informed treatment decision. The nuclear protein Ki-67 is increased in cells as they prepare to divide or proliferate and is therefore widely used as a proliferation marker for tumor progression. This degree of tumor cell proliferation, or the proliferative index, is commonly detailed in pathology reports shared with the patient care team. In this study, we utilized the Ki-67 [K2] immunohistochemistry (IHC) assay to stain 10 breast cancer specimens. Stained slides were imaged using the AT2 scanner (Leica Biosystems, Buffalo Grove, IL) and analyzed using the Visiopharm Image Analysis platform. Previous efforts to assess Ki-67 positivity utilizing image analysis have relied on the use of a secondary stain or manual effort by the pathologist to exclude non-invasive tumor regions. These antiquated methods are costly to the lab as they require additional materials or valuable pathologist time. Our novel image analysis approach utilizes artificial intelligence (AI) to automatically denote non-invasive verses invasive tumor regions, which can then be used to quantify the Ki-67 proliferative index. This valuable tool will allow for greater accuracy, cost-savings, and time efficiency when analyzing breast cancer samples compared to traditional methods.

Citation Format: Bhavika Patel, Stephanie Allen, Sameer Talwalkar, Navi Mehra, Jeppe Thagaard, Thomas W. Ramsing, Agnete Overgaard, Jenifer Caldara. An AI-based, automated workflow for identification and scoring of invasive tumors in Ki-67 stained breast cancer specimens [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4144.

Abstract 2769: Advance understanding of the tumor microenvironment with multiplex immunofluorescence

Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the advancement of treatments to enhance a patient’s immune system. Akoya’s MOTiF™ PD-1/PD-L1 Panel is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial biomarkers: PD-1, PD-L1, FoxP3, CD8, CD68, and PanCK. The MOTiF™ PD-1/PD-L1 Panel was used to analyze the tumor microenvironment and specifically assess immune phenotypes of different types of cancers: non-small cell lung cancer (NSCLC), colon adenocarcinoma, head and neck squamous cell carcinoma (HNSCC), and breast cancer. We demonstrate the utility of Akoya’s MOTiF™ PD-1/PD-L1 panel kit in studying the cellular diversity of various cancers while retaining spatial context. Stained slides were analyzed using the InForm® and PhenoptrReports image analysis platforms to identify and better understand spatial relationships between a variety of simple and complex cell phenotypes. The MOTiF™ PD-1/PD-L1 panel kit provides reproducibility across different tissue types. These data provide insight into the innate and adaptive immune environment for targeted design of new immunotherapies and have implications for improving the treatment paradigm across many tumor types.

Citation Format: Bhavika Patel, Stephanie Allen, Brittney Boldt, Najiba Mammadova, Agnes Haggerty, Navi Mehra. Advance understanding of the tumor microenvironment with multiplex immunofluorescence [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2769.

The utilization of artificial intelligence to produce clinically relevant scores on PD-L1 immunostained non-small cell lung cancer biopsies

e14576

Background: Immunotherapies targeting complex programmed death-ligand 1 (PD-L1) interactions have been groundbreaking in the treatment of non-small cell lung cancer (NSCLC), offering new strategies for patients who are likely to respond. PD-L1 binds to the checkpoint PD-1 to regulate T cells, which has an important role in boosting the immune response. Identifying patients who may benefit from PD-L1 focused care is dependent on the interpretation of the drug’s associated companion diagnostic (CDx) immunohistochemistry (IHC) assay. PD-L1 IHC assays stratify NSCLC patients using a Tumor Proportion Score (TPS), a manual scoring paradigm which must be applied by a clinical pathologist. Application of the score is complex as it requires the reader to visually exclude stromal and tumor-infiltrating immune cells across a full sample, retaining PD-L1 expression information for true tumor cells only. Methods: In this study, we utilized the PD-L1 [28-8] immunohistochemistry (IHC) assay to stain 10 NCSLC specimens. Stained slides were then imaged using the AT2 scanner (Leica Biosystems, Buffalo Grove, IL) scanner and analyzed using the Visiopharm Image Analysis platform. Results: The intricacy of TPS application is time consuming for the pathologist and introduces opportunity for inter- and intra-reader variability. Our novel image analysis approach utilizes artificial intelligence (AI) to automatically denote tumor nests and exclude tumor-infiltrating immune cells. The remaining true tumor cells may then be quantified for PD-L1 expression across the full biopsy, producing a TPS for each sample. Conclusions: This method allows for great accuracy and time-efficiency in providing a TPS than traditional methods, which may result in improved patient care.

An AI-based, automated workflow for identification and scoring of invasive tumors in Ki-67 stained breast cancer specimens

e15108

Background: Understanding the rate of tumor cell growth in breast cancer specimens may be indicative of disease aggressiveness, a tumor characteristic which can be used to make an informed treatment decision. The nuclear protein Ki-67 is increased in cells as they prepare to divide or proliferate and is therefore widely used as a proliferation marker for tumor progression. This degree of tumor cell proliferation, or the proliferative index, is commonly detailed in pathology reports shared with the patient care team. Methods: In this study, we utilized the Ki-67 [K2] immunohistochemistry (IHC) assay to stain 10 breast cancer specimens. Stained slides were imaged using the AT2 scanner (Leica Biosystems, Buffalo Grove, IL) and analyzed using the Visiopharm Image Analysis platform. Results: Previous efforts to assess Ki-67 positivity utilizing image analysis have relied on the use of a secondary stain or manual effort by the pathologist to exclude non-invasive tumor regions. These antiquated methods are costly to the lab as they require additional materials or valuable pathologist time. Our novel image analysis approach utilizes artificial intelligence (AI) to automatically denote non-invasive verses invasive tumor regions, which can then be used to quantify the Ki-67 proliferative index. Conclusions: This valuable tool will allow for greater accuracy, cost-savings, and time efficiency when analyzing breast cancer samples compared to traditional methods.

Whole-slide multispectral imaging reveals the immune subtypes of melanoma associated with the tumor microenvironment: An automated 7-color mIF assay

e21591

Background: Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the advancement of treatments to enhance a patient’s immune system. Akoya’s MOTiF PD-1/PD-L1 Auto Melanoma Kit is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial biomarkers: FoxP3, PD-L1, Sox10/S100, PD-1, CD8 and CD68. Methods: In this study, the MOTiF PD-1/PD-L1 panel was used to analyze the tumor microenvironment and specifically assess immune phenotypes within melanoma samples from 3 patients. This study demonstrates a fully optimized and end-to-end workflow solution for biomarker discovery in melanoma. Results: We demonstrate the utility of Akoya’s MOTiF PD-1/PD-L1 Melanoma panel kit in studying the cellular diversity while retaining spatial context. Stained slides were analyzed using the InForm and Phenoptr Reports image analysis platforms to identify phenotypes and better understand spatial relationships between cell phenotypes. The MOTiF PD-1/PD-L1 panel kit provides reproducibility across different patient samples. Conclusions: This data provides insight into the innate and adaptive immune landscape for targeted design of new immunotherapies as well as improved efficacy and reduced toxicity in the treatment of melanoma.

Multispectral imaging to detect immune phenotypes associated with the tumor microenvironment in a multi-tissue study: A full automated 7-color mIF immuno-oncology workflow

Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the advancement of treatments to enhance a patient’s immune system. Akoya’s MOTiF™ PD-1/PD-L1 Panel is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial biomarkers: PD-1, PD-L1, FoxP3, CD8, CD68, and PanCK. The MOTiF™ PD-1/PD-L1 Panel was used to analyze the tumor microenvironment and specifically assess immune phenotypes of different types of cancers: non-small cell lung cancer (NSCLC), colon adenocarcinoma, head and neck squamous cell carcinoma (HNSCC), and breast cancer. We demonstrate the utility of Akoya’s MOTiF™ PD-1/PD-L1 panel kit in studying the cellular diversity of various cancers while retaining spatial context. Stained slides were analyzed using the InForm® and PhenoptrReports image analysis platforms to identify and better understand spatial relationships between a variety of simple and complex cell phenotypes. The MOTiF™ PD-1/PD-L1 panel kit provides reproducibility across different tissue types. These data provide insight into the innate and adaptive immune environment for targeted design of new immunotherapies and have implications for improving the treatment paradigm across many tumor types.

Whole-slide multispectral imaging reveals the immune subtypes of melanoma associated with the tumor microenvironment: An automated 7-color mIF assay

Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the advancement of treatments to enhance a patient’s immune system. Akoya’s MOTiF™ PD-1/PD-L1 Auto Melanoma Kit is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial biomarkers: FoxP3, PD-L1, Sox10/S100, PD-1, CD8 and CD68. In this study, the MOTiF™ PD-1/PD-L1 panel was used to analyze the tumor microenvironment and specifically assess immune phenotypes within melanoma samples from 3 patients. This study demonstrates a fully optimized and end-to-end workflow solution for biomarker discovery in melanoma. We demonstrate the utility of Akoya’s MOTiF™ PD-1/PD-L1 Melanoma panel kit in studying the cellular diversity while retaining spatial context. Stained slides were analyzed using the InForm® and PhenoptrReports image analysis platforms to identify phenotypes and better understand spatial relationships between cell phenotypes. The MOTiF™ PD-1/PD-L1 panel kit provides reproducibility across different patient samples. This data provides insight into the innate and adaptive immune landscape for targeted design of new immunotherapies as well as improved efficacy and reduced toxicity in the treatment of melanoma.

Patient perceptions of clinical pharmacists in general practice

Introduction

As a result of changes in the demands and pressures on the NHS, the role of the pharmacist has advanced from purely dispensing and compounding medicines to a more clinical and patient-centred approach to care (1). Since 2015, NHS England set a target of recruiting practice-based pharmacists into 20% of practices by 2020-2021 as a way of reducing these pressures (2). Conducting evaluations of clinical pharmacists in individual practices is essential for role integration and evolution.

Aim

To explore patient perceptions of clinical pharmacists across three general practices.

Methods

A paper-based questionnaire consisting of open and closed questions was used to gather patient perceptions on the role of a clinical pharmacist and their consultation experiences. Participants included patients over the age of 18 who had attended a face-to-face appointment with a clinical pharmacist from one of three general practice surgeries in England between November and December 2019. The clinical pharmacists were used as a gateway to recruit participants; post-consultation, the pharmacist asked patients if they would complete a questionnaire. Patients were provided with an information sheet and consent form prior to completion of the questionnaire. The questionnaire was anonymous. Data were analysed using descriptive statistics and content analysis.

Results

A total of 39 participants completed the questionnaire. Most participants were elderly (28%) and female (64%). The primary reason for the consultations was due to an acute illness (79%), and the most common outcome was the supply of a prescription (83%). Patients were predominantly unfamiliar with the role of a clinical pharmacist (56%) and 31% of patients reportedly thought their appointment had been with a doctor. All patients were positive about their experience and reported they would “be more than happy to see a pharmacist in the future” and that the role was “a very necessary addition to the practice”. All patients reported that their consultation was the same (51%) or better than they have had with a doctor (49%). Patients commented on the pharmacists’ consultation skills, making statements such as [they] “listened to me”, “asked me questions”, “were really good at explaining” and “spoke in a way I understood”. Clinical pharmacists were reported as being “very professional” and knowledgeable as “[they] knew more about my medication [than the doctor] and prescribed me something to help”. Patients reported that they would recommend the clinical pharmacist to their family and friends when seeking an appointment.

Conclusion

This research highlights patient acceptance towards consultations with a clinical pharmacist and reinforces the competence of pharmacists to undertake this role. A key finding related to the effective consultation skills of the pharmacists and involving the patients in their care. The number of patients who participated limits the generalisability of the findings, and the patient responses may have been a reaction to the individual clinical pharmacists rather than their thoughts on the role overall. Increased publicity and patient education of the role of a clinical pharmacist may promote a greater integration into the multidisciplinary team.

References

(1) Robertson R, Wenzel L, Thompson J, Charles A. Understanding NHS financial pressures. How are they affecting patient care. 2017. The Kings Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding%20NHS%20financial%20pressures%20-%20full%20report.pdf

(2) NHS England 2016. General Practice Forward View. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

Urological issues in cyclists

Cycle use has grown rapidly over the last few years in the UK. British Cycling membership has increased threefold since the 2012 Olympic and Paralympic Games, and this is likely to rise in the wake of the Coronavirus pandemic. As urologists, day-to-day encounters with cyclists are commonplace, who may present with acute traumatic injuries or chronic overuse injuries. The aim of this literature review was to evaluate the effect of cycling on conditions presenting to the urology clinic, in particular those of raised prostate-specific antigen (PSA), haematuria and soft-tissue lesions (‘cyclist nodules’). Furthermore, the review aimed to summarize the relationship between cycling and pudendal nerve entrapment (PNE) syndromes. A PubMed search of the literature on cycling and genitourinary disorders was performed. The literature suggests no significant change in PSA levels after a bout of cycling. Age appears to have no effect on the change in PSA experienced following a bout of cycling, in particular when comparing those <50 years of age to those >50 years of age. Haematuria appears to be rare with cycling but has been described, even with stationary bike riding. It is imperative to exclude coexisting urinary-tract pathological conditions, and cycling-induced haematuria should always be considered a diagnosis of exclusion. Perineal nodular induration (‘cyclist nodules’) is a rare condition, related to pressure and repetitive micro-trauma between the perineum and saddle. Pudendal Nerve Entrapment (PNE) represents the most common bicycling-associated urogenital complaint. Numbness in the perineum, penis, scrotum or buttocks—‘genital numbness’—is the most common and most recognized symptom of pudendal compression. Despite several studies demonstrating a link between elite cyclists and erectile dysfunction, for the average cyclist riding may actually have a protective effect on sexual function.

1 Mobile Health Apps in Burns: Where Is the Quality Control?

Aim

High quality mobile health applications (mhealth apps) have the potential to enhance the prevention, diagnosis, and treatment of burns. The primary aim of this study was to evaluate whether the quality of mhealth apps for burns care is being adequately assessed. The secondary aim was to determine whether these apps meet UK regulatory standards.

Method

We searched AMED, BNI, CINAHL, Cochrane library, Embase, Emcare, Medline and PsychInfo to identify studies assessing mhealth app quality for burns. The PRISMA reporting guideline was adhered to. Two independent reviewers screened s to identify relevant studies. We analysed whether seven established domains of mhealth app quality were assessed: design, information/content, usability, functionality, ethical issues, security/privacy, and user-perceived value.

Results

Of the 28 included studies, none assessed all seven domains of quality. Design was assessed in 4/28 studies; information/content in 26/28 studies; usability in 12/28 studies; functionality in 10/28 studies; ethical issues were never assessed in any studies; security/privacy was not assessed; subjective assessment was made in 9/28 studies. 17/28 studies included apps that met the definition of ‘medical device’ according to MHRA guidance, yet only one app was appropriately certified with the UK Conformity Assessed (UKCA) mark.

Conclusions

The quality of mHealth apps for burns are not being adequately assessed. The majority of apps should be considered medical devices according to UK standards, but only one was appropriately certified. Regulatory bodies should support mhealth app developers, so as to improve quality control whilst simultaneously fostering innovation.

937 Advanced understanding of the tumor microenvironment with multiplex analysis: an automated 7-color multiplex assay using Akoya’s opal technology

Background

Immunotherapy and precision medicine are rapidly developing approaches to cancer therapy. Biomarkers that detect the tumor and tumor microenvironment allow for the development of strategies that accelerate the development of treatments that enhance a patient‘s immune system. Akoya’s MOTiF™ PD-1/PD-L1 Panel is a validated, multiplex immunoassay enabling detection of the 6 most clinically relevant immuno-oncology and spatial markers: PD-1, PD-L1, FoxP3, CD8, CD68, and PanCK. This panel provides unparalleled quantitative data for pre-clinical and translational IO research.

Methods

The MOTiF™ PD-1/PD-L1 Panel was used to stain normal and tumor lung tissues. Stained slides were analyzed using the InForm® and Visiopharm® image analysis platforms.

Results

We introduce the workflow and image analysis solutions using InForm® and Visiopharm® software to provide robust, quantifiable data.

Conclusions

This data provides insight into the innate and adaptive immune environment for targeted design of new immunotherapies. These new targeted immunotherapies could potentially improve efficacy and reduce toxicity.

510 Transitioning to an In-House In-Situ Hybridisation Assay Accelerates Indeterminate HER-2 Lesion Results

Introduction

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

Method

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

Results

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

Conclusions

By setting up an in-house ISH assay, we significantly reduced the delay between biopsy and HER2 status result for patients with borderline HER2 results. HER2 status is now available at the pre-operative MDT meeting to optimise treatment decision making, as recommended by NICE.

860 Distal Radius Fracture Management in A DGH Do the Guidelines Fit?

Aim

Distal radial fractures are common injuries within adults at a variety of ages. The best treatment option remains a debated subject. The BOAST guidelines aim to guide the initial management of these fractures in the emergency department we audited against these guidelines in a local district general hospital.

Method

A retrospective audit was performed of adult patients with distal radius fractures who attended in December 2019, at a local district General Hospital. Patients were identified by using the Orthopaedic Take lists. Notes were reviewed for patient demographics, quality of documentation of neurovascular status, documentation of fracture information, including further management.

Results

There were 16 cases identified, 87.5% were female with mean age of 63 with over 56 % in the over 65s category. Only 19% of cases had appropriately documented neurovascular status. 57% were lacking specific documentation of each nerve as per BOAST guidelines, as well as 57% had no documentation of radial pulse. With regards to reductions undertaken in ED only 44% were documented if reduction took place. Of the reductions that were documented 66% documented type of analgesia used. 17% used regional anaesthesia as preferred in BOAST guidelines.

Conclusions

Overall compliance with BOAST guidelines was poor. Several areas to improve were seen, for which the recent launch of a new in-house smartphone application is aimed to improve access to BOAST guidelines. There was great difficulty in achieving the BOAST guidance with regards to the use of regional anaesthesia, nationally most A&E departments reduce these fractures under a haematoma block.

145 Mind the App: A Guide for the Orthopaedic Senior House Officer on Call

Aim

Many senior house officers (SHOs) have little experience in Trauma and Orthopaedics. While junior doctors are encouraged to seek help from the registrar during on call shifts, they are also dependent on a variety of guidelines to assist in the management of common orthopaedic presentations to the Emergency Department. The main issue is that site-specific guidance is not readily accessible on a single platform.

Method

Smartphone and web-based applications were designed summarising the initial management for such conditions for the SHO on-call to use as a quick reference tool. The efficacy of this was evaluated with questionnaires specific to the rating of the application and by two closed loop audits of BOAST standards for the management of distal radius and ankle fractures.

Results

Pre-app implementation questionnaire ratings revealed a mediocre confidence levels and high stress during an on-call shift. Post-app implementation questionnaires demonstrated the app was useful. Future use was recommended use for new SHOs. All responders felt that this would improve stress levels on call. Closed-loop audits for BOAST guidelines for ankle and distal radius fracture management were completed. Improvements were evident for obtaining appropriate radiographs ankle fractures (50.0% vs 77.8%) and positions of manipulated distal radius fractures (80% vs 100%).

Conclusions

This application proved a useful reference tool for junior staff to aid and initiate the management of common orthopaedic presentations to the emergency department. This tool could be used to improve confidence and ensure timely management of patients from the take.

534 Use of Ultrasound by Breast Surgeons Reduces the Need for Wire-Guided Localisation Of Impalpable Breast Tumours By Radiologists

Aim

Ultrasound is increasingly being used by non-radiologists in clinical practice. Currently wire-guided localisation (WGL) of impalpable breast tumours requires the expertise of radiologists but can be uncomfortable and demands significant radiology resource. Furthermore, for logistical reasons at our institution during the COVID pandemic, wires were inserted the day before surgery, resulting in disruption to patients. At our institution, two of eight breast surgeons use ultrasound intraoperatively for localisation of breast lesions, thus obviating the need for a radiologist to localise the lesion for the surgeon. We hypothesise that ultrasound-localisation by surgeons is an effective way to improve patient experience.

Method

We undertook a retrospective review of all patients undergoing wire-guided localisation of impalpable breast tumours between 01/05/20-01/08/20. We retrospectively collected the following data: modality of image-guided insertion (ultrasound versus x-ray), operating surgeon and size of tumour.

Results

48 tumours were excised using WGL. 45 of these relied on ultrasound guidance for insertion. The median lesion size was 17mm, with 30 (62.5%) of lumps being ³10mm in size.

Conclusions

Most impalpable lumps were visualised using ultrasound. The majority of these lumps were &gt;10mm. Surgeons trained in ultrasound did not need localisation by radiologists. If breast surgeons were unanimously trained to use ultrasound for intra-operative localisation, a significant proportion of wires could be avoided, saving cost, radiology time, patient time and improving the patient experience. We argue that ultrasound should be a core part of breast trainees’ curriculum.

529 Safeguarding Skin Grafts: A 21st Century Algorithm for Fixation Techniques

Aim

Effective skin graft fixation is fundamental in preventing sheering forces, seroma and haematoma from compromising graft take. However, determining the ideal method of graft fixation remains a contentious subject. Currently, there is significant variation in fixation techniques used, based not only on clinical requirement, but also surgeon preference. Evidence-based recommendations are necessary to guide the decision-making process.

Method

We undertook a PRISMA-based assessment of the literature to define all fixation techniques and analyse their outcomes. Inclusion and exclusion criteria were composed. A search of Medline and Embase was performed, yielding 399 articles. After abstract screening, 96 were included for qualitative data analysis.

Results

Nine fixation techniques were identified: ‘tie over bolster’, ‘staple fixation’, ‘simple dressings’, ‘quilting sutures’, ‘re-look methods’, ‘foam sponge bolster’, ‘adhesive glues’, ‘negative pressure wound therapy’ and ‘less common techniques. We analyse the available evidence for each technique, identifying 13 studies with level I/II evidence. We summarise the research that underpins these nine categories, proposing an algorithm to facilitate technique selection based on anatomical and patient-specific factors.

Conclusions

An array of skin graft fixation techniques are used in plastic surgery, without clear guidelines. To our knowledge, this is the first time all fixation techniques have been defined. Our suggested algorithm is intended to aid surgeons in selecting an appropriate fixation technique and should be challenged by future research, particularly randomised control trials.

77 Lessons Learnt from Managing Orthopaedic Trauma During the First Wave of the COVID-19 Pandemic at a UK District General Hospital

Background

The Coronavirus disease (COVID-19) pandemic has contributed to over 900,000 deaths worldwide. Hospitals responded by expanding services to accommodate the forecasted rise in COVID-19-related admissions. We describe the effects these changes had on management of orthopaedic trauma and patient outcomes at a district general hospital in Southern England.

Method

Data were extrapolated retrospectively from two separate six-week periods in 2019 and 2020 (1st April - 13th May) using electronic records of patients referred to the orthopaedic team. Soft tissue injuries were included where a confirmed diagnosis was made with radiological evidence. Patients were excluded if no orthopaedic intervention was required. Data were compared between the two time periods.

Results

There were fewer attendances to hospital in 2020 compared with 2019 (178 vs 328), but time from presentation to surgery significantly increased in 2020 (2.94 days vs 4.91 days, p = 0.009). There were fewer operative complications in 2020 (36/145 vs 11/88, p &lt; 0.001). However, ordinal logistic regression analysis found a significantly greater complication severity in 2020 including death (p = 0.039). Complication severity was unrelated to COVID-19 status.

Conclusions

Restructuring of orthopaedic services in response to the COVID-19 pandemic has been associated with significant delays to surgery and higher post-operative complication severity. Our results demonstrate the need for fast-track emergency operative orthopaedic services in UK district general hospitals whilst the COVID-19 pandemic continues.

364 The Cycling Urologist: Effect on PSA, Haematuria, Pudendal Nerve Entrapment and Cyclists Nodules

Aim

Cycle use has vastly increased over the last few years in the UK. The aim of this review was to evaluate the effect of cycling on the common conditions presenting to the urology clinic, in particular those of raised PSA, haematuria, soft tissue lesions (“cyclist nodules”) and pudendal nerve entrapment syndromes.

Method

A PUBMED search of the literature on cycling and genitourinary disorders was performed. The keywords included “Bicycling” AND “Prostate-specific antigen”, “Bicycling” AND “Haematuria”, “Bicycling” AND “Cyclist Nodules”, “Bicycling” AND “Pudendal Nerve Entrapment”.

Results

The literature suggests no significant change in total PSA levels after a bout of cycling, regardless of age. The type of cycling (mountain biking vs. road cycling) does not influence PSA levels. It is possible that the saddle used in cycling may displace the pressure across the perineal and gluteal region to effectively alleviate pressure on the prostate. Haematuria appears to be rare with cycling but has been described. Perineal nodular induration is a very rare - although possibly under diagnosed condition. It is thought to be caused by repetitive micro trauma from contact between the perineum and saddle. Pudendal nerve entrapment (PNE) represents the most common bicycling associated urogenital problem. Numbness in the perineum, penis, scrotum or the buttocks is the most common and most recognised symptom. Genital numbness may occur unrelated to erectile dysfunction (ED) although cycling related ED is invariably associated with genital numbness.

Conclusions

Urology Trainees and Consultants should be aware of how recreational and high-level cycling may result in presentation to the Urology clinic.