A Systematic Review and Meta-analysis of Clinical Outcomes in Autologous Breast Reconstruction Using Internal Mammary Artery Perforators as Recipient Vessels

Recipient vessel selection is vital for successful autologous free-flap breast reconstruction. Internal mammary artery perforators have gained interest as a recipient vessel option. However, previous studies on their microsurgical safety and efficacy are limited and inconsistent. Thus, we conducted a systematic review and meta-analysis to assess the safety and effectiveness of using internal mammary artery perforators as recipient vessels in breast reconstruction.

Methods

The protocol has been previously published in PROSPERO (CRD42020190020). The PubMed, Scopus, Web of Science, and PROSPERO databases were searched. Two independent reviewers evaluated the articles for inclusion in the study. Study quality was assessed using the Newcastle-Ottawa Scale and the MINORS instrument (Methodological Index for Non-Randomized Studies).

Results

Of the 361 articles screened, 13 studies were included (313 patients with 318 flaps; 223 unilateral, 31 bilateral, mean average age 51.2 and mean BMI 27.8 ± 1.9). The mean overall success rate was 99.8%, the pooled surgical success rate was 100% [95% confidence interval (CI): 97%-100%], and the overall rate of complications was 11% (95% CI: 7%-18%). The most common complication was vascular-related to microanastomoses, with an incidence of 5% (95% CI: 2%-10%). The fat necrosis rate was 3% (95% CI: 2%-6%).

Conclusions

This study verified that internal mammary artery perforator vessels are reliable in breast reconstruction, with a high success rate and a relatively low complication rate. Moreover, in selected microsurgical breast reconstruction patients, internal mammary artery perforators may be the primary recipient vessel choice over the internal mammary artery or thoracodorsal vessels.

Abstract 5696: A prognostic machine learning model for early breast cancer which combines clinical and genetic data in patients treated with neo/adjuvant chemotherapy

Background: Accurate modelling of the impact of patient-specific features and cancer treatments on survival allows the assignment of targeted therapy. There has not been any effort to build a multi-source model for the survival analysis of breast cancer. We show in this study a prognostic model, which integrates genetic (DNA), clinical and therapy inputs to predict survival for early breast cancer (stages 1-3) for all breast cancer subtypes.

Methods: We used a data-driven Random Survival Forest approach, a statistical non-parametric ensemble learning method, that incorporates censor and time-to-event data. The learning is performed by creating numerous decision trees and selecting the model based on the correct responses in unseen data. We used The Cancer Genome Atlas Breast Cancer (TCGA) dataset and observed improvements in the accuracy when more sources of data were used, in line with the previous research. Integrating the impact of non-silent somatic tumor mutations (whole exome) and gene copy number variation (CNV) were analyzed on all mutations and per particular mutation.

Results: Data from 1096 women with stage 1-3 early breast cancer were inputs to the model n=437 ER+ve HER2-ve, n=123 HER2+ve ER+ve, n=40 HER2+ ER-ve and n=126 TNBC. Pathological stage 1, n=183; stage 2, n=620; and stage 3, n=249. The following chemotherapy and hormonal treatments were used in the analysis: anthracycline, taxanes, platinum, alkylating and anti-metabolite agents, anti-oestrogen, aromatase inhibitors, ovarian suppression and HER2 antibody treatment.

The model accuracy for predicting survival for early breast cancer using only clinical data was 0.78 for Area Under Curve (AUC) and c-index. The predictive accuracy improved stepwise by adding hormone, genetic and treatment data to AUC of 0.86 and c-index to 0.85. We observed the same trend if the proportion of test data increased from 0.25 to 0.75. Changes in median genes FGFR2 and CDKN2A copy number were strongly prognostic with p=0.0001 and p=0.002, and weaker signals for CBFB p=0.05, HRAS p=0.06, AKT p=0.07.

Conclusion: Using public datasets, we developed a predictive survival model for an individual with early breast cancer up to 5 years from diagnosis using multi-source and patient-specific data. We show that using this approach for survival analysis yields good accuracy.

Citation Format: Aidan (Amanzhol) Kubeyev, Andrea Giorni, Prabu Siva, Luiz Silva, Jordan Laurie, Matthew Foster, Matthew Griffiths, Uzma Asghar. A prognostic machine learning model for early breast cancer which combines clinical and genetic data in patients treated with neo/adjuvant chemotherapy. [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 5696.

Abstract 5424: A deep learning approach (AI) which accurately identifies breast tumor cells, tumor infiltrating lymphocytes (TILS) and fibroblasts from H&E slides

Background: Histopathology assessments of cancers require highly skilled pathologists, are labor intensive and prone to errors without proper training or fatigue. Machine learning can assist pathologists by increasing efficiency and minimizing individual variability. This study adapted a deep learning model to reliably identify 3 cell types from triple negative breast cancers fixed on H&E slides and verified performance with an expert pathologist.

Methods: We apply the U-Net architecture to analyse pathology slides fixed with triple negative breast cancer (TNBC) tissue. The public dataset NuCLS was used for training. Semantic segmentation was used to identify single cells of 3 types: tumor cells, fibroblasts, and tumor infiltrating lymphocyte (TILs). For validation, the pathologist annotated 8 random H&E tiles. The 3 cell types accuracy for NuCLS and the model was evaluated by our pathologist.

Results: Overall, there was a 73% agreement with the pathologists (Pathologist vs. NuCLS). A set of 1,555 (90%) TNBC slides were used for training and 173 for validation (10%; unseen data). Table 1 outlines the accuracy metrics for each cell type and for each comparison. Compared to our pathologist, the model accurately identified TILs (62%), followed by fibroblasts (42%) and lastly tumor cells (26%). A significant source of discrepancy was variation in labeled single cell boundaries. The model was better at identifying TILs. The pathologist took 1.5 hours to annotate 8 tiles for the 3 cells and our model 644ms.

Conclusion: It is possible to develop a deep learning model to identify breast cancer cells, fibroblasts and TILs from H&E stained slides, with similar accuracy levels as a trained pathologist. The model performed better than a pathologist in identifying TILs, but both struggled with fibroblasts. Accuracy of 71% overall and 87% for TILs, motivates expansion to further datasets and other cancer types.

Table 1. - Accuracy metrics. Quality assessment8 H&E tiles Pathologist vs. NuCLS U-Net model vs. NuCLs U-Net model vs. Pathologist U-Net model vs. NuCLs (Full) Background 86% 71% 62% 73% Tumour 43% 35% 26% 71% Fibroblast 45% 39% 42% 31% TILs 34% 96% 62% 87% Overall 73% 74% 61% 71%

Citation Format: Luiz Augusto Zillmann da Silva, Alistair R. Williams, Aidan Kubeyev, Andrea Giorni, Jordan Laurie, Prabu Sivasubramaniam, Matthew Foster, Matthew Griffiths, Uzma Asghar. A deep learning approach (AI) which accurately identifies breast tumor cells, tumor infiltrating lymphocytes (TILS) and fibroblasts from H&E slides. [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 5424.

A conceptual model of nitrogen dynamics for the Great Barrier Reef catchments

Nitrogen (N) from anthropogenic sources has been identified as a major pollutant of the Great Barrier Reef (GBR), Australia. We developed a conceptual framework to synthesise and visualise the fate and transport of N from the catchments to the sea from a literature review. The framework was created to fit managers and policymakers' requirements to reduce N in the GBR catchments. We used this framework to determine the N stocks and transformations (input, sources, and outputs) for ecosystems commonly found in the GBR: rainforests, palustrine wetlands, lakes, rivers (in-stream), mangroves and seagrasses. We included transformations of N such as nitrogen fixation, nitrification, denitrification, mineralisation, anammox, sedimentation, plant uptake, and food web transfers. This model can be applied to other ecosystems to understand the transport and fate of N within and between catchments. Importantly, this approach can guide management actions that attenuate N at different scales and locations within the GBR ecosystems. Finally, when combined with local hydrological modelling, this framework can be used to predict outcomes of management activities.

Nitrogen processing by treatment wetlands in a tropical catchment dominated by agricultural landuse

Agriculture is a major contributor to marine nitrogen pollution, and treatment wetlands can be a strategy to reduce it. However, few studies have assessed the potential of treatment wetlands to mitigate nitrogen pollution in tropical regions. We quantify the nitrogen removal rates of four recently constructed treatment wetlands in tropical Australia. We measured denitrification potential (D_t), the inflow-outflow of nutrients, and tested whether the environment in these tropical catchments is favourable for nitrogen removal. D_t was detected in three of the four systems with rates between 2.0 and 12.0 mg m^-2 h^-1; the highest rates were measured in anoxic soils (ORP -100 to 300 mV) that were rich in carbon and nitrogen (>2% and >0.2%, respectively). The highest nitrogen removal rates were measured when NO₃^--N concentrations were >0.4 mg L^-1 and when water flows were slow. Treatment wetlands in tropical regions can deliver high removal rates of nitrogen and other pollutants when adequately managed. This strategy can reduce nutrient loads and their impacts on sensitive coastal zones such as the Great Barrier Reef.

Ethnic minority women’s interactions with antenatal care providers in Europe

Background

Ethnic minority women are at greater risk of maternal morbidity and mortality. Antenatal care reduces risks of adverse maternal and neonatal outcomes and supports a positive transition to motherhood. Important components of quality antenatal care are interactions between women and care providers which are supportive and empowering.

Methods

We conducted a systematic review to identify and synthesise qualitative evidence on ethnic minority women's experiences of accessing antenatal care in European countries. Following a comprehensive search of 8 databases and two-step screening process, we included 27 studies from various European countries. Study findings were coded and synthesised using a ‘best-fit' framework approach.

Findings

Overall women expressed satisfaction with their antenatal care, frequently framed in relation to experiences of maternity care in countries of origin. Women highly valued interactions with antenatal care providers which were supportive and trust-inducing, and when there was continuity of carer to facilitate this. However, studies frequently showed a dichotomy between reported satisfaction with antenatal care and experiences of interactions with care providers which could be discriminatory, stigmatising and disempowering. Some women blamed themselves for negative interactions. Language barriers were frequently identified by women as a factor which hindered their communication with antenatal care providers and the subsequent quality of care received, when suitable interpreters were not available. Negative interactions with antenatal care providers could result in a withdrawal from ongoing antenatal care for some women.

Conclusions

This review highlights the importance of quality interactions between ethnic minority women and antenatal care providers. Policy implications: Antenatal care should be provided in such a way as to facilitate trust, support and effective communication between women and care providers.

Key messages

Positive interactions with care providers form an important element of quality antenatal care for ethnic minority women in Europe. Trust, support and the provision of suitable interpreters, where needed, contribute to positive interactions with antenatal care providers for ethnic minority women in Europe.

1469 Audit of Clinical Notes Filing in Vascular Surgery

Aim

Assess the correctness of patient's notes filing following the Royal College of Physicians, Record Keeping Standards, and the General Medical Council, Good Medical Practice, guidance: medical notes must be filed in the correct section, in a chronological order, three key identifiers on each page.

Method

Over 3 months, the general surgical wards, using case notes and those using folders for the current admission were assessed to identify loose notes. The vascular surgery patients’ notes were reviewed for the following criteria: not loose, filed in the correct section, in chronological order, and had three key identifiers.

Results

Surgical wards using case notes had 28.6% of the notes filed (n = 21) compared with 78.9% filed on wards with admission folders (n = 57). Within vascular surgery (n = 15), 13.3% had all notes filed, 20% were in chronological order, 6.7% had notes filed in the correct section, and 20% had key identifiers on every page.

Conclusions

The filing of case notes on the vascular ward resulted in loose notes more than other wards that use admission folders. To resolve this, “Admission Folders” were introduced (alongside full case notes) to assist with filing and label sheets used to assist with fast identification of current admission documents. After implementation of Admission Folders, the staff found notes easier to access and follow, according to the staff surveys, and notes were correctly filed and given identifiers, ensuring continued quality care for the patients.

P–416 Radiotherapy inflicts long-term damage upon the uterus, causing uterine artery endothelial dysfunction and pregnancy loss in mice

Study question

Does the uterus sustain direct and long-term damage following radiotherapy, independent of ovarian damage?

Summary answer

Radiotherapy causes direct and long-term uterine damage. Ovariectomised and hormonally supplemented mice experience uterine artery endothelial dysfunction and pregnancy loss following transfer of healthy blastocysts.

What is known already

The detrimental off-target impacts of cancer therapies on the ovary are well established, with some fertility preservation techniques available to ensure patients maintain their fertility following gonadotoxic treatment. Low doses of radiotherapy kill the majority of primordial follicle oocytes in the ovary, reducing the ovarian reserve and fertile lifespan. Patients who have received radiotherapy experience higher rates of pregnancy complications including preterm birth, low birth weight, and stillbirth. However, no studies have investigated if radiation inflicts direct, fertility compromising damage to the uterus.

Study design, size, duration

Adolescent female mice were untreated or exposed to whole body y-irradiation (7Gy), then ovariectomised. Immediate damage was assessed up to 24 hours post-irradiation (n = 4/group). Four weeks following treatment, mice were hormone primed to induce endometrial receptivity (n = 7/group), artificial decidualisation (n = 7–8/group), or receive embryo transfers from healthy, unexposed donor mice to assess embryo implantation (n = 11–13/group), and mid-gestation development (n = 8–10/group).

Participants/materials, setting, methods

Four week old C57BL6/CBA (F1) female mice were used for this study. Immunofluorescence and in situ hybridisation were utilised to localise markers of immediate DNA damage and cell death following irradiation, and markers of receptivity in hormone primed uteri. Measurements of uterine artery blood flow were recorded using Doppler ultrasonography, and indices of pulsatility and resistance calculated. Uterine artery wire myography was performed to assess competency of endothelial and smooth muscle compartments following irradiation.

Main results and the role of chance

Within 24 hours of irradiation, DNA damage (yH2AX) and apoptosis (Puma/TUNEL) were elevated in uteri, compared to control. Irradiated mice that received embryo transfers from untreated donors had similar numbers of implantation sites 3-days post-transfer versus controls, however uteri were pale and atrophic suggesting impaired vascularisation. By 10-days post-transfer, implantation sites in irradiated mice were resorbing (p < 0.001), although uterine artery Doppler ultrasound measurements demonstrated no change in pulsatility or resistance indices. When the brain was shielded from irradiation to protect the hypothalamic-pituitary-gonadal axis, resorption still occurred (p < 0.001), suggesting direct uterine damage is the likely cause of pregnancy loss. To investigate uterine damage in the absence of an embryo, endometrial receptivity was induced artificially. Uteri from irradiated animals were lighter compared to control (p < 0.05), however localisation of receptivity markers (E-cadherin, Mucin1, Ki67) was normal. When decidualisation was artificially induced irradiated uteri were also lighter (p < 0.01) indicating impaired decidualisation and reduced capacity to adapt to pregnancy. Wire myography performed on uterine arteries demonstrated endothelial dysfunction in irradiated mice (p < 0.0001).

Limitations, reasons for caution

Here, only a single age and dose of radiotherapy exposure are modelled. Patients of all ages can receive many doses of radiotherapy in combination with various chemotherapies. Our highly manipulable model enables any treatment variation to be modelled and the effect on the uterus and pregnancy examined.

Wider implications of the findings: Reproductive aged cancer patients need to be appropriately counselled regarding the risks to their long-term fertility following treatment. Until now, potential permanent impacts to the uterus following cancer treatment have not been considered. It is clear radiotherapy can impose long-term damage to the uterus and influence pregnancy success and fertility.

Trial registration number

NA

Recovery from aortic valve surgery: the trajectory of muscle mass, strength, and quality, and health-related quality of life (HRQoL)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Barts Charity

OnBehalf

Queen Mary University of London (QMUL) and Barts Health NHS Trust

Background/Introduction:

The impact of intensive care unit-acquired weakness (ICUAW) is considerable and is associated with reduced physical function and impaired health-related quality of life (HRQoL). Patients’ undergoing elective cardiac surgery are known to lose significant muscle mass and strength in the first seven days after surgery, but little is known beyond that time. 

Purpose

We sought to investigate the effect of cardiac surgery on ICUAW (including muscle mass, strength, muscle quality) and HRQoL (including anxiety and depression and reintegration into society) until out-patient follow-up.

Methods

Eligible patients included adults undergoing a surgical elective aortic valve replacement without any pre-existing causes of severe muscle weakness or wasting. Muscle mass was measured using ultrasound of the rectus femoris cross-sectional area (RFcsa). Muscle quality was calculated using histogram analysis, specifically pixel intensity (PI), whereby a lower value is indicative of healthier muscle tissue. Muscle strength was measured using hand-held dynamometry specifically grip strength. HRQoL (EQ5D), anxiety and depression (hospital anxiety and depression scale (HADS)) and reintegration to normal living (RNLI index) were also collected. Measurements were assessed preoperatively, at day 7 and at out-patient follow-up.

Results

Thirty-one patients were recruited, with 22 (70.9%) patients attending follow-up. Patients lost 6.5% RFcsa (p= <0.0001) in the first seven days post-surgery and 10.1% (p = 0.0014) between preoperative assessment and follow-up. Hand-held grip strength decreased significantly (10.6%, p= <0.0001) in the first seven days post-surgery, however, differing to RFcsa, recovered considerably between day 7 and follow-up (7.7%, p = 0.018). Decreased muscle quality was observed solely in the first seven days after surgery (8.3%, p = 0.0094). The EQ5D visual analogue scale and crosswalk index increased significantly from preoperative assessment to follow-up (10%, p = 0.0250; 17.6%, p = 0.022 respectively) and day 7 to follow-up (11.7%, p = 0.0311; 27.9%, p = 0.011 respectively). While depression scores significantly decreased between the same time points as the EQ5D, changes in anxiety and RNLI scores, were non-significant.

Conclusion

Patients undergoing surgical aortic valve replacements lose considerable muscle mass in hospital, failing to recover even at out-patient follow-up. Furthermore, muscle quality decreases in the first seven days after surgery in line with the acute muscle loss. However, the impact on strength is less extensive as patients appear to recover the loss by follow-up. Patients’ health scores, function index and depression scores also improve, suggesting that muscle mass is the only outcome to not recover at follow-up. Therefore, patients appear to recover well from AVR surgery even surpassing some of their preoperative results, with the exception of the RFcsa.

Muscle-sparing transverse rectus abdominis musculocutaneous free flap breast reconstruction following cryolipolysis

Cryolipolysis refers to the sub-physiological cooling of regional body parts (typically the abdomen) in order to reduce the volume of adipose tissue. It provides a non-invasive alternative to procedures such as liposuction, which have traditionally been considered as relative contraindications for future abdominal free flap-based reconstructions. We describe the first case of a patient undergoing skin-sparing mastectomy and a muscle-sparing transverse rectus abdominis musculocutaneous (msTRAM) free flap breast reconstruction, following cryolipolysis therapy. Pre- and intraoperative radiological investigations and clinical examination showed no obvious adverse effect of cryolipolysis on the flap. The patient recovered well, with no vascular complications noted on follow up.

Comparison of PEAK PlasmaBlade™ to conventional diathermy in abdominal-based free-flap breast reconstruction surgery-A single-centre double-blinded randomised controlled trial

BACKGROUND

Electrosurgery makes dissection with simultaneous haemostasis possible. The produced heat can cause injury to the surrounding tissue. The PEAK PlasmaBlade™(PPB) is a new electrosurgery device which may overcome this by having the ability to operate on a lower temperature, therefore reducing collateral thermal damage.

METHOD

A single-centre, double-blinded, randomised controlled trial (RCT) was conducted which included 108 abdominal-based free-flap breast reconstruction patients who had their flap raise performed using either the PPB (n = 56) or the conventional diathermy (n = 52). Data were collected during their in-patient stay and out-patient appointments. The primary outcome value was the number of days the abdominal drains were required.

RESULTS

Baseline characteristics were similar between the groups, except a significantly lower flap weight in the PPB group. The median number of days the drains were required did not differ significantly (p = 0.48; 6.0 days for the diathermy and 5.0 days for the PPB). The total drain output (p = 0.68), the inflammatory cytokine in the drain fluid (p>0.054) and complications (p>0.24) did not differ significantly between the two groups. At the 2-week follow-up appointment, there was a trend towards less abdominal seromas on abdominal ultrasound (p = 0.09) in the PPB group which were significantly smaller (p = 0.04).

CONCLUSION

The use of the PPB did not result in a significant reduction of drain requirement, total drain output or inflammatory cytokines but did reduce the size of seroma collections at the 2-week follow-up appointment. Therefore, the use of the PPB device could reduce early seroma formation after drain removal.

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience

AIM

To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment.

METHODS AND MATERIALS

Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy.

RESULTS

The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI.

CONCLUSION

Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Video game addiction: Providing evidence for Internet gaming disorder through a systematic review of clinical studies

Introduction

The American Psychiatric Association introduced in Internet Gaming Disorder (IGD) in the appendix as a tentative disorder in the last edition of the Diagnostic and Statistical Manual of Mental Disorders. However, currently no systematic review exists about excessive gaming viewed from a clinical perspective.

Objectives and aims

To review clinical studies on gaming addiction in order to ascertain characteristics of both clinical and research studies to provide retrospective evidence in relation with the proposed IGD classification (including criteria, measures and therapies).

Methods

A systematic literature review of studies published from 1980 to 2015 has been conducted using three major psychology databases: Academic Search Complete, PsycInfo, and PsycArticles. A total of 5033 results from peer-reviewed journals were obtained, where 32 were identified as empirical clinical papers focused on gaming addiction.

Results

The clinical research studies on gaming identified were published between 1998 and 2015, most of which included patient samples. Categorizations identified in the research papers included: (i) patients’ characteristics (e.g., socio-demographics), (ii) criteria and measures used (e.g., scales to diagnose), (iii) types of gaming problems (e.g., game genre), (iv) and treatments (e.g., type of therapy).

Conclusions

Findings will be discussed against the background of the controversial IGD diagnostic criteria proposed in the DSM-5 in order to assess the extent to which previously published clinical knowledge matched the current proposal for including gaming addiction as behavioral addiction in the next diagnostic manual.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract P5-06-06: Clinically significant changes of receptors status (ER, PR and HER2) after receiving neoadjuvant chemotherapy (NACT) in breast cancer (BC) predicts the prognosis and guides the choice of the optimal adjuvant therapy (AT): Retesting of the receptor status should be mandatory

Background: NACT is a standard option for BC (T2-4, N0-3, M0) and certain BC phenotypes. The choice of AT based on the pre-NACT biomarkers status may not be optimum for individual patient because dynamic phenotypic changes induced by NACT may alter the response to treatment. Aim: The aim of this study is to determine the incidence of changes in the receptor status (ER, PR and HER2) and other proliferation biomarkers (Ki67 and SPAG5) before and after NACT and to assess the clinical significance of such changes. Methods Immunohistochemistry staining of ER, PR, HER2, Ki67 and SPAG5 in pre and post NACT tumors tissues from a consecutive series of 850 of BC (T2-4, N0-3, M0) treated at the Nottingham University Hospital (NUH) from 2000 to 2018, have been centrally evaluated according to ASCO guidelines. All cases with conversion in HER2 status had also been retested by HER2-FISH. The results were validated in an external cohort of 250 cases. Treatment options and patients characteristics are the same between the centres: (68%) received anthracycline plus Taxane (AC+T) NACT and 32% of patients have received NACT Anthracycline only (AC). Neoadjuvant HER2 targeting agents (Trastuzumab) or (Trastuzumab + Petruzumab) had been prescribed to 16% of patients in addition to AC+T followed by adjuvant Trastuzumab (total=18 cycles). All pre-NACT ER+ patients were given at least 5 year of adjuvant endocrine therapy (ET). In 2013 NUH started a prospective audit of retesting of receptor status in all post NACT surgical tumour samples. The results of the tests were presented to the weekly tumour board meeting and any change in the receptor status (ER and HER2) from negative (in the pre NACT core biopsies) to positive (in the post NACT surgical specimen) being considered for additional AT (ET for ER+ and Trastuzumab for HER2+ cases).The primary end points for this study are the % changes of biomarker changes and the disease free survival (DFS). The median follow up was 72 months. Results In pre NACT core biopsies 32% and 68% were HER2+ and HER2-; respectively. Twelve percent (12%) of the pre NACT HER2- tumours had a conversion to HER2+ in the post NACT surgical specimens. In this group of patients who subsequently received adjuvant Trastuzumab, 95% 3-year DFS was reported; which was similar to those patients who achieved pCR (3-year DFS; 90%) and was superior to cases which remained HER- in post NACT specimens (3-year DFS; 41%); (p<0.0001). Furthermore, similar group of patients with pre NACT HER- tumour before the 2013 audit, who did not receive Trastuzumab for the change to post NACT HER2+ receptors, has inferior 3-year DFS to those received adjuvant Trastuzumab based on the conversion (HR (95% CI)= 7.40 (1.04-52.86); p=0.046). In pre NACT HER2+ BC, 20% of cases had been converted into HER2- in the post NACT surgical specimens. These patients had better 3y-DFS (94%) compared to those who remained HER2+ in post NACT specimens (3y-DFS=70%; HR (95% CI)= 0.86 (0.77-0.97); p=0.01). Furthermore those patients who received neoadjuvant HER2 targeting therapy had statistically higher incidence of post HER2- conversion (p=0.005) and lower level of post NACT proliferation markers (Ki67 and SPAG5); p=0.01. In pre NACT ER+/PR+ patients, those who has converted into ER+/PR- in post NACT specimens had shorter 5-year DFS (40%) in spite of receiving ET, compared to those who remained ER+/PR+ in post NACT specimen [5-DFS= 72%]; HR (95% CI)= 1.98 (1.18-3.31); p=0.009). Conclusion: To our knowledge, this is the first report, which showed the significant clinical benefit of adjuvant therapy, based on the re-testing of the standard receptors status.

Citation Format: Tarek M. a. Abdel-Fatah, Rebekah Webb, Jennifer Walker, Jun Lim, A. Graham Pockley, Graham Ball, Matthew Griffiths, Ian Ellis, Emad Rakhah, Zsolt Hodi, Andrew Lee, Arlene Chan, Stephen Chan. Clinically significant changes of receptors status (ER, PR and HER2) after receiving neoadjuvant chemotherapy (NACT) in breast cancer (BC) predicts the prognosis and guides the choice of the optimal adjuvant therapy (AT): Retesting of the receptor status should be mandatory [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-06-06.

Nested Basin-Sampling

We report an embarrassingly parallel method for the evaluation of thermodynamic properties over an energy landscape exhibiting broken ergodicity, nested is the likelihood of the observed data D givenbasin-sampling (NBS). We also introduce the No Galilean U-Turn Sampler (NoGUTS), a new sampling scheme based on the No U-Turn Sampler (NUTS) introduced by Hoffman and Gelman (2014) that works with the Galilean Monte Carlo scheme introduced by Betancourt (2012) to aid the efficient generation of new live points. NoGUTS can be thought of as a form of reflective slice sampling with an automatic stopping criterion. We apply this approach to a benchmark atomic cluster of 31 Lennard-Jones atoms, which exhibits a low temperature solid-solid heat capacity peak. The calculated heat capacity is compared with results generated by parallel tempering (PT), basin-sampling parallel tempering (BSPT), and standard nested sampling (NS) simulations. NBS reproduces the full heat capacity curve predicted by PT and BSPT, while the NS calculation with similar computational cost fails to resolve the low-temperature solid-solid phase transition.

Rational Design of 5-(4-(Isopropylsulfonyl)phenyl)-3-(3-(4-((methylamino)methyl)phenyl)isoxazol-5-yl)pyrazin-2-amine (VX-970, M6620): Optimization of Intra- and Intermolecular Polar Interactions of a New Ataxia Telangiectasia Mutated and Rad3-Related (ATR) Kinase Inhibitor

The DNA damage response (DDR) is a DNA damage surveillance and repair mechanism that can limit the effectiveness of radiotherapy and DNA-damaging chemotherapy, commonly used treatment modalities in cancer. Two related kinases, ataxia telangiectasia mutated (ATM) and ATM and Rad3-related kinase (ATR), work together as apical proteins in the DDR to maintain genome stability and cell survival in the face of potentially lethal forms of DNA damage. However, compromised ATM signaling is a common characteristic of tumor cells, which places greater reliance on ATR to mediate the DDR. In such circumstances, ATR inhibition has been shown to enhance the toxicity of DNA damaging chemotherapy to many cancer cells in multiple preclinical studies, while healthy tissue with functional ATM can tolerate ATR inhibition. ATR therefore represents a very attractive anticancer target. Herein we describe the discovery of VX-970/M6620, the first ATR inhibitor to enter clinical studies, which is based on a 2-aminopyrazine core first reported by Charrier ( J. Med. Chem. 2011 , 54 , 2320 - 2330 , DOI: 10.1021/jm101488z ).

P96 Screening for cerebrovascular pathology on the basis of positive family history in the paediatric population

Objectives

Neurovascular disorders are uncommon, complex conditions in children. We reviewed the screening practice and outcome of children referred to the neurovascular service on the basis of positive family history.

Design

Retrospective review of prospectively maintained database.

Subjects

Children referred to the neurovascular service on the basis of family history, for screening at our hospital.

Methods

We retrospectively examined our database between July 2008 and April 2018 for the reasons for referral, family history, investigations performed, and the outcome of the screening process.

Results

44 children were reviewed (23 male, median age 10). Thirty-one children had an MRI/MRA brain. One child subsequently had uncomplicated digital subtraction angiography. Thirty children were referred due to a family history of subarachnoid haemorrhage, of which 17 had a single first-degree relative, and two had two first-degree relatives. Nine children were referred with a family history of arteriovenous malformation, (2 were associated with hereditary haemorrhagic telangiectasia). Five children were discussed due to a family history of non-specific haemorrhagic stroke. Seven children had a history of headache, (4 were prescribed Pizotifen for migraine). No neurovascular pathology was detected following screening within our cohort.

Conclusions

A consensus screening policy does not exist but is required both to guide clinical practice and to assuage parental or patient concerns. We will survey UK paediatric centres to commence this process.

Optimal Alignment of Structures for Finite and Periodic Systems

Finding the optimal alignment between two structures is important for identifying the minimum root-mean-square distance (RMSD) between them and as a starting point for calculating pathways. Most current algorithms for aligning structures are stochastic, scale exponentially with the size of structure, and the performance can be unreliable. We present two complementary methods for aligning structures corresponding to isolated clusters of atoms and to condensed matter described by a periodic cubic supercell. The first method (Go-PERMDIST), a branch and bound algorithm, locates the global minimum RMSD deterministically in polynomial time. The run time increases for larger RMSDs. The second method (FASTOVERLAP) is a heuristic algorithm that aligns structures by finding the global maximum kernel correlation between them using fast Fourier transforms (FFTs) and fast SO(3) transforms (SOFTs). For periodic systems, FASTOVERLAP scales with the square of the number of identical atoms in the system, reliably finds the best alignment between structures that are not too distant, and shows significantly better performance than existing algorithms. The expected run time for Go-PERMDIST is longer than FASTOVERLAP for periodic systems. For finite clusters, the FASTOVERLAP algorithm is competitive with existing algorithms. The expected run time for Go-PERMDIST to find the global RMSD between two structures deterministically is generally longer than for existing stochastic algorithms. However, with an earlier exit condition, Go-PERMDIST exhibits similar or better performance.

Use of key performance indicators in histological dissection

AIMS

Reports into standards in the National Health Service and quality in pathology have focused on the way we work in pathology and how to provide assurance that this is of a high standard. There are a number of external quality assurance schemes covering pathology and histopathology specifically; however, there is no scheme covering the process of histological surgical dissection. This is an area undergoing development, emerging from the sole preserve of medically qualified pathologists to a field populated by a number of highly trained biomedical scientists, but remains without any formal quality assurance.

METHODS

This work builds on Barnes, taking the guidance of the Royal College of Pathologists (RCPath)and Institute of Biomedical Science (IBMS)to form a series of key performance indicators relating to dissection. These were developed for use as an indicator of individual practice, highlighting areas of variation, weakness or strength. Once identified, a feedback event provided opportunities to address these errors and omissions, or to enable areas of strength to be shared.

RESULTS

The data obtained from the checklists demonstrate a large variation in practice at the outset of this study. The use of the checklists alone served to reduce this variation in practice, the addition of the training event showed further reduction in variation. The combination of these two tools was an effective method for enhancing standardisation of practice.

CONCLUSIONS

The results of this work show that training events serve to reduce variation in practice by, and between, dissectors, driving up standards in dissection-directly addressing the needs of the modern pathology service.

Giving the tap the elbow? An observational study

BACKGROUND

Handwashing is viewed as the most important barrier to cross-infection. Incorrect use of clinical handwash basins may lead to cross-infection either from contaminated water or due to failure to decontaminate hands. Elbow-operated taps used correctly prevent recontamination of hands during operation. Many elbow-operated taps are installed incorrectly, with the handle flush with the back panel, making it difficult to open using the elbow.

AIM

To determine the effect of altering the angle of the handle of elbow-operated taps on handwashing technique.

METHODS

An observational study was conducted using two rooms; in one the handles of the elbow-operated taps were flush with the inspection panel behind, and in the other they were set at 35°.

FINDINGS

Thirty-five staff members washed their hands in both rooms. Hands were used to turn on the taps in 97% of instances. In 57% of washes hands were recontaminated when used to turn the tap off. Only six individuals consistently used their elbows to turn outlets off. Surprisingly, more individuals used their elbows to operate taps whose handles were flush with the inspection panel behind.

CONCLUSION

Greater emphasis needs to be placed on correct use of elbow-operated outlets. The decision to use elbow- or sensor-operated outlets is not clear-cut, as each has pros and cons. There is much room for improvement in design and standardization of handwash basins. Given the importance of handwashing it is surprising that these gaps exist.

Ascorbic acid ameliorates renal injury in a murine model of contrast-induced nephropathy

BACKGROUND

Contrast induced nephropathy (CIN) is the commonest cause of iatrogenic renal injury and its incidence has increased with the advent of complex endovascular procedures. Evidence suggests that ascorbic acid (AA) has a nephroprotective effect in percutaneous coronary interventions when contrast media are used. A variety of biomarkers (NGAL, NGAL:creatinine, mononuclear cell infiltration, apoptosis and RBP-4) in both the urine and kidney were assayed using a mouse model of CIN in order to determine whether AA can reduce the incidence and/or severity of renal injury.

METHODS

Twenty-four BALB/c mice were divided into 4 groups. Three groups were exposed to high doses of contrast media (omnipaque) in a well-established model of CIN, and then treated with low or high dose AA or placebo (saline). CIN severity was determined by measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL):creatinine at specific time intervals. Histological analysis was performed to determine the level of mononuclear inflammatory infiltration as well as immunohistochemistry to determine apoptosis in the glomeruli by staining for activated caspase-3 and DNA nicking (TUNEL assays). Reverse transcriptase PCR (rtPCR) of mRNA transcripts prepared from mRNA extracted from mouse kidneys was also performed for both lipocalin-2 (Lcn2) encoding NGAL and retinol binding protein-6 (RBP4) genes. NGAL protein expression was also confirmed by ELISA analysis of kidney lysates.

RESULTS

Urinary NGAL:creatinine ratio was significantly lower at 48 h with a 44% and 62% (204.3μg/mmol versus 533.6μg/mmol, p = 0.049) reduction in the low and high dose AA groups, respectively. The reduced urinary NGAL:creatinine ratio remained low throughout the time period assessed (up to 96 h) in the high dose AA group. In support of the urinary analysis ELISA analysis of NGAL in kidney lysates also showed a 57% reduction (12,576 ng/ml versus 29,393 ng/ml) reduction in the low dose AA group. Immunohistochemistry for apoptosis demonstrated decreased TUNEL and caspase-3 expression in both low and high dose AA groups.

CONCLUSIONS

Ascorbic acid reduced the frequency and severity of renal injury in this murine model of CIN. Further work is required to establish whether AA can reduce the incidence of CIN in humans undergoing endovascular procedures.

pRotective vEntilation with veno-venouS lung assisT in respiratory failure: A protocol for a multicentre randomised controlled trial of extracorporeal carbon dioxide removal in patients with acute hypoxaemic respiratory failure

One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO₂R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lung assisT (REST) is a randomised, allocation concealed, controlled, open, multicentre pragmatic trial to determine the clinical and cost-effectiveness of lower tidal volume mechanical ventilation facilitated by vv-ECCO₂R in patients with acute hypoxaemic respiratory failure. Patients requiring intubation and mechanical ventilation for acute hypoxaemic respiratory failure will be randomly allocated to receive either vv-ECCO₂R and lower tidal volume mechanical ventilation or standard care with stratification by recruitment centre. There is a need for a large randomised controlled trial to establish whether vv-ECCO₂R in acute hypoxaemic respiratory failure can allow the use of a more protective lung ventilation strategy and is associated with improved patient outcomes.

Cost Utility of Omalizumab Compared with Standard of Care for the Treatment of Chronic Spontaneous Urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) negatively impacts patient quality of life and productivity and is associated with considerable indirect costs to society.

OBJECTIVE

The aim of this study was to assess the cost utility of add-on omalizumab treatment compared with standard of care (SOC) in moderate or severe CSU patients with inadequate response to SOC, from the UK societal perspective.

METHODS

A Markov model was developed, consisting of health states based on Urticaria Activity Score over 7 days (UAS7) and additional states for relapse, spontaneous remission and death. Model cycle length was 4 weeks, and total model time horizon was 20 years in the base case. The model considered early discontinuation of non-responders (response: UAS7 ≤6) and retreatment upon relapse (relapse: UAS7 ≥16) for responders. Clinical and cost inputs were derived from omalizumab trials and published sources, and cost utility was expressed as incremental cost-effectiveness ratios (ICERs). Scenario analyses included no early discontinuation of non-responders and an altered definition of response (UAS7 <16).

RESULTS

With a deterministic ICER of £3183 in the base case, omalizumab was associated with increased costs and benefits relative to SOC. Probabilistic sensitivity analysis supported this result. Productivity inputs were key model drivers, and individual scenarios without early discontinuation of non-responders and adjusted response definitions had little impact on results. ICERs were generally robust to changes in key model parameters and inputs.

CONCLUSIONS

In this, the first economic evaluation of omalizumab in CSU from a UK societal perspective, omalizumab consistently represented a treatment option with societal benefit for CSU in the UK across a range of scenarios.

Testicular atrophy following paediatric primary orchidopexy: A prospective study

BACKGROUND

With the Nordic consensus statement advocating orchidopexy at an earlier age, the present study sought to investigate the outcomes of primary paediatric orchidopexy at a tertiary UK centre.

OBJECTIVE

To prospectively assess testicular atrophy following primary orchidopexy for undescended testes in a paediatric population. Secondary outcomes were complication rates and whether outcomes were dependent on grade of operating surgeon.

STUDY DESIGN

Prospective data regarding age at operation, classification of the undescended testis, length of follow-up, and subjective comparison of intraoperative and postoperative testicular volumes compared with the contralateral testis were collected. Testicular atrophy was defined as >50% loss of testicular volume or a postoperative testicular volume <25% of the volume of the contralateral testis. Patients were excluded for incomplete data and follow-up <6 months.

RESULTS

Data for 234 patients were analysed. Testicular atrophy occurred in 2.6% of cases. There was no reported testicular re-ascent. All secondary acquired cases underwent a previous ipsilateral hernia repair. There was no significant difference in outcomes comparing the grade of surgeon (consultant n = 8, trainee/staff-grade surgeon n = 7-8). There was a trend towards postoperative catch-up growth in approximately one fifth of cases.

DISCUSSION

Previous studies have reported a testicular atrophy rate of 5%. The present study reported a similar rate of 2.6%. In agreement with a previous publication, it was also found that testicular atrophy was not dependent on the grade of operating surgeon. The mechanism for testicular catch-up growth is not well understood. Animal studies have supported the hypothesis that increased temperature has a detrimental effect on testicular volume. However, follow-up in the present cohort was short (median 6.9 months), making interpretation of this finding difficult. It is acknowledged that clinical palpation alone to determine testicular volume potentially introduces intra-observer and inter-observer error. However, prospective studies using ultrasound to determine testicular volumes following orchidopexy have reported catch-up growth.

CONCLUSION

This study represented one of the larger collections of prospective assessments of outcomes following primary orchidopexy. It was acknowledged that subjectively assessing testicular volume is not ideal; however, the data correlated with similar studies.

Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema

Early detection and diagnosis of upper extremity lymphoedema in patients after mastectomy and axillary lymph node clearance is important in order to treat disease before it is too advanced to achieve favourable outcomes. Patients with disease refractory to conservative management can be efficiently assessed for diagnosis and surgical intervention using advanced lymphatic imaging techniques. The current paper highlights the more readily available of these: lymphoscintigraphy, indocyanine green (ICG) lymphangiography and immunofluorescence, magnetic resonance lymphangiography (MRL) and computed tomographic lymphangiography in combination or individually. With such techniques, both diagnosis and treatment of lymphoedema has become more readily achieved, with lymphatico-venous and lymphatico-lymphatic anastomosis, and lymph node transfer now increasingly common undertakings.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes

BACKGROUND

Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature.

METHODS

A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014.

RESULTS

Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001).

CONCLUSIONS

The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.

Preoperative computed tomography angiography for planning DIEP flap breast reconstruction reduces operative time and overall complications

BACKGROUND

The approach and operative techniques associated with breast reconstruction have steadily been refined since its inception, with abdominal perforator-based flaps becoming the gold standard reconstructive option for women undergoing breast cancer surgery. The current study comprises a cohort of 632 patients, in whom specific operative times are recorded by a blinded observer, and aims to address the potential benefits seen with the use of computer tomography (CT) scanning preoperatively on operative outcomes, complications and surgical times.

METHODS

A prospectively recorded, retrospective review was undertaken of patients undergoing autologous breast reconstruction with a DIEP flap at the St Andrews Centre over a 4-year period from 2010 to 2014. Computed tomography angiography (CTA) scanning of patients began in September 2012 and thus 2 time periods were compared: 2 years prior to the use of CTA scans and 2 years afterwards. For all patients, key variables were collected including patient demographics, operative times, flap harvest time, pedicle length, surgeon experience and complications.

RESULTS

In group 1, comprising patients within the period prior to CTA scans, 265 patients underwent 312 flaps; whilst in group 2, the immediately following 2 years, 275 patients had 320 flaps. The use of preoperative CTA scans demonstrated a significant reduction in flap harvest time of 13 minutes (P<0.013). This significant time saving was seen in all flap modifications: unilateral, bilateral and bipedicled DIEP flaps. The greatest time saving was seen in bipedicle flaps, with a 35-minute time saving. The return to theatre rate significantly dropped from 11.2% to 6.9% following the use of CTA scans, but there was no difference in the total failure rate.

CONCLUSIONS

The study has demonstrated both a benefit to flap harvest time as well as overall operative times when using preoperative CTA. The use of CTA was associated with a significant reduction in complications requiring a return to theatre in the immediate postoperative period. Modern scanners and techniques can reduce the level of ionising radiation, facilitating patients being able to benefit from the advantages that this preoperative planning can convey.

Indocyanine green-based fluorescent angiography in breast reconstruction

BACKGROUND

Fluorescent angiography (FA) has been useful for assessing blood flow and assessing tissue perfusion in ophthalmology and other surgical disciplines for decades. In plastic surgery, indocyanine green (ICG) dye-based FA is a relatively novel imaging technology with high potential in various applications. We review the various FA detector systems currently available and critically appraise its utility in breast reconstruction.

METHODS

A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken.

RESULTS

In comparison to the old fluorescein dye, ICG has a superior side effect profile and can be accurately detected by various commercial devices, such as SPY Elite (Novadaq, Canada), FLARE (Curadel LLC, USA), PDE-Neo (Hamamatsu Photonics, Japan), Fluobeam 800 (Fluoptics, France), and IC-View (Pulsion Medical Systems AG, Germany). In breast reconstruction, ICG has established as a safer, more accurate tracer agent, in lieu of the traditional blue dyes, for detection of sentinel lymph nodes with radioactive isotopes ((99m)-Technetium). In prosthesis-based breast reconstruction, intraoperative assessment of the mastectomy skin flap to guide excision of hypoperfused areas translates to improved clinical outcomes. Similarly, in autologous breast reconstructions, FA can be utilized to detect poorly perfused areas of the free flap, evaluate microvascular anastomosis for patency, and assess SIEA vascular territory for use as an alternative free flap with minimal donor site morbidity.

CONCLUSIONS

ICG-based FA is a novel, useful tool for various applications in breast reconstruction. More studies with higher level of evidence are currently lacking to validate this technology.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping

BACKGROUND

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome.

METHODS

A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap.

RESULTS

Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged.

CONCLUSIONS

Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.

Police Mental Health Partnership project: Police Ambulance Crisis Emergency Response (PACER) model development

OBJECTIVES

To review internationally recognized models of police interactions with people experiencing mental health crises that are sometimes complex and associated with adverse experience for the person in crisis, their family and emergency service personnel. To develop, implement and review a partnership model trial between mental health and emergency services that offers alternative response pathways with improved outcomes in care.

METHODS

Three unique models of police and mental health partnership in the USA were reviewed and used to develop the PACER (Police Ambulance Crisis Emergency Response) model. A three month trial of the model was implemented and evaluated.

RESULTS

Significant improvements in response times, the interactions with and the outcomes for people in crisis were some of the benefits shown when compared with usual services.

CONCLUSIONS

The pilot showed that a partnership involving mental health and police services in Melbourne, Australia could be replicated based on international models. Initial data supported improvements compared with usual care. Further data collection regarding usual care and this new model is required to confirm observed benefits.

A multidisciplinary team approach minimises prophylactic mastectomy rates

BACKGROUND

Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making.

METHODS

We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded.

RESULTS

Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%).

DISCUSSION

MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): trial protocol

BACKGROUND

Relapse prevention interventions for Bipolar Disorder are effective but implementation in routine clinical services is poor. Web-based approaches offer a way to offer easily accessible access to evidence based interventions at low cost, and have been shown to be effective for other mood disorders.

METHODS/DESIGN

This protocol describes the development and feasibility testing of the ERPonline web-based intervention using a single blind randomised controlled trial. Data will include the extent to which the site was used, detailed feedback from users about their experiences of the site, reported benefits and costs to mental health and wellbeing of users, and costs and savings to health services. We will gain an estimate of the likely effect size of ERPonline on a range of important outcomes including mood, functioning, quality of life and recovery. We will explore potential mechanisms of change, giving us a greater understanding of the underlying processes of change, and consequently how the site could be made more effective. We will be able to determine rates of recruitment and retention, and identify what factors could improve these rates.

DISCUSSION

The findings will be used to improve the site in accordance with user needs, and inform the design of a large scale evaluation of the clinical and cost effectiveness of ERPonline. They will further contribute to the growing evidence base for web-based interventions designed to support people with mental health problems.