Implementation of streamlining measures in selecting and prioritising complex cases for the cancer multidisciplinary team meeting: a mini review of the recent developments

In January 2020, NHS England and NHS Improvement, in the United Kingdom, issued a permissive framework for streamlining cancer multidisciplinary (MDT) meetings. Streamlining is defined as a process whereby complex cases are prioritized for full discussion by an MDT in an MDT meeting (MDM), while the management of straightforward cases is expedited using Standards of Care (SoC). SoC are points in the pathway of patient management where there are recognized guidelines and clear clinical consensus on the options for management and should be regionally agreed and uniformly applied by regional Cancer Alliances. While this report marks the first major change in cancer MDT management since the Calman-Hine report in 1995, its implementation, nationally, has been slow with now nearly four years since its publication. It is argued however that streamlining is a necessary step in ensuring the viability of MDT processes, and therefore maintaining patient care in the current socioeconomic context of rising workload and cancer incidence, financial pressures, and workforce shortages. In this mini review, we offer a succinct summary of the recent developments around the implementation of the 2020 streamlining framework, including challenges and barriers to its implementation, and the potential future directions in this field, which we propose should increase utilisation of implementation science. We conclude that ensuring successful implementation of the framework and the SOC requires securing a buy-in from key stakeholders, including MDTs and hospital management teams, with clearly defined (a) management approaches that include triage (e.g. through a mini MDT meeting), (b) assessment of case complexity (something that directly feeds into the SOC), and (c) roles of the MDT lead and the members, while acknowledging that the SOC cannot be universally applied without the consideration of individual variations across teams and hospital Trusts.

Cochlear implants and deafness: a global case study to increase policy awareness and action on an under-resourced health issue

There has been a major growth in global health networks in recent decades to address health issues including tobacco use, alcohol abuse, and maternal mortality. Most conditions that incur high costs have provoked networks of advocates working to mitigate the impact, increase investment in research, and establish campaigns. Global health networks often work simultaneously across policy, knowledge creation, and advocacy. Until recently there has been limited activity in global health networks and advocacy addressing hearing loss and deafness which has contributed to its relatively low visibility with policymakers compared to other health conditions. This discussion paper reports on a global consultation that explored the views of advocacy groups and individuals on advocacy for the management of hearing loss, and cochlear implantation (CI). It focussed on stakeholders' views of current advocacy endeavours, opportunities and barriers, and the possible development of a global advocacy network to improve access to cochlear implantation and the supporting services. The subsequent development of a global health network, the Cochlear Implant International Community of Action (CIICA) is discussed and the conditions necessary for the successful development of health networks are explored. This paper will be of interest to those wishing to understand the factors influencing the development of health networks and advocacy.

Diagnostic value of the abnormal digital rectal examination in the modern MRI-based prostate cancer diagnostic pathway

Objective

Currently the National Institute for Health and Care Excellence (NICE) recommends an abnormal digital rectal examination (DRE) as a standalone referral criterion for suspected prostate cancer. Unlike referrals for a raised prostate-specific antigen (PSA) which are triaged directly to magnetic resonance imaging (MRI), an abnormal DRE requires re-examination in a secondary clinic first. Here, we investigated the ongoing value of the abnormal DRE as a referral criterion.

Methods

This study is a retrospective review of patients referred to secondary care for suspected prostate cancer based on an abnormal DRE over a 15-month period at a single UK hospital (n = 158). Age, PSA, primary and repeat DRE findings and eventual diagnosis were collated.

Results

A concurrent raised PSA was present in 65/158 (41%). Concordance between primary and secondary care DRE was only 72/158 (46%). The overall and significant cancer detection rate was 26/158 (16%) and 22/158 (14%), respectively. Among men with a concurrent raised PSA, 19/65 (29%) had significant cancer found, whereas with an abnormal primary care DRE and normal PSA (n = 93), only 3/93 (3%) had a significant cancer. Mandating a PSA before referral for an abnormal DRE would have redirected 65/158 (41%) of men to MRI first, negating the need for a repeat DRE (p < 0.0001). This finding was recapitulated in a second prospective validation cohort (n = 30) with 9/30 (30%) redirected to MRI first.

Conclusions

This is one of the first studies to investigate the value of the DRE in contemporary practice. We propose that PSA is used to triage men with an abnormal DRE to MRI without needing a repeat DRE. If the PSA is normal, the diagnostic yield is low but may still warrant a repeat DRE to assess the need for further investigations. Additional multicentre studies are required to further validate our findings.

Level of evidence

4.

The provision of prostate cancer patient information leaflets on an electronic tablet: A further step to paperless health-care provision

Introduction

The provision of patient information leaflets (PILs) for cancer treatment options is primarily via a paper format. PILs can now be provided on an electronic tablet with the added benefits of providing audio-visual information.

Materials and Methods

Between February 2017 and August 2019, 112 patients with newly diagnosed prostate cancer (PCa) were enrolled into our prospective cohort study. The control group (n = 56) were all given PILs on a paper as the standard of care (SoC). The intervention (tablet) group (n = 56) were given the same paper PILs as that of the control group plus an electronic tablet computer with an application containing all SoC paper PILs in an electronic format and supplementary videos detailing treatments. Both groups were asked to complete a validated questionnaire (Telemedicine, Satisfaction and Usefulness questionnaire) with regard to satisfaction with care, provided information, and tablet usage.

Results

The response rate for our study was 78/112 (70%). The control and tablet groups were highly satisfied with their care (91%-100% agreed or strongly agreed) and with the information they received (80%-100% agreed or strongly agreed). In the tablet group, 41/46 (89%) reported its utilization. Of those 41, 38 (92%) considered the tablet easy to use and 13 (32%) reported a preference for the paper format.

Conclusions

The provision of electronic PILs in PCa treatment is an innovative method of providing oncological care, with positive feedback from our patients. With further development as a mobile application, electronic PILs may allow a more environmentally and fiscally advantageous method of providing PCa care.

281 Impact of Using Risk Communication Tools in Counselling Patients with Newly Diagnosed Non-Metastatic Prostate Cancer

Introduction

There have been substantial advances in risk communication tools that help patients understand prognosis associated with prostate cancer and the benefit/gain from treatment. Over the last three years, two tools; Cambridge Prognostic Groups (CPG), and Predict Prostate (https://prostate.predict.nhs.uk), along with decision-making consultations with clinical nurse specialists (CNS) have been integrated into the new diagnosis pathway in our unit.

Method

Treatment decisions for patients with new non-metastatic prostate cancer were audited after (2019–2020) and before (2016–2017) new risk communication tools were implemented. Data were compared between the two time periods and also benchmarked against national level data from the National Prostate Cancer Audit (NPCA) (Parry et al 2020; PMID: 32460859). The main outcome measured was comparison of rates of over and under-treatment of disease.

Results

168 and 95 patients were included in the 2019–2020 and 2016–2017 cohorts, respectively. Following implementation there was a reduction in over-treatment (use of radical surgery/radiotherapy) in patients with low risk/CPG1 (23% to 4%). These rates were also better than the national average from NPCA data (4% vs 11%). In parallel, there was an increase in use of radical treatment (reduced under-treatment) in high risk and very high-risk/CPG4-5 disease (84% vs 73%). Again, these rates were also superior to national level data from the NPCA (84% vs 76%).

Conclusions

Incorporating personalised risk-communication tools and dedicated CNS counselling in our unit has reduced over-treatment of early disease and under-treatment of advanced disease. Wider uptake could enhance risk-appropriate treatment of patients with a new prostate cancer diagnosis.

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day &gt;14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p &lt; 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P &lt; 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

Virtual Interactive Surgical Skills Classroom: Protocol for a Parallel-Group, Noninferiority, Adjudicator-Blinded, Randomized Controlled Trial (VIRTUAL)

Background

Traditional face-to-face training (FFT) for basic surgical skills is inaccessible and resource-intensive. Noninteractive computer-based learning is more economical but less educationally beneficial. Virtual classroom training (VCT) is a novel method that permits distanced interactive expert instruction. VCT may optimize resources and increase accessibility.

Objective

We aim to investigate whether VCT is superior to computer-based learning and noninferior to FFT in improving proficiency in basic surgical skills.

Methods

This is a protocol for a parallel-group, noninferiority, randomized controlled trial. A sample of 72 undergraduates will be recruited from 5 medical schools in London. Participants will be stratified by subjective and objective suturing experience level and allocated to 3 intervention groups at a 1:1:1 ratio. VCT will be delivered using the BARCO weConnect software, and FFT will be provided by expert instructors. Optimal student-to-teacher ratios of 12:1 for VCT and 4:1 for FFT will be maintained. The assessed task will be interrupted suturing with hand-tied knots.

Results

The primary outcome will be the postintervention Objective Structured Assessment of Technical Skills score, adjudicated by 2 experts blinded to the study and adjusted for baseline proficiency. The noninferiority margin (δ) will be defined using historical data.

Conclusions

This study will serve as a comprehensive appraisal of the suitability of virtual basic surgical skills classroom training as an alternative to FFT. Our findings will assist the development and implementation of further resource-efficient, accessible, virtual basic surgical skills training programs during the COVID-19 pandemic and in the future.

Trial Registration

International Standard Randomized Controlled Trial Number ISRCTN12448098; https://www.isrctn.com/ISRCTN12448098

International Registered Report Identifier (IRRID)

PRR1-10.2196/28671

236 Novel Guidelines to Avoid Routine Blood Tests After Robotic Assisted Radical Prostatectomy (RARP)

Introduction

Patients undergoing RARP commonly require routine post-operative blood tests. This practice dates from an era of open surgery, with increased blood loss and complications. We aim to improve specificity of blood test requests with novel guidelines.

Method

1039 consecutive RARP patients at two tertiary urology centres in the UK were audited. Novel guidelines constructed based on risk stratified evidence from the initial audit were used to prospectively audit 133 patients.

Results

16% had clinical concerns post-operatively. 1% and 4% had an intra- and post-operative complication. Intra- or post-operative clinical judgement flagged post-operative complications in 99.9%. 80% had routine blood tests with no clinical concerns. 6% had delayed discharge due to delayed processing of blood tests. 0.9% received a peri-operative transfusion.

Re-Audit Novel guidelines reduced the number of blood tests requested from 100% to 36%. Specificity in diagnosing a complication improved from 0% to 67%. Discharge delays reduced from 6% to 0% and no post-operative complications were missed (sensitivity 100%).

Conclusions

Routine blood tests, without an indication, did not flag any additional post-operative complications. Blood transfusion is rare for RARP. Novel guidelines to request post-operative blood tests will reduce costs and discharge delays whilst maintaining appropriate patient safety and care.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

V12 VIRTUAL: Virtual InteRacTive sUrgicAl skiLls classroom – A Randomized Controlled Trial Proposal

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction and feedback. They may optimise resources and increase accessibility, facilitating larger-scale training whilst producing a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will receive virtual classroom training. The assessed task will be to place three interrupted sutures with hand tied knots. Pre- and post-intervention Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will be measured. Feasibility and accessibility will also be assessed.

Results

Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine relative performance.

Conclusion

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual BSS classroom training as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient virtual BSS training programs during the COVID-19 pandemic and in the future.

Major Urological Cancer Surgery for Patients is Safe and Surgical Training Should Be Encouraged During the COVID-19 Pandemic: A Multicentre Analysis of 30-day Outcomes

COVID-19 has resulted in the deferral of major surgery for genitourinary (GU) cancers with the exception of cancers with a high risk of progression. We report outcomes for major GU cancer operations, namely radical prostatectomy (RP), radical cystectomy (RC), radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy performed at 13 major GU cancer centres across the UK between March 1 and May 5, 2020. A total of 598 such operations were performed. Four patients (0.7%) developed COVID-19 postoperatively. There was no COVID-19–related mortality at 30 d. A minimally invasive approach was used in 499 cases (83.4%). A total of 228 cases (38.1%) were described as training procedures. Training case status was not associated with a higher American Society of Anesthesiologists (ASA) score (p =  0.194) or hospital length of stay (LOS; p >  0.05 for all operation types). The risk of contracting COVID-19 was not associated with longer hospital LOS (p =  0.146), training case status (p =  0.588), higher ASA score (p =  0.295), or type of hospital site (p =  0.303). Our results suggest that major surgery for urological cancers remains safe and training should be encouraged during the ongoing COVID-19 pandemic provided appropriate countermeasures are taken. These real-life data are important for policy-makers and clinicians when counselling patients during the current pandemic.

Patient summary

We collected outcome data for major operations for prostate, bladder, and kidney cancers during the COVID-19 pandemic. These surgeries remain safe and training should be encouraged during the ongoing pandemic provided appropriate countermeasures are taken. Our real-life results are important for policy-makers and clinicians when counselling patients during the COVID-19 pandemic.

Blood biomarkers for memory: toward early detection of risk for Alzheimer disease, pharmacogenomics, and repurposed drugs

Short-term memory dysfunction is a key early feature of Alzheimer's disease (AD). Psychiatric patients may be at higher risk for memory dysfunction and subsequent AD due to the negative effects of stress and depression on the brain. We carried out longitudinal within-subject studies in male and female psychiatric patients to discover blood gene expression biomarkers that track short term memory as measured by the retention measure in the Hopkins Verbal Learning Test. These biomarkers were subsequently prioritized with a convergent functional genomics approach using previous evidence in the field implicating them in AD. The top candidate biomarkers were then tested in an independent cohort for ability to predict state short-term memory, and trait future positive neuropsychological testing for cognitive impairment. The best overall evidence was for a series of new, as well as some previously known genes, which are now newly shown to have functional evidence in humans as blood biomarkers: RAB7A, NPC2, TGFB1, GAP43, ARSB, PER1, GUSB, and MAPT. Additional top blood biomarkers include GSK3B, PTGS2, APOE, BACE1, PSEN1, and TREM2, well known genes implicated in AD by previous brain and genetic studies, in humans and animal models, which serve as reassuring de facto positive controls for our whole-genome gene expression discovery approach. Biological pathway analyses implicate LXR/RXR activation, neuroinflammation, atherosclerosis signaling, and amyloid processing. Co-directionality of expression data provide new mechanistic insights that are consistent with a compensatory/scarring scenario for brain pathological changes. A majority of top biomarkers also have evidence for involvement in other psychiatric disorders, particularly stress, providing a molecular basis for clinical co-morbidity and for stress as an early precipitant/risk factor. Some of them are modulated by existing drugs, such as antidepressants, lithium and omega-3 fatty acids. Other drug and nutraceutical leads were identified through bioinformatic drug repurposing analyses (such as pioglitazone, levonorgestrel, salsolidine, ginkgolide A, and icariin). Our work contributes to the overall pathophysiological understanding of memory disorders and AD. It also opens new avenues for precision medicine- diagnostics (assement of risk) as well as early treatment (pharmacogenomically informed, personalized, and preventive).

Soluble TREM2 and biomarkers of central and peripheral inflammation in neurodegenerative disease

Alzheimer's disease (AD) has been genetically and pathologically associated with neuroinflammation. Triggering receptor expressed on myeloid cells 2 (TREM2) is a microglial receptor involved in innate immunity. TREM2 rare protein coding genetic variants have been linked to AD. A soluble TREM2 (sTREM2) cleavage product is elevated in AD. It is unclear whether there is a relationship between elevated sTREM2 and markers of inflammation. The hypothesis of this investigation was that central and peripheral inflammation play a role in sTREM2 levels in AD. A consistent association of peripheral or central markers of inflammation and CSF sTREM2 levels was not found, suggesting a limited impact of general inflammation on sTREM2 levels. An association between peripheral sTREM2 levels and CSF sTREM2, as well as an association between CSF sTREM2 and a marker of blood brain barrier integrity, was observed in AD, suggesting a potential role of peripheral TREM2 in central TREM2 biology.

The Role of Robotics in the Invasive Management of Bladder Cancer

Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes

OBJECTIVES

To report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC).

METHODS AND MATERIALS

A total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS).

RESULTS

Median follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5-45.4) for ORC; and 16.1 months (IQR: 11.2-27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed.

CONCLUSION

This study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

The effects of building-related factors on classroom relative humidity among North Carolina schools participating in the 'Free to Breathe, Free to Teach' study

Both high and low indoor relative humidity (RH) directly impact Indoor Air Quality (IAQ), an important school health concern. Prior school studies reported a high prevalence of mold, roaches, and water damage; however, few examined associations between modifiable classroom factors and RH, a quantitative indicator of dampness. We recorded RH longitudinally in 134 North Carolina classrooms (n = 9066 classroom-days) to quantify the relationships between modifiable classroom factors and average daily RH below, within, or above levels recommended to improve school IAQ (30-50% or 30-60% RH). The odds of having high RH (>60%) were 5.8 [95% Confidence Interval (CI): 2.9, 11.3] times higher in classrooms with annual compared to quarterly heating, ventilating, and air-conditioning (HVAC) system maintenance and 2.5 (95% CI: 1.5, 4.2) times higher in classrooms with HVAC economizers compared to those without economizers. Classrooms with direct-expansion split systems compared to chilled water systems had 2.7 (95% CI: 1.7, 4.4) times higher odds of low RH (<30%). When unoccupied, classrooms with thermostat setbacks had 3.7 (95% CI: 1.7, 8.3) times the odds of high RH (>60%) of those without setbacks. This research suggests actionable decision points for school design and maintenance to prevent high or low classroom RH.

PRACTICAL IMPLICATIONS

This study combines longitudinal measurements of classroom relative humidity with school inspection data from several schools to describe the problem of relative humidity control in schools. Our findings on how maintenance and mechanical factors affect classroom humidity provide suggestions on building operations policies and heating, ventilating, and air-conditioning (HVAC) design considerations that may improve classroom relative humidity control.

Vasitis: the need for imaging and clinical acumen

A 55-year-old man presented with an acute, painful groin mass with signs of sepsis. On examination, it was difficult to tell whether this was a strangulated hernia or a testicular torsion. Biochemical investigations revealed raised inflammatory markers and radiological investigations showed a rare inflammatory condition, vasitis, which could be mistaken for various other 'surgical' groin masses. This case report summarises the importance of realising the vast differential diagnoses that come with acute groin masses and how imaging can prevent unnecessary surgery.

The cancer multi-disciplinary team from the coordinators' perspective: results from a national survey in the UK

Background

The MDT-Coordinators’ role is relatively new, and as such it is evolving. What is apparent is that the coordinator’s work is pivotal to the effectiveness and efficiency of an MDT. This study aimed to assess the views and needs of MDT-coordinators.

Methods

Views of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators’ educational/training needs.

Results

265 coordinators responded to the survey. More than one third of the respondents felt that the job plan does not reflect their actual duties. It was reported that medical members of the MDT always contribute to case discussions. 66.9% of the respondents reported that the MDTs are chaired by Surgeons. The majority reported having training on data management and IT skills but more than 50% reported that they felt further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills.

Conclusions

MDT-Coordinators’ role is central to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the resources and training available to MDT-coordinators can give them an opportunity to develop the required additional skills and contribute to improved MDT performance and ultimately cancer care. Finally, this study looks forward to the impact of the recent launch of a new e-learning training programme for MDT coordinators and discusses implications for future research.

Developing and testing TEAM (Team Evaluation and Assessment Measure), a self-assessment tool to improve cancer multidisciplinary teamwork

BACKGROUND

Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the "characteristics of an effective MDT."

METHODS

Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity.

RESULTS

A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r < 0.20). Team members were positive about its value.

CONCLUSIONS

Self-assessment of team performance using this tool may support MDT development.

The role of oncologists in multidisciplinary cancer teams in the UK: an untapped resource for team leadership?

BACKGROUND AND AIMS

In the UK, cancer care is managed via multidisciplinary teams (MDT). Core members of these teams are typically surgeons, oncologists, radiologists, pathologists and clinical nurse specialists (with other health care professionals potentially present). Good teamwork, including team communication and leadership, has been shown to be a prerequisite for safe care delivery in other health care contexts, but cancer MDT team working processes are yet to be fully explored. This study aimed to assess the self-perceived contribution of oncologists to MDTs, with emphasis on their potential role as team leaders.

METHODS

Data were collected at the British Uro-oncology Group 6th Annual Meeting (Sep 11-12 2009, York, UK). Respondents completed various items related to their perceived contribution to MDTs, aspects of current and potential MDT leadership, team decision making in these meetings, and also demographic information.

RESULTS

Seventy-seven oncologists attended the meeting, of whom 61 fully completed the survey (response rate 79%). Oncologists reported that their contribution to the MDT discussion carries equal weight to those of surgeons, radiologists and pathologists. Whereas 83% of respondents reported that MDT chairmanship could rotate, only 39% reported that it does in their own MDTs. More than 90% of respondents thought that oncologists (clinical or medical) could chair these meetings, but only 25% of them had ever chaired their own MDT.

CONCLUSIONS

Despite a high level of contribution to MDTs and the respect of their colleagues, oncologists are not taking leadership roles within MDTs at the level that they expect. This study raises the question of whether a re-evaluation the leadership of MDTs is required with clinicians from a variety of specialities being given opportunities to develop skills necessary to lead cancer MDTs and improve team performance and ultimately cancer care.

Future research into the treatment of vitiligo: where should our priorities lie? Results of the vitiligo priority setting partnership

BACKGROUND

Vitiligo is the most frequent depigmentation disorder of the skin and is cosmetically and psychologically devastating. A recently updated Cochrane systematic review 'Interventions for vitiligo' showed that the research evidence for treatment of vitiligo is poor, making it difficult to make firm recommendations for clinical practice.

OBJECTIVES

To stimulate and steer future research in the field of vitiligo treatment, by identifying the 10 most important research areas for patients and clinicians.

METHODS

A vitiligo priority setting partnership was established including patients, healthcare professionals and researchers with an interest in vitiligo. Vitiligo treatment uncertainties were gathered from patients and clinicians, and then prioritized in a transparent process, using a methodology advocated by the James Lind Alliance.

RESULTS

In total, 660 treatment uncertainties were submitted by 461 participants. These were reduced to a list of the 23 most popular topics through an online/paper voting process. The 23 were then prioritized at a face-to-face workshop in London. The final list of the top 10 treatment uncertainties included interventions such as systemic immunosuppressants, topical treatments, light therapy, melanocyte-stimulating hormone analogues, gene therapy, and the impact of psychological interventions on the quality of life of patients with vitiligo.

CONCLUSIONS

The top 10 research areas for the treatment of vitiligo provide guidance for researchers and funding bodies, to ensure that future research answers questions that are important both to clinicians and to patients.

Decision making in surgical oncology

Decisions in surgical oncology are increasingly being made by multi-disciplinary teams (MDTs). Although MDTs have been widely accepted as the preferred model for cancer service delivery, the process of decision making has not been well described and there is little evidence pointing to the ideal structure of an MDT. Performance in surgery has been shown to depend on non-technical skills, such as decision making, as well as patient factors and the technical skills of the healthcare team. Application of this systems approach to MDT working allows the identification of factors that affect the quality of decision making for cancer patients. In this article we review the literature on decision making in surgical oncology and by drawing from the systems approach to surgical performance we provide a framework for understanding the process of decision making in MDTs. Technical factors that affect decision making include the information about patients, robust ICT and video-conferencing equipment, a minimum dataset with expert review of radiological and pathological information, implementation and recording of the MDTs decision. Non-technical factors with an impact on decision making include attendance of team members at meetings, leadership, teamwork, open discussion, consensus on decisions and communication with patients and primary care. Optimising these factors will strengthen the decision making process and raise the quality of care for cancer patients.

Introduction of large insert DNA into mammalian cells and embryos

This unit provides a set of protocols for introducing large insert DNA into cultured mammalian cells and embryos. Two different methods, spheroplast fusion and lipofection, are described for effecting transfer of YACs or gel-purified YAC DNA into cells. Additional protocols discuss preparing and transferring BACs into cells by lipofection and into embryos by microinjection.

Performance of recommended screening tests for undiagnosed diabetes and dysglycemia

OBJECTIVE

To evaluate the performance, in settings typical of opportunistic and community screening programs, of screening tests currently recommended by the American Diabetes Association (ADA) for detecting undiagnosed diabetes.

RESEARCH DESIGN AND METHODS

Volunteers aged > or =20 years without previously diagnosed diabetes (n = 1,471) completed a brief questionnaire and underwent recording of postprandial time and measurement of capillary blood glucose (CBG) with a portable sensor. Participants subsequently underwent a 75-g oral glucose tolerance test; fasting serum glucose (FSG) and 2-h postload serum glucose (2-h SG) concentrations were measured. The screening tests we studied included the ADA risk assessment questionnaire, the recommended CBG cut point of 140 mg/dl, and an alternative CBG cut point of 120 mg/dl. Each screening test was evaluated against several diagnostic criteria for diabetes (FSG > or =126 mg/dl, 2-h SG > or =200 mg/dl, or either) and dysglycemia (FSG > or =110 mg/dl, 2-h SG > or =140 mg/dl, or either).

RESULTS

Among all participants, 10.7% had undiagnosed diabetes (FSG > or =126 or 2-h SG > or =200 mg/dl), 52.1% had a positive result on the questionnaire, 9.5% had CBG > or =140 mg/dl, and 18.4% had CBG > or =120 mg/dl. The questionnaire was 72-78% sensitive and 50-51% specific for the three diabetes diagnostic criteria; CBG > or =140 mg/dl was 56-65% sensitive and 95-96% specific, and CBG > or =120 mg/dl was 75-84% sensitive and 86-90% specific. CBG > or =120 mg/dl was 44-62% sensitive and 89-90% specific for dysglycemia.

CONCLUSIONS

Low specificity may limit the usefulness of the ADA questionnaire. Lowering the cut point for a casual CBG test (e.g., to 120 mg/dl) may improve sensitivity and still provide adequate specificity.

Modeling the effects of VOC/NOx emissions on ozone synthesis in the cascadia airshed of the Pacific Northwest

A modeling system consisting of MM5, Calmet, and Calgrid was used to investigate the sensitivity of anthropogenic volatile organic compound (VOC) and oxides of nitrogen (NOx) reductions on ozone formation within the Cascadia airshed of the Pacific Northwest. An ozone episode that occurred on July 11-14, 1996, was evaluated. During this event, high ozone levels were recorded at monitors downwind of Seattle, WA, and Portland, OR, with one monitor exceeding the 1 hr/120 ppb National Ambient Air Quality Standard (at 148 ppb), and six monitors above the proposed 8 hr/80 ppb standard (at 82-130 ppb). For this particular case, significant emissions reductions, between 25 and 75%, would be required to decrease peak ozone concentrations to desired levels. Reductions in VOC emissions alone, or a combination of reduced VOC and NOx emissions, were generally found to be most effective; reducing NOx emissions alone resulted in increased ozone in the Seattle area. When only VOC emissions were curtailed, ozone reductions occurred in the immediate vicinity of densely populated areas, while NOx reductions resulted in more widespread ozone reductions.