Imperial College London

Professor the Lord Darzi of Denham PC KBE FRS FMedSci HonFREng

Faculty of MedicineDepartment of Surgery & Cancer

Professor of Surgery
 
 
 
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Contact

 

+44 (0)20 3312 1310a.darzi

 
 
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Location

 

Queen Elizabeth the Queen Mother Wing (QEQM)St Mary's Campus

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Summary

 

Publications

Publication Type
Year
to

1357 results found

Ahmed I, Ahmad NS, Ali S, Ali S, George A, Saleem H, Uppal E, Soo J, Mobasheri M, King D, Cox BM, Darzi Aet al., Medication adherence apps: A review and content analysis, JMIR mHealth and uHealth, ISSN: 2291-5222

Background:Medication adherence is a costly and damaging problem for both healthcare providers and patients alike. Patients adhere to only 50% of drugs prescribed for chronic diseases in developed nations. Digital health has paved the way for innovative smartphone solutions to tackle this challenge. However, despite the numerous applications (apps) available claiming to improve adherence, a thorough review of adherence applications has not been carried out to date.Objective:(i)To review medication adherence apps (otherwise known as mAdherence app) in the Apple App store and the Google Play repository in terms of their evidence base, medical professional involvement in development, and strategies used to facilitate behaviour change and improve adherence.(ii)To provide a system of classification for these apps. Methods:In April 2015, relevant mAdherence apps were identified by systematically searching the Apple and Google Play app stores using a combination of relevant search terms. Data extracted for each app included app store source, app price, documentation of healthcare professional (HCP) involvement during app development and evidence base for each respective app.Free apps were downloaded to explore the strategies used to promote medication adherence. Testing involved a standardised medication regimen of three reminders over a four-hour period. Non-adherence features designed to enhance user experience were also documented.Results:The App repository search identified a total of 5889 applications. 806 fulfilled the inclusion criteria initially and were tested. 682 applications were further analysed for data extraction. Of these, 61.7% were free for testing, 8.5% were inaccessible and 29.8% required payment. Of the 421 free applications, 13.8% were developed with HCP involvement and an evidence base was identified in only 0.95%. Of the paid apps, 4.4% had HCP involvement, 0.5% had a documented evidence base and 0.5% had both. 31% of inaccessible apps were produce

JOURNAL ARTICLE

Archer SA, Hull L, Soukup T, Mayer E, Athanasiou T, Sevdalis N, Darzi Aet al., Development of a Theoretical Framework of Factors Affecting Patient Safety Incident Reporting: A Theoretical Review of the Literature, BMJ Open, ISSN: 2044-6055

JOURNAL ARTICLE

Attaelmanan I, Bhatti YA, Harris M, Prime M, Darzi Aet al., The development and diffusion of surgical frugal innovations – lessons for the NHS, LSE International Health Policy Conference 2017

CONFERENCE PAPER

Byrne B, Aylin P, Bottle RA, Faiz OD, Darzi A, Vincent CAet al., Failure to engage in surgical quality improvement research is associated with poorer quality of care, Royal Society of Medicine, Coloproctology section: Overseas meeting in Leuven

CONFERENCE PAPER

Byrne B, Faiz O, Darzi A, Vincent Cet al., Do gastrointestinal cancer patients want to decide where they have tests and surgery? A questionnaire study., Digestive Disorders Federation

CONFERENCE PAPER

Harling L, Athanasiou T, Ashrafian H, Darzi A, Gooderham N, Lambert Jet al., Pre-operative serum VCAM-1 as a biomarker of atrial fibrillation after coronary artery bypass grafting, Journal of Cardiothoracic Surgery, ISSN: 1749-8090

JOURNAL ARTICLE

Khan DZ, Oude Vrielink TJC, Marcus H, Darzi A, Mylonas Get al., NeuroCYCLOPS: development and preclinical validation of a robotic platform for endoscopic neurosurgery, European Association of Neurosurgical Societies (EANS 2016), Publisher: European Association of Neurosurgical Societies

CONFERENCE PAPER

Kogkas A, Darzi A, Mylonas GP, Gaze-Driven Human-Robot Interaction in the Operating Theatre, 6th Joint Workshop on New Technologies for Computer/Robot Assisted Surgery (CRAS 2016)

CONFERENCE PAPER

Leff DR, Shetty K, Yang GZ, Darzi Aet al., Persistent Attentional Demands Despite Laparoscopic Skills Acquisition, JAMA Surgery, ISSN: 2168-6262

JOURNAL ARTICLE

Modi HN, Singh H, Yang G, Darzi A, Leff Det al., A decade of imaging surgeons' brain function (Part II): a systematic review of applications for technical and non-technical skills assessment, Surgery, ISSN: 1532-7361

Background: Functional neuroimaging technologies enable assessment of operator brain function, and can deepen our understanding of skills learning, ergonomic optima and cognitive processes in surgeons. Whilst there has been a critical mass of data detailing surgeons’ brain function, this literature has not been systematically reviewed.Methods: A systematic search of original neuroimaging studies assessing surgeons’ brain function, and published up until November 2016, was conducted using Medline, Embase and PsycINFO databases.Results: Twenty-seven studies fulfilled the inclusion criteria, including three feasibility studies, fourteen studies exploring the neural correlates of technical skill acquisition, and the remainder investigating brain function in the context of intraoperative decision-making (n=1), neurofeedback training (n=1), robot-assisted technology (n=5), and surgical teaching (n=3). Early stages of learning open surgical tasks (knot-tying) are characterised by prefrontal cortical (PFC) activation which subsequently attenuates with deliberate practice. However, with complex laparoscopic skills (intra-corporeal suturing), PFC engagement requires substantial training and attenuation occurs over a longer time-course, following years of refinement. Neurofeedback and interventions that improve neural efficiency may enhance technical performance and skills learning. Conclusions: Imaging surgeons’ brain function has identified neural signatures of expertise which might help inform objective assessment and selection processes. Interventions which improve neural efficiency may target skill-specific brain regions and augment surgical performance.

JOURNAL ARTICLE

king HK, shang JS, liu JL, Seneci CA, wisanuvej PW, giataganas PG, patel NS, clark JC, vitiello VV, bergeles CB, pratt PP, di marco AD, kerr KK, darzi AD, yang GZYet al., Micro-IGES Robot for Transanal Robotic Microsurgery., In The Hamlyn Symposium on Medical Robotics.

CONFERENCE PAPER

patel NP, seneci CS, yang GZY, darzi AD, teare JTet al., Flexible platforms for natural orifice transluminal and endoluminal surgery. Endoscopy International Open, 2(02), E117-E123., Endoscopy International Open

JOURNAL ARTICLE

Abeles A, Kwasnicki RM, Darzi A, Abeles A, Kwasnicki RM, Darzi A, Abeles A, Kwasnicki RM, Darzi A, Abeles A, Kwasnicki RM, Darzi A, Abeles A, Kwasnicki RM, Darzi Aet al., 2017, Enhanced recovery after surgery: Current research insights and future direction, WORLD JOURNAL OF GASTROINTESTINAL SURGERY, Vol: 9, Pages: 37-45, ISSN: 1948-9366

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

JOURNAL ARTICLE

Abeles A, Kwasnicki RM, Pettengell C, Murphy J, Darzi A, Abeles A, Kwasnicki RM, Pettengell C, Murphy J, Darzi A, Abeles A, Kwasnicki RM, Pettengell C, Murphy J, Darzi A, Abeles A, Kwasnicki RM, Pettengell C, Murphy J, Darzi Aet al., 2017, The relationship between physical activity and post-operative length of hospital stay: A systematic review., Int J Surg, Vol: 44, Pages: 295-302, ISSN: 1743-9191

BACKGROUND: Recovery from surgery has traditionally been measured using specific outcome measures, such as length of hospital stay. However, advances in technology have enabled the measurement of continuous, objective physical activity data in the perioperative period. The aim of this systematic review was to determine the relationship between length of hospital stay and physical activity data for patients undergoing surgery. METHODS: A systematic search of EMBASE, Medline and the Cochrane Library, from inception until January 2017, was performed to identify all study designs that evaluated physical activity after surgery. Studies were included if a wearable sensor measured patient activity as an in-patient and the length of hospital stay was reported. Only English articles were included. RESULTS: Six studies with a total of 343 participants were included in this review. All the studies were prospective observational studies. Each study used a different sensor, with the commonest being a tri-axial accelerometer, and multiple different physical activity outcome measures were used, thereby prohibiting meta-analysis. Four of the studies demonstrated a relationship between physical activity levels and length of hospital stay, while two studies did not show any significant relationship. CONCLUSION: The amount of physical activity performed post-operatively negatively correlates with the length of hospital stay. This suggests that objective physical activity data collected by body worn sensors may be capable of predicting functional recovery post-operatively.

JOURNAL ARTICLE

Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ, Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ, Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ, Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ, Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ, Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZet al., 2017, Meta-analysis of adjuvant therapy following curative surgery for periampullary adenocarcinoma, BRITISH JOURNAL OF SURGERY, Vol: 104, Pages: 814-822, ISSN: 0007-1323

BACKGROUND: Periampullary cancers are uncommon malignancies, often amenable to surgery. Several studies have suggested a role for adjuvant chemotherapy and chemoradiotherapy in improving survival of patients with periampullary cancers, with variable results. The aim of this meta-analysis was to determine the survival benefit of adjuvant therapy for periampullary cancers. METHODS: A systematic review was undertaken of literature published between 1 January 2000 and 31 December 2015 to elicit and analyse the pooled overall survival associated with the use of either adjuvant chemotherapy or chemoradiotherapy versus observation in the treatment of surgically resected periampullary cancer. Included articles were also screened for information regarding stage, prognostic factors and toxicity-related events. RESULTS: A total of 704 titles were screened, of which 93 full-text articles were retrieved. Fourteen full-text articles were included in the study, six of which were RCTs. A total of 1671 patients (904 in the control group and 767 who received adjuvant therapy) were included. The median 5-year overall survival rate was 37·5 per cent in the control group, compared with 40·0 per cent in the adjuvant group (hazard ratio 1·08, 95 per cent c.i. 0·91 to 1·28; P = 0·067). In 32·2 per cent of patients who had adjuvant therapy, one or more WHO grade 3 or 4 toxicity-related events were noted. Advanced T category was associated worse survival (regression coefficient -0·14, P = 0·040), whereas nodal status and grade of differentiation were not. CONCLUSION: This systematic review found no associated survival benefit for adjuvant chemotherapy or chemoradiotherapy in the treatment of periampullary cancer.

JOURNAL ARTICLE

Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Z, Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Z, Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Z, Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Z, Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Z, Alexander J, Gildea L, Balog J, Speller A, McKenzie J, Muirhead L, Scott A, Kontovounisios C, Rasheed S, Teare J, Hoare J, Veselkov K, Goldin R, Tekkis P, Darzi A, Nicholson J, Kinross J, Takats Zet al., 2017, A novel methodology for in vivo endoscopic phenotyping of colorectal cancer based on real-time analysis of the mucosal lipidome: a prospective observational study of the iKnife, SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, Vol: 31, Pages: 1361-1370, ISSN: 0930-2794

BACKGROUND: This pilot study assessed the diagnostic accuracy of rapid evaporative ionization mass spectrometry (REIMS) in colorectal cancer (CRC) and colonic adenomas. METHODS: Patients undergoing elective surgical resection for CRC were recruited at St. Mary's Hospital London and The Royal Marsden Hospital, UK. Ex vivo analysis was performed using a standard electrosurgery handpiece with aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Histological examination was performed for validation purposes. Multivariate analysis was performed using principal component analysis and linear discriminant analysis in Matlab 2015a (Mathworks, Natick, MA). A modified REIMS endoscopic snare was developed (Medwork) and used prospectively in five patients to assess its feasibility during hot snare polypectomy. RESULTS: Twenty-eight patients were recruited (12 males, median age 71, range 35-89). REIMS was able to reliably distinguish between cancer and normal adjacent mucosa (NAM) (AUC 0.96) and between NAM and adenoma (AUC 0.99). It had an overall accuracy of 94.4 % for the detection of cancer versus adenoma and an adenoma sensitivity of 78.6 % and specificity of 97.3 % (AUC 0.99) versus cancer. Long-chain phosphatidylserines (e.g., PS 22:0) and bacterial phosphatidylglycerols were over-expressed on cancer samples, while NAM was defined by raised plasmalogens and triacylglycerols expression and adenomas demonstrated an over-expression of ceramides. REIMS was able to classify samples according to tumor differentiation, tumor budding, lymphovascular invasion, extramural vascular invasion and lymph node micrometastases (AUC's 0.88, 0.87, 0.83, 0.81 and 0.81, respectively). During endoscopic deployment, colonoscopic REIMS was able to detect target lipid species such as ceramides during hot snare polypectomy. CONCLUSION: REIMS demonstrates high diagnostic accuracy for tumor type and for established histological fe

JOURNAL ARTICLE

Bagnall NM, Pucher PH, Johnston MJ, Arora S, Athanasiou T, Faiz O, Darzi LA, Bagnall NM, Pucher PH, Johnston MJ, Arora S, Athanasiou T, Faiz O, Darzi LA, Bagnall NM, Pucher PH, Johnston MJ, Arora S, Athanasiou T, Faiz O, Darzi LA, Bagnall NM, Pucher PH, Johnston MJ, Arora S, Athanasiou T, Faiz O, Darzi LAet al., 2017, Informing the process of consent for surgery: identification of key constructs and quality factors, JOURNAL OF SURGICAL RESEARCH, Vol: 209, Pages: 86-92, ISSN: 0022-4804

BACKGROUND: Informed consent is a fundamental requirement of any invasive procedure. Failure to obtain appropriate and informed consent may result in unwanted or unnecessary procedures, as well as financial penalty in case of litigation. The aim of this study was to identify key constructs of the consent process which might be used to determine the performance of clinicians taking informed consent in surgery. METHODS: A multimodal methodology was used. A systematic review was conducted in accordance with PRISMA guidelines to identify evidence-based components of the consent process. Results were supplemented by semistructured interviews with senior trainees and attending surgeons which were transcribed and subjected to emergent theme analysis with repeated sampling until thematic saturation was reached. RESULTS: A total of 710 search results were returned, with 26 articles included in the final qualitative synthesis of the systematic review. Significant variation existed between articles in the description of the consent procedure. Sixteen semistructured interviews were conducted before saturation was reached. Key components of the consent process were identified with broad consensus for the most common elements. Trainers felt that experiential learning and targeted skills training courses should be used to improve practice in this area. CONCLUSIONS: Key components for obtaining informed consent in surgery have been identified. These should be used to influence curricular design, possible assessment methods, and focus points to improve clinical practice and patient experience in future.

JOURNAL ARTICLE

Beyer-Berjot L, Pucher P, Patel V, Hashimoto DA, Ziprin P, Berdah S, Darzi A, Aggarwal R, Beyer-Berjot L, Pucher P, Patel V, Hashimoto DA, Ziprin P, Berdah S, Darzi A, Aggarwal R, Beyer-Berjot L, Pucher P, Patel V, Hashimoto DA, Ziprin P, Berdah S, Darzi A, Aggarwal Ret al., 2017, Colorectal surgery and enhanced recovery: Impact of a simulation-based care pathway training curriculum., J Visc Surg, ISSN: 1878-7886

BACKGROUND: The aim was to determine whether a simulation-based care pathway approach (CPA) curriculum could improve compliance for enhanced recovery programs (ERP), and residents' participation in laparoscopic colorectal surgery (LCS). Indeed, trainee surgeons have limited access to LCS as primary operator, and ERP have improved patients' outcomes in colorectal surgery (CS). METHODS: All residents of our department were trained in a simulation-based CPA: perioperative training consisted in virtual patients built according to guidelines in both ERP and CS, whilst intraoperative training involved a virtual reality simulator curriculum. Twenty consecutive patients undergoing CS were prospectively included before (n=10) and after (n=10) the training. All demographic and perioperative data were prospectively collected, including compliance for ERP. Residents' participation as primary operator in LCS was measured. RESULTS: Five residents (PGY 4-7) were enrolled. None had performed LCS as primary operator. Overall satisfaction and usefulness were both rated 4.5/5, usefulness of pre-, post- and intraoperative training was rated 5/5, 4.5/5 and 4/5, respectively. Residents' participation in LCS significantly improved after the training (0% (0-100) vs. 82.5% (10-100); P=0.006). Pre- and intraoperative data were comparable between groups. Postoperative morbidity was also comparable. Compliance for ERP improved at Day 2 in post-training patients (3 (30%) vs. 8 (80%); P=0.035). Length of stay was not modified. CONCLUSIONS: A simulated CPA curriculum to training in LCS and ERP was correctly implemented. It seemed to improve compliance for ERP, and promoted residents participation as primary operator without adversely altering patients' outcomes.

JOURNAL ARTICLE

Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi A, Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi A, Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi A, Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi A, Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi Aet al., 2017, Linked hospital and primary care database analysis of the impact of short-term complications on recurrence in laparoscopic inguinal hernia repair, HERNIA, Vol: 21, Pages: 191-198, ISSN: 1265-4906

OBJECTIVE: To study the effects of short-term complications on recurrence following laparoscopic inguinal hernia repair using routine data. BACKGROUND: Linked primary and secondary care databases can evaluate the quality of inguinal hernia surgery by quantifying short- and long-term outcome together. METHODS: Longitudinal analysis of linked primary care (Clinical Practice Research Datalink) and hospital administrative (Hospital Episodes Statistics) databases quantified 30-day complications (wound infection and bleeding) and surgery for recurrence after primary repair performed between 1st April 1997 and 31st March 2012. RESULTS: Out of 41,545 primary inguinal hernia repairs, 10.3% (4296/41,545) were laparoscopic. Complications were less frequent following laparoscopic (1.8%, 78/4296) compared with open (3.5%, 1288/37,249) inguinal hernia repair (p < 0.05). Recurrence was more frequent following laparoscopic (3.5%, 84/2541) compared with open (1.2%, 366/31,859) repair (p < 0.05). Time to recurrence was shorter for laparoscopic (26.4 months SD 28.5) compared with open (46.7 months SD 37.6) repair (p < 0.05). Overall, complications were associated with recurrence (3.2%, 44/1366 with complications; 1.7%, 700/40,179 without complications; p < 0.05). Complications did not significantly increase the risk of recurrence in open hernia repair (OR = 1.49; 95% CI 0.97-2.30, p = 0.069). Complications following laparoscopic repair was significantly associated with increased risk of recurrence (OR = 7.86; 95% CI 3.46-17.85, p < 0.05). CONCLUSIONS: Complications recorded in linked routine data predicted recurrence following laparoscopic inguinal hernia repair. Focus must, therefore, be placed on achieving good short-term outcome, which is likely to translate to better longer term results using the laparoscopic approach.

JOURNAL ARTICLE

Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GB, Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GB, Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GB, Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GB, Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GBet al., 2017, The psychological impact of symptoms related to esophagogastric cancer resection presenting in primary care: A national linked database study, EJSO, Vol: 43, Pages: 454-460, ISSN: 0748-7983

BACKGROUND: The objective was to evaluate incidence, risk factors and impact of postoperative symptoms following esophagogastric cancer resection in primary care. METHODS: Patients undergoing esophagogastrectomy for cancer from 1998 to 2010 with linked records in Clinical Practice Research Datalink, Hospital Episodes Statistics and Office of National Statistics databases were studied. The recording of codes for reflux, dysphagia, dyspepsia, nausea, vomiting, dumping, diarrhea, steatorrhea, appetite loss, weight loss, pain and fatigue were identified up to 12 months postoperatively. Psychiatric morbidity was also examined and its risk evaluated by logistic regression analysis. RESULTS: Overall, 58.6% (1029/1755) of patients were alive 2 years after surgery. Of these, 41.1% had recorded postoperative symptoms. Reflux, dysphagia, dyspepsia and pain were more frequent following esophagectomy compared with gastrectomy (p < 0.05). Complications (OR = 1.40 95%CI 1.00-1.95) and surgical procedure predicted postoperative symptoms (p < 0.05). When compared with partial gastrectomy, esophagectomy (OR = 2.03 95%CI 1.26-3.27), total gastrectomy (OR = 2.44 95%CI 1.57-3.79) and esophagogastrectomy (OR = 2.66 95%CI 1.85-2.86) were associated with postoperative symptoms (p < 0.05). The majority of patients with postoperative psychiatric morbidity had depression or anxiety (98%). Predictors of postoperative depression/anxiety included younger age (OR = 0.97 95%CI 0.96-0.99), complications (OR = 2.40 95%CI 1.51-3.83), psychiatric history (OR = 6.73 95%CI 4.25-10.64) and postoperative symptoms (OR = 1.78 95%CI 1.17-2.71). CONCLUSIONS: Over 40% of patients had symptoms related to esophagogastric cancer resection recorded in primary care, and were associated with an increase in postoperative depression and anxiety.

JOURNAL ARTICLE

Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ, Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ, Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ, Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJ, Chana P, Joy M, Casey N, Chang D, Burns EM, Arora S, Darzi AW, Faiz OD, Peden CJet al., 2017, Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative, BMJ OPEN, Vol: 7, Pages: e014484-e014484, ISSN: 2044-6055

OBJECTIVE: This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care. DESIGN: A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set. SETTING: 23 large hospitals in Australia, England and the USA. METHODS: Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. RESULTS: 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay. CONCLUSIONS: Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.

JOURNAL ARTICLE

Cohen D, Vlaev I, McMahon L, Harvey S, Mitchell A, Borovoi L, Darzi A, Cohen D, Vlaev I, McMahon L, Harvey S, Mitchell A, Borovoi L, Darzi A, Cohen D, Vlaev I, McMahon L, Harvey S, Mitchell A, Borovoi L, Darzi A, Cohen D, Vlaev I, McMahon L, Harvey S, Mitchell A, Borovoi L, Darzi Aet al., 2017, The Crucible simulation: Behavioral simulation improves clinical leadership skills and understanding of complex health policy change., Health Care Manage Rev, Pages: 1-1, ISSN: 0361-6274

BACKGROUND: The Health and Social Care Act 2012 represents the most complex National Health Service reforms in history. High-quality clinical leadership is important for successful implementation of health service reform. However, little is known about the effectiveness of current leadership training. PURPOSE: This study describes the use of a behavioral simulation to improve the knowledge and leadership of a cohort of medical doctors expected to take leadership roles in the National Health Service. METHODOLOGY: A day-long behavioral simulation (The Crucible) was developed and run based on a fictitious but realistic health economy. Participants completed pre- and postsimulation questionnaires generating qualitative and quantitative data. Leadership skills, knowledge, and behavior change processes described by the "theory of planned behavior" were self-assessed pre- and postsimulation. RESULTS: Sixty-nine medical doctors attended. Participants deemed the simulation immersive and relevant. Significant improvements were shown in perceived knowledge, capability, attitudes, subjective norms, intentions, and leadership competency following the program. Nearly one third of participants reported that they had implemented knowledge and skills from the simulation into practice within 4 weeks. CONCLUSIONS: This study systematically demonstrates the effectiveness of behavioral simulation for clinical management training and understanding of health policy reform. Potential future uses and strategies for analysis are discussed. PRACTICE IMPLICATIONS: High-quality care requires understanding of health systems and strong leadership. Policymakers should consider the use of behavioral simulation to improve understanding of health service reform and development of leadership skills in clinicians, who readily adopt skills from simulation into everyday practice.

JOURNAL ARTICLE

D'Lima D, Crawford M, Darzi A, Archer SAet al., 2017, Patient safety and quality of care in mental health: a world of its own?, BJPsych Bulletin, ISSN: 2056-4694

Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.

JOURNAL ARTICLE

Erridge S, Pucher PH, Markar SR, Malietzis G, Athanasiou T, Darzi A, Sodergren MH, Jiao LR, Erridge S, Pucher PH, Markar SR, Malietzis G, Athanasiou T, Darzi A, Sodergren MH, Jiao LR, Erridge S, Pucher PH, Markar SR, Malietzis G, Athanasiou T, Darzi A, Sodergren MH, Jiao LR, Erridge S, Pucher PH, Markar SR, Malietzis G, Athanasiou T, Darzi A, Sodergren MH, Jiao LRet al., 2017, Meta-analysis of determinants of survival following treatment of recurrent hepatocellular carcinoma., Br J Surg, ISSN: 0007-1323

BACKGROUND: Intrahepatic recurrence of hepatocellular carcinoma (HCC) following resection is common. However, no current consensus guidelines exist to inform management decisions in these patients. Systematic review and meta-analysis of survival following different treatment modalities may allow improved treatment selection. This review aimed to identify the optimum treatment strategies for HCC recurrence. METHODS: A systematic review, up to September 2016, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of different treatment modalities was carried out using a random-effects model, with further assessment of additional prognostic factors for survival. RESULTS: Nineteen cohort studies (2764 patients) were included in final data analysis. The median 5-year survival rates after repeat hepatectomy (525 patients), ablation (658) and transarterial chemoembolization (TACE) (855) were 35·2, 48·3 and 15·5 per cent respectively. Pooled analysis of ten studies demonstrated no significant difference between overall survival after ablation versus repeat hepatectomy (hazard ratio 1·03, 95 per cent c.i. 0·68 to 1·55; P = 0·897). Pooled analysis of seven studies comparing TACE with repeat hepatectomy showed no statistically significant difference in survival (hazard ratio 1·61, 0·99 to 2·63; P = 0·056). CONCLUSION: Based on these limited data, there does not appear to be a significant difference in survival between patients undergoing repeat hepatectomy or ablation for recurrent HCC. The results also identify important negative prognostic factors (short disease-free interval, multiple hepatic metastases and large hepatic metastases), which may influence choice of treatment.

JOURNAL ARTICLE

Flott K, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi A, Flott K, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi A, Flott K, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi A, Flott K, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi A, Flott K, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi A, Flott KM, Fontana G, Dhingra-Kumar N, Yu A, Durkin M, Darzi Aet al., 2017, Health care must mean safe care: enshrining patient safety in global health, LANCET, Vol: 389, Pages: 1279-1281, ISSN: 0140-6736

JOURNAL ARTICLE

Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, Mayer E, Flott KM, Graham C, Darzi A, mayer Eet al., 2017, Can we use patient-reported feedback to drive change? The challenges of using patient-reported feedback and how they might be addressed, BMJ QUALITY & SAFETY, Vol: 26, Pages: 502-507, ISSN: 2044-5415

JOURNAL ARTICLE

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou T, Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou Tet al., 2017, Networks of Surgical Innovation: Measuring Value and the Virality of Diffusion The example of Robotic Surgery, BRITISH JOURNAL OF SURGERY, Vol: 104, Pages: 229-229, ISSN: 0007-1323

JOURNAL ARTICLE

Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham NJ, Athanasiou T, Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham NJ, Athanasiou T, Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham NJ, Athanasiou T, Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham NJ, Athanasiou T, Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham NJ, Athanasiou T, Harling L, Lambert J, Ashrafian H, Darzi A, Gooderham N, Athanasiou Tet al., 2017, Elevated serum microRNA 483-5p levels may predict patients at risk of post-operative atrial fibrillation, EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY, Vol: 51, Pages: 73-78, ISSN: 1010-7940

OBJECTIVES: Post-operative atrial fibrillation (POAF) is the commonest post-operative cardiac arrhythmia, affecting ∼1 in 3 patients undergoing coronary artery bypass grafting (CABG). Although its aetiology is complex, atrial substrate changes may pre-dispose to its onset. This study aims to ascertain the atrial microRNA signature of POAF and determine the potential for circulating microRNA as a pre-operative biomarker for this arrhythmia. METHODS: Thirty-four patients undergoing non-emergent, on-pump CABG were prospectively recruited. Right atrial biopsies were taken intra-operatively and snap frozen for RNA extraction. Plasma was obtained at 24 h pre-operatively and at 2 and 4 days post-operatively. POAF was defined by continuous Holter recording. Inter-group comparisons were performed using Student's t-test or analysis of variance as required. Receiver operating characteristic (ROC) analysis was used to determine the diagnostic accuracy of pre-operative serum miRNA as a POAF biomarker. RESULTS: Sixteen microRNAs were differentially expressed in the atrial myocardium of POAF patients when compared with those maintaining sinus rhythm. miR-208a was the most underexpressed [fold change (FC) = 2.458] and miR-483-5p the most overexpressed (FC = 1.804). miR-483-5p also demonstrated significant overexpression in the pre-operative serum of these patients, with ROC analysis demonstrating an overall predictive accuracy of 78%. CONCLUSIONS: This study provides the first description of atrial myocardial and circulating plasma microRNA in POAF patients. Our findings suggest POAF may be associated with pre-existing atrial substrate differences predisposing to arrhythmogenesis. Moreover, this study highlights the potential for miR-483-5p in biomarker development. Further work must now perform prospective, targeted validation of these results in a larger patient cohort.

JOURNAL ARTICLE

Hassen Y, Johnston M, Barrow EJ, Darzi Aet al., 2017, Safety and the Use of Checklists in Acute Care Surgery, Acute Care Surgery Handbook Volume 1 General Aspects, Non-gastrointestinaI and Critical Care Emergencies, Publisher: Springer, ISBN: 9783319153407

This pocket manual is a practically oriented, wide-ranging guide to acute care surgery general aspects and to non-gastrointestinal emergencies.

BOOK CHAPTER

Howell A-M, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A, Howell A-M, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A, Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A, Howell A-M, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A, Howell A-M, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A, Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi Aet al., 2017, Incident reporting: rare incidents may benefit from national problem solving, BMJ QUALITY & SAFETY, Vol: 26, Pages: 517-517, ISSN: 2044-5415

JOURNAL ARTICLE

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