Imperial College London

Professor the Lord Darzi of Denham PC KBE FRS FMedSci HonFREng

Faculty of MedicineDepartment of Surgery & Cancer

Co-Director of the Institute of Global Health Innovation
 
 
 
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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

1595 results found

Aufegger L, Bicknell C, Soane E, Ashrafian H, Darzi Aet al., 2019, Understanding health management and safety decisions using signal processing and machine learning, BMC Medical Research Methodology, Vol: 19, ISSN: 1471-2288

BackgroundSmall group research in healthcare is important because it deals with interaction and decision-making processes that can help to identify and improve safer patient treatment and care. However, the number of studies is limited due to time- and resource-intensive data processing. The aim of this study was to examine the feasibility of using signal processing and machine learning techniques to understand teamwork and behaviour related to healthcare management and patient safety, and to contribute to literature and research of teamwork in healthcare.MethodsClinical and non-clinical healthcare professionals organised into 28 teams took part in a video- and audio-recorded role-play exercise that represented a fictional healthcare system, and included the opportunity to discuss and improve healthcare management and patient safety. Group interactions were analysed using the recurrence quantification analysis (RQA; Knight et al., 2016), a signal processing method that examines stability, determinism, and complexity of group interactions. Data were benchmarked against self-reported quality of team participation and social support. Transcripts of group conversations were explored using the topic modelling approach (Blei et al., 2003), a machine learning method that helps to identify emerging themes within large corpora of qualitative data.ResultsGroups exhibited stable group interactions that were positively correlated with perceived social support, and negatively correlated with predictive behaviour. Data processing of the qualitative data revealed conversations focused on: (1) the management of patient incidents; (2) the responsibilities among team members; (3) the importance of a good internal team environment; and (4) the hospital culture.ConclusionsThis study has shed new light on small group research using signal processing and machine learning methods. Future studies are encouraged to use these methods in the healthcare context, and to conduct further research

JOURNAL ARTICLE

Dilley J, Camara M, Omar I, Carter A, Pratt P, Vale J, Darzi A, Mayer EKet al., 2019, Evaluating the impact of image guidance in the surgical setting: A systematic review, Surgical Endoscopy, ISSN: 0930-2794

BACKGROUND: Image guidance has been clinically available for over a period of 20 years. Although research increasingly has a translational emphasis, overall the clinical uptake of image guidance systems in surgery remains low. The objective of this review was to establish the metrics used to report on the impact of surgical image guidance systems used in a clinical setting. METHODS: A systematic review of the literature was carried out on all relevant publications between January 2000 and April 2016. Ovid MEDLINE and Embase databases were searched using a title strategy. Reported outcome metrics were grouped into clinically relevant domains and subsequent sub-categories for analysis. RESULTS: In total, 232 publications were eligible for inclusion. Analysis showed that clinical outcomes and system interaction were consistently reported. However, metrics focusing on surgeon, patient and economic impact were reported less often. No increase in the quality of reporting was observed during the study time period, associated with study design, or when the clinical setting involved a surgical specialty that had been using image guidance for longer. CONCLUSIONS: Publications reporting on the clinical use of image guidance systems are evaluating traditional surgical outcomes and neglecting important human and economic factors, which are pertinent to the uptake, diffusion and sustainability of image-guided surgery. A framework is proposed to assist researchers in providing comprehensive evaluation metrics, which should also be considered in the design phase. Use of these would help demonstrate the impact in the clinical setting leading to increased clinical integration of image guidance systems.

JOURNAL ARTICLE

Qiu S, Nikolaou S, Fiorentino F, Rasheed S, Darzi A, Cunningham D, Tekkis P, Kontovounisios Cet al., 2019, Exploratory Analysis of Plasma Neurotensin as a Novel Biomarker for Early Detection of Colorectal Polyp and Cancer, HORMONES & CANCER, Vol: 10, Pages: 128-135, ISSN: 1868-8497

JOURNAL ARTICLE

Cohen D, Vlaev I, Heitmueller A, Parston G, Schmidtke KA, Darzi Aet al., 2019, Validation of behavioral simulations: a case study on enhancing collaboration between partnership organizations, JOURNAL OF PUBLIC HEALTH-HEIDELBERG, Vol: 27, Pages: 367-378, ISSN: 2198-1833

JOURNAL ARTICLE

Patel VM, Panzarasa P, Ashrafian H, Evans TS, Kirresh A, Sevdalis N, Darzi A, Athanasiou Tet al., 2019, Collaborative patterns, authorship practices and scientific success in biomedical research: a network analysis., J R Soc Med, Vol: 112, Pages: 245-257

OBJECTIVE: To investigate the relationship between biomedical researchers' collaborative and authorship practices and scientific success. DESIGN: Longitudinal quantitative analysis of individual researchers' careers over a nine-year period. SETTING: A leading biomedical research institution in the United Kingdom. PARTICIPANTS: Five hundred and twenty-five biomedical researchers who were in employment on 31 December 2009. MAIN OUTCOME MEASURES: We constructed the co-authorship network in which nodes are the researchers, and links are established between any two researchers if they co-authored one or more articles. For each researcher, we recorded the position held in the co-authorship network and in the bylines of all articles published in each three-year interval and calculated the number of citations these articles accrued until January 2013. We estimated maximum likelihood negative binomial panel regression models. RESULTS: Our analysis suggests that collaboration sustained success, yet excessive co-authorship did not. Last positions in non-alphabetised bylines were beneficial for higher academic ranks but not for junior ones. A professor could witness a 20.57% increase in the expected citation count if last-listed non-alphabetically in one additional publication; yet, a lecturer suffered from a 13.04% reduction. First positions in alphabetised bylines were positively associated with performance for junior academics only. A lecturer could experience a 8.78% increase in the expected citation count if first-listed alphabetically in one additional publication. While junior researchers amplified success when brokering among otherwise disconnected collaborators, senior researchers prospered from socially cohesive networks, rich in third-party relationships. CONCLUSIONS: These results help biomedical scientists shape successful careers and research institutions develop effective assessment and recruitment policies that will ultimately sustain the quality of biomedical r

JOURNAL ARTICLE

Moussa OM, Ardissino M, Kulatilake P, Faraj A, Muttoni E, Darzi A, Ziprin P, Scholtz S, Purkayastha Set al., 2019, Effect of body mass index on depression in a UK cohort of 363 037 obese patients: A longitudinal analysis of transition, Clinical Obesity, Vol: 9, ISSN: 1758-8103

With obesity levels increasing, it is important to consider the mental health risks associated with this condition to optimize patient care. Links between depression and obesity have been explored, but few studies focus on the risk profiles of patients across stratified body mass index (BMI) classes above 30 kg/m2 . This study aims to determine the impact of BMI on depression risk in patients with obesity and to investigate trends of depression in a large cohort of British patients with BMI > 30 kg/m2 . A nationwide primary care database, the Clinical Practice Research Datalink (CPRD), was analysed for diagnoses of obesity (BMI > 30 kg/m2 ). Obese patients were then sub-classified into seven BMI categories. Primary health care-based records of patients entered in the CPRD were analysed. A total of 363 037 patients had a BMI ≥ 30 kg/m2 ; of these patients 97 392 (26.8%) also had a diagnosis of depression. Absolute event rates over time and hazard risk of depression were analysed by BMI category. On Cox regression analysis of time to development of depression, the cumulative hazard increased significantly and linearly across BMI groups (P < 0.001). Compared to those with BMI 30 to 35 kg/m2 , patients with BMI 35 to 40 kg/m2 had a 20% higher risk of depression (hazard ratio [HR] 1.206, confidence interval [CI] 1.170-1.424), and those with BMI > 60 kg/m2 had a 98% higher risk (HR 1.988, CI 1.513-2.612). This study identified the prevalence and time course of depression in a cohort of obese patients in the United Kingdom. Findings suggest the risk of depression is directly proportional to BMI above 30 kg/m2 . Therefore, clinicians should note higher BMI levels confer increased risk of depression.

JOURNAL ARTICLE

Modi H, Singh H, Fiorentino F, Orihuela-Espina F, Athanasiou T, Yang G-Z, Darzi A, Leff Det al., Neural signatures of resident resilience, JAMA Surgery, ISSN: 2168-6254

Importance: Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC).Objective: To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline. The a priori hypothesis being that under temporal demand sustained prefrontal “activation(s)” reflect performance stability, whereas performance decline is manifest as “deactivation(s)”.Design: Cohort study conducted from July 2015 to September 2016. Setting: Single center (Imperial College Healthcare NHS Trust, United Kingdom). Participants: 102 surgical residents (PGY1 and above) were invited to participate, of which 33 agreed to partake (median age [range]: 33 [29-56] years, 27 [82%] males).Exposure: Subjects performed a laparoscopic suturing task under two conditions: ‘self-paced’ (SP; without time per knot restrictions), and ‘time pressure’ (TP; two-minute per knot time restriction). Main Outcomes and Measures: A composite deterioration score was computed based on between-condition differences in task performance metrics [(task progression score (au), error score (mm), leak volume (ml) and knot tensile strength (N)]. Based on the composite score, quartiles were computed reflecting performance stability (Q1) and decline (Q4). Changes in PFC oxygenated haemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate. Results: Q1 residents demonstrated task-induced incr

JOURNAL ARTICLE

Gooderham N, Alkandari A, Ashrafian H, Sathyapalan T, Darzi A, Holmes E, Athanasiou T, Atkin Set al., 2019, Bariatric surgery modulates urinary levels of microRNAs involved in the regulation of renal function, Frontiers in Endocrinology, Vol: 10, ISSN: 1664-2392

Background: Obesity and diabetes cause chronic kidney disease with a common pathophysiology that is characterized by the accumulation of collagen in the extracellular matrix. Recent evidence has implicated the epithelial-to-mesenchymal transition (EMT) as a key step in this pathology with regulation by microRNAs. Weight loss leads to improvements in renal function; therefore, this study hypothesized that bariatric-surgery aided weight loss would lead to changes in urinary microRNAs involved in the regulation of renal function.Materials and methods: Twenty-four bariatric patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy donated urine pre-operatively and at 2–6 months and 1–2 years post-operatively. Urine samples were also obtained from 10 healthy weight and 7 morbidly obese non-surgical controls. Expression levels of kidney microRNAs were assessed in urine and the function of microRNAs was assessed through the in vitro transfection of HK-2 cells, a kidney proximal tubule cell line.Results: Levels of miR 192, miR 200a, and miR 200b were upregulated in urine following bariatric surgery. This increase was consistent across surgical type and diabetes status and was maintained and enhanced with time. Bariatric surgery alters urinary miR 192 expression from levels seen in morbidly obese patients to levels seen in healthy weight control patients. In mechanistic studies, the transfection of miR 192 in HK-2 cells increased miR 200a expression and decreased ZEB2, a key transcriptional promoter of kidney fibrosis.Conclusions: Bariatric surgery increased miR 192 and miR 200 urinary levels, key anti-fibrotic microRNAs that could contribute to a renal-protective mechanism and may be of value as urinary biomarkers following surgery. These findings suggest that urinary microRNAs may represent potential novel biomarkers for obesity-associated renal function.

JOURNAL ARTICLE

Martin G, Clarke J, Liew F, Arora S, King D, Paul A, Darzi Aet al., 2019, Evaluating the impact of organisational digital maturity on clinical outcomes in secondary care in England, npj Digital Medicine, Vol: 2, ISSN: 2398-6352

All healthcare systems are increasingly reliant on health information technology to support the delivery of high-quality, efficient and safe care. Data on its effectiveness are however limited. We therefore sought to examine the impact of organisational digital maturity on clinical outcomes in secondary care within the English National Health Service. We conducted a retrospective analysis of routinely collected administrative data for 13,105,996 admissions across 136 hospitals in England from 2015 to 2016. Data from the 2016 NHS Clinical Digital Maturity Index were used to characterise organisational digital maturity. A multivariable regression model including 12 institutional covariates was utilised to examine the relationship between one measure of organisational digital maturity and five key clinical outcome measures. There was no significant relationship between organisational digital maturity and risk-adjusted 30-day mortality, 28-day readmission rates or complications of care. In multivariable analysis risk-adjusted long length of stay and harm-free care were significantly related to aspects of organisational digital maturity; digitally mature hospitals may not only deliver more harm-free care episodes but also may have a significantly increased risk of patients experiencing a long length of stay. Organisational digital maturity is to some extent related to selected clinical outcomes in secondary care in England. Digital maturity is, however, also strongly linked to other institutional factors that likely play a greater role in influencing clinical outcomes. There is a need to better understand how health IT impacts care delivery and supports other drivers of hospital quality.

JOURNAL ARTICLE

Aufegger L, Shariq O, Bicknell C, Ashrafian H, Darzi Aet al., 2019, Can shared leadership enhance clinical team management? A systematic review, Leadership in Health Services, Vol: 32, Pages: 309-335, ISSN: 1751-1879

PurposeResearch in psychology or management science has shown that shared leadership (SL) enhances information sharing, fosters participation and empowers team members within the decision-making processes, ultimately improving the quality of performance outcomes. Little has been done and, thus, less is known of the value and use of SL in acute healthcare teams. The purpose of this study is to (1) explore, identify and critically assess patterns and behaviour of SL in acute healthcare teams; and (2) evaluate to what extent SL may benefit and accomplish safer care in acute patient treatment and healthcare delivery.Design/methodology/approachThe authors conducted a review that followed the PRISMA-P reporting guidelines. A variety of sources were searched in April 2018 for studies containing primary research that focused on SL in acute healthcare teams. The outcome of interest was a well-specified assessment of SL, and an evaluation of the extent SL may enhance team performance, lead to safer patient care and healthcare delivery in acute healthcare teams.FindingsAfter the study selection process, 11 out of 1,383 studies were included in the review. Studies used a qualitative, quantitative or mixed-methods approach. Emerging themes based on behavioural observations that contributed to SL were: shared mental model; social support and situational awareness; and psychological safety. High-performing teams showed more SL behaviour, teams with less seniority displayed more traditional leadership styles and SL was associated with increased team satisfaction.Research limitations/implicationsEvidence to date suggests that SL may be of benefit to improve performance outcomes in acute healthcare team settings. However, the discrepancy of SL assessments within existing studies and their small sample sizes highlights the need for a large, good quality randomized controlled trial to validate this indication.Originality/valueAlthough studies have acknowledged the relevance of SL in he

JOURNAL ARTICLE

Ghafur S, Grass E, Jennings N, Darzi Aet al., 2019, The challenges of cybersecurity in health care: the UK National Health Service as a case study, The Lancet Digital Health, Vol: 1, Pages: e10-e12, ISSN: 2589-7500

JOURNAL ARTICLE

Lewis J, Mason S, Paizs P, Brinkman DJ, Cameron S, Perdones-Montero A, Darzi A, Takats Z, de Jonge W, Kinross JMet al., 2019, THE PREOPERATIVE FAECAL LIPODOME BUT NOT MICROBIAL DIVERSITY PREDICTS POST-OPERATIVE ILEUS IN ELECTIVE COLORECTAL SURGERY, Digestive Disease Week (DDW), Publisher: W B SAUNDERS CO-ELSEVIER INC, Pages: S1453-S1454, ISSN: 0016-5085

CONFERENCE PAPER

Shah N, Martin G, Archer S, Arora S, King D, Darzi Aet al., 2019, Exploring mobile working in healthcare: Clinical perspectives on transitioning to a mobile first culture of work, INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS, Vol: 125, Pages: 96-101, ISSN: 1386-5056

JOURNAL ARTICLE

Smalley K, Aufegger L, Flott K, Holt G, Mayer E, Darzi Aet al., 2019, Which behaviour change techniques are most effective in improving healthcare utilisation in COPD self-management programmes? A protocol for a systematic review, BMJ Open Respiratory Research, Vol: 6, ISSN: 2052-4439

IntroductionSelf-management interventions are often presented as a way to improve the quality of care for patients with chronic illness. However self-management is quite broadly-defined and it remains unclear which types of interventions are most successful. This review will use the Theoretical Domains Framework (TDF) as a lens through which to categorise self-management interventions regarding which programmes are most likely to be effective, and under which circumstances. The aim of this study is to (1) describe the types of self-management programmes that have been developed in chronic obstructive pulmonary disease (COPD); and identify the common elements between these to better classify the self-management. (2) Evaluate the effect that self-management programmes have on COPD patients’ healthcare behaviour, by classifying those programmes by the behaviour change techniques used. Methods and analysisA systematic search of the literature will be performed in MEDLINE, EMBASE, HMIC, and PsycINFO. This review will be limited to randomised controlled trials (RCTs) and quasi-experimental studies. The review will follow PRISMA-P guidelines, and will provide a PRISMA checklist and flowchart. Risk of bias in individual studies will be assessed using the Cochrane Risk of Bias criteria, and the quality of included studies will be evaluated using the GRADE criteria, and will be reported in a Summary of Findings table.The primary analysis will be a catalogue of the interventions based on the components of the TDF that were utilised in the intervention. A matrix comparing included behaviour change techniques to improvements in utilisation will summarise the primary outcomes. Ethics and dissemination Not applicable, as this is a secondary review of the literature.Registration detailsPROSPERO: CRD42018104753

JOURNAL ARTICLE

Rao A, Dani K, Darzi A, Aylin P, Majeed A, Bottle Ret al., 2019, Regional variation in trajectories of long-term readmission rates among patients in England with heart failure, BMC Cardiovascular Disorders, Vol: 19, ISSN: 1471-2261

BackgroundWe aimed to compare the characteristics and types of heart failure (HF) patients termed “high-impact users”, with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care.MethodsPatients with a primary diagnosis of heart failure (HF) in the period 2008–2009 were identified using nationally representative primary care data linked to national hospital data and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions.ResultsIn each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions.ConclusionThere is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users.

JOURNAL ARTICLE

Miraldo M, Silva F, Gregorio M, Cruz-e-Silva D, Severo M, Nogueira P, Nunes A, Graça P, Lopes C, Breda J, Allen L, Wickramasinghe K, Darzi A, Mikkelsen B, Araújo Fet al., Modelling the impact of a food industry co-regulation agreement on Portugal’s non-communicable disease mortality, Bulletin of the World Health Organization, ISSN: 0042-9686

ObjectiveIn this paper we model the reduction in premature mortality associated with Noncommunicacle Diseases as a result of the establishment of a co-regulation agreement between the Portuguese Ministry of Health and the Portuguese food industry. We also assess whether Portugal is on track to meet the international targets of reducing baseline 2010 premature deaths from noncommunicable diseases by 25% by 2025, and by 30% before 2030. We also aimed to model the impact of the industry co-regulation agreement on premature mortality.MethodsThe 2015co-regulation agreement agreement between the Portuguese food industry and the Portuguese government sets targets of reducing sugar by 20%, salt content by 16% (30% for bread), and <2g trans fatty acids per 100g of fat in a range of products by 2021. The WHO Europe-endorsed PRIME modelling tool was used to estimate the number of Noncommunicacle Diseases deaths that would be averted if these reformulation targets were fully met in the year 2016. Using data on population structure, Noncommunicacle Diseases mortality, and dietary intake from the Portuguese Directorate General of Health, we calculated the actual trends on premature mortality probability for Noncommunicacle Diseases, and projected future trends using regression modelling. FindingsThe risk of premature Noncommunicacle Diseases mortality fell from 13.9% to 10.9% between 2000-2010 but remained relatively unchanged up until 2016. We project that the risk will rise to 11.0% by 2030. If the industry reformulation targets are met we estimate reductions in salt intake of around 7%; total energy reductions from 1,911Kcal/day to 1,897 kcal/day due to reduced sugar intake; and reductions in total fat (% total energy) from 30.4% to 30.3% due to reduced trans fat intake. The PRIME modelling tool calculates that this consumption profile would have resulted in 873 fewer Noncommunicacle Diseases deaths (95%CI 483–1,107) and 247 fewer premature Noncommunicacle Diseases

JOURNAL ARTICLE

Moylan A, Appelbaum N, Clarke J, Feather C, Tairraz AF, Maconochie I, Darzi Aet al., 2019, Assessing the agreement of 5 ideal body weight calculations for selecting medication dosages for children with obesity, JAMA Pediatrics, ISSN: 2168-6203

JOURNAL ARTICLE

Goiana-da-Silva F, Cruz-e-Silva D, Carrico M, Teixeira NR, Darzi A, Araujo Fet al., 2019, Changing the channel: television health campaigns in Portugal, LANCET PUBLIC HEALTH, Vol: 4, Pages: E179-E179, ISSN: 2468-2667

JOURNAL ARTICLE

Runciman M, Darzi A, Mylonas G, Soft robotics in minimally invasive surgery, Soft Robotics, ISSN: 2169-5172

Soft robotic devices have desirable traits for applications in minimally invasive surgery (MIS) but many interdisciplinary challenges remain unsolved. To understand current technologies, we carried out a keyword search using the Web of Science and Scopus databases, applied inclusion and exclusion criteria, and compared several characteristics of the soft robotic devices for MIS in the resulting articles. There was low diversity in the device designs and a wide-ranging level of detail regarding their capabilities. We propose a standardised comparison methodology to characterise soft robotics for various MIS applications, which will aid designers producing the next generation of devices.

JOURNAL ARTICLE

Yeung KTD, Penney N, Ashrafian L, Darzi A, Ashrafian Het al., 2019, Does sleeve gastrectomy expose the distal esophagus to severe reflux?: A systematic review and meta-analysis, Annals of Surgery, ISSN: 0003-4932

MINI: The reported prevalence of new-onset or worsening gastroesophageal reflux disease after sleeve gastrectomy is controversial. Subsequent esophagitis and Barrett's esophagus can be serious unintended sequalae. The aim of this study was to systematically appraise all existing published data to assess the effect of sleeve gastrectomy on gastroesophageal reflux, esophagitis, and Barrett's esophagus. OBJECTIVE: The aim of this study was to appraise the prevalence of gastroesophageal reflux disease (GERD), esophagitis, and Barrett's esophagus (BE) after sleeve gastrectomy (SG) through a systematic review and meta-analysis. BACKGROUND: The precise prevalence of new-onset or worsening GERD after SG is controversial. Subsequent esophagitis and BE can be a serious unintended sequalae. Their postoperative prevalence remains unclear. METHODS: A systematic literature search was performed to identify studies evaluating postoperative outcomes in primary SG for morbid obesity. The primary outcome was prevalence of GERD, esophagitis, and BE after SG. Meta-analysis was performed to calculate combined prevalence. RESULTS: A total of 46 studies totaling 10,718 patients were included. Meta-analysis found that the increase of postoperative GERD after sleeve (POGAS) was 19% and de novo reflux was 23%. The long-term prevalence of esophagitis was 28% and BE was 8%. Four percent of all patients required conversion to RYGB for severe reflux. CONCLUSIONS: The postoperative prevalence of GERD, esophagitis, and BE following SG is significant. Symptoms do not always correlate with the presence of pathology. As the surgical uptake of SG continues to increase, there is a need to ensure that surgical decision-making and the consent process for this procedure consider these long-term complications while also ensuring their postoperative surveillance through endoscopic and physiological approaches. The long-term outcomes of this commonly performed bariatric procedure should be considered alongsid

JOURNAL ARTICLE

Pucher P, Johnston M, Archer S, Whitby J, Dawson P, Arora S, Darzi Aet al., 2019, Informing the consent process for surgeons: A survey study of patient preferences, perceptions and risk tolerance, Journal of Surgical Research, Vol: 235, Pages: 298-302, ISSN: 0022-4804

BackgroundDespite the ethical and statutory requirement to obtain consent for surgical procedures, the actual process itself is less well defined. The degree of disclosure and detail expected may vary greatly. A recent shift toward a more patient-centered approach in both clinical and medico-legal practice has significant implications for ensuring appropriate and legal practice in obtaining informed consent before surgery.MethodsTwo hundred patients undergoing elective surgery across two hospitals returned a survey of attitudes toward consent, perceived important elements in the consent process, and risk tolerance, as well as demographic details.ResultsNo significant associations between patient demographics and survey responses were found. Patients were least concerned with the environment in which consent was taken and the disclosure of uncommon complications. The most important factors related to communication and rapport between clinician and patients, as opposed to procedure- or complication-specific items. A majority of patients preferred risks to be described using proportional descriptors, rather than percentage or non-numeric descriptors.ConclusionsRisk tolerance and desired level of disclosure varies for each patient and should not be presumed to be covered by standardized proformas. We suggest an individualized approach, taking into account each patient's background, understanding, and needs, is crucial for consent. Communications skills must be prioritized to ensure patient satisfaction and reduced risk of litigation.

JOURNAL ARTICLE

Arhi CS, Markar S, Burns EM, Bouras G, Bottle A, Hanna G, Aylin P, Ziprin P, Darzi Aet al., 2019, Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer, Diseases of the Esophagus, ISSN: 1120-8694

NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

JOURNAL ARTICLE

Grant Y, Al-Khudairi R, St John E, Barschkett M, Cunningham D, Al-Mufti R, Hogben K, Thiruchelvam P, Hadjiminas DJ, Darzi A, Carter AW, Leff DRet al., 2019, Patient-level costs in margin re-excision for breast-conserving surgery, 19th Annual Meeting of the American-Society-of-Breast-Surgeons, Publisher: WILEY, Pages: 384-394, ISSN: 0007-1323

CONFERENCE PAPER

Goiana-da-Silva F, Cruz-e-Silva D, Gregorio MJ, Nunes AM, Calhau C, Hercberg S, Rito A, Bento A, Cruz D, Almeida F, Darzi A, Araujo Fet al., 2019, Nutri-Score: A Public Health Tool to Improve Eating Habits in Portugal, ACTA MEDICA PORTUGUESA, Vol: 32, Pages: 175-178, ISSN: 1646-0758

JOURNAL ARTICLE

Jiao LR, Fajardo Puerta AB, Gall TMH, Sodergren MH, Frampton AE, Pencavel T, Nagendran M, Habib NA, Darzi A, Pai M, Thomas R, Tait Pet al., 2019, Rapid induction of liver regeneration for major hepatectomy (REBIRTH): A randomized controlled trial of portal vein embolisation versus ALPPS assisted with radiofrequency., Cancers, Vol: 11, ISSN: 2072-6694

To avoid liver insufficiency following major hepatic resection, portal vein embolisation (PVE) is used to induce liver hypertrophy pre-operatively. Associating liver partition with portal vein ligation for staged hepatectomy assisted with radiofrequency (RALPPS) was introduced as an alternative method. A randomized controlled trial comparing PVE with RALPPS for the pre-operative manipulation of liver volume in patients with a future liver remnant volume (FLRV) ≤25% (or ≤35% if receiving preoperative chemotherapy) was conducted. The primary endpoint was increase in size of the FLRV. The secondary endpoints were length of time taken for the volume gain, morbidity, operation length and post-operative liver function. Between July 2015 and October 2017, 57 patients were randomised to RALPPS (n = 29) and PVE (n = 28). The mean percentage of increase in the FLRV was 80.7 ± 13.7% after a median 20 days following RALPPS compared to 18.4 ± 9.8% after 35 days (p < 0.001) following PVE. Twenty-four patients after RALPPS and 21 after PVE underwent stage-2 operation. Final resection was achieved in 92.3% and 66.6% patients in RALPPS and PVE, respectively (p = 0.007). There was no difference in morbidity, and one 30-day mortality after RALPPS (p = 0.991) was reported. RALPPS is more effective than PVE in increasing FLRV and the number of patients for surgical resection.

JOURNAL ARTICLE

Jiao LR, Fajardo Puerta AB, Gall T, Sodergren M, Frampton A, Pencavel T, Nagendran M, Habib NA, Darzi A, Pai M, Thomas R, Tait Pet al., Rapid induction of liver hypertrophy for major hepatecomy:PVE vs RAPPS - a randominsed clinical trial, Cancers, ISSN: 2072-6694

To avoid liver insufficiency following major hepatic resection, portal vein embolisation (PVE) is used to induce liver hypertrophy pre-operatively. Associating liver partition with portal vein ligation for staged hepatectomy assisted with radiofrequency(RALPPS) was introduced as an alternative method. A randomized controlled trial comparing PVE with RALPPSfor pre-operative manipulation of liver volume in patients with a FLRV ≤25% (≤35% if preoperative chemotherapy) was conducted. The primary endpoint was increase in size of the FLRV. The secondary endpoints were length of time taken for the volume gain, morbidity, operation length andpost-operative liver function. Between July 2015 and October 2017, 57 patients were randomised to RALPPS(n=29) and PVE (n=28). The mean percentage of increase in the FLRV was 80·713·7% after a median 20 days followingRALPPScompared to 18·49·8% after 35 days (p<0.001) following PVE. Twenty-four patients after RALPPSand 21 after PVE underwent stage 2 operation. Final resection was achieved in 92·3% and 66·6% patients in RALPPSand PVE, respectively (p=0.007). There was no difference in morbidity and one 30-day mortality after RALPPS(p=0·991). RALPPSis more effective than PVE in increasing FLRV and the number of patients for surgicalresection.

JOURNAL ARTICLE

Mason SE, Poynter L, Takats Z, Darzi A, Kinross JMet al., 2019, Optical technologies for endoscopic real-time histologic assessment of colorectal polyps: a meta-analysis, American Journal of Gastroenterology, ISSN: 1572-0241

OBJECTIVES: Accurate, real-time, endoscopic risk stratification of colorectal polyps would improve decision-making and optimize clinical efficiency. Technologies to manipulate endoscopic optical outputs can be used to predict polyp histology in vivo; however, it remains unclear how accuracy has progressed and whether it is sufficient for routine clinical implementation. METHODS: A meta-analysis was conducted by searching MEDLINE, Embase, and the Cochrane Library. Studies were included if they prospectively deployed an endoscopic optical technology for real-time in vivo prediction of adenomatous colorectal polyps. Polyposis and inflammatory bowel diseases were excluded. Bayesian bivariate meta-analysis was performed, presenting 95% confidence intervals (CI). RESULTS: One hundred two studies using optical technologies on 33,123 colorectal polyps were included. Digital chromoendoscopy differentiated neoplasia (adenoma and adenocarcinoma) from benign polyps with sensitivity of 92.2% (90.6%-93.9% CI) and specificity of 84.0% (81.5%-86.3% CI), with no difference between constituent technologies (narrow-band imaging, Fuji intelligent Chromo Endoscopy, iSCAN) or with only diminutive polyps. Dye chromoendoscopy had sensitivity of 92.7% (90.1%-94.9% CI) and specificity of 86.6% (82.9%-89.9% CI), similarly unchanged for diminutive polyps. Spectral analysis of autofluorescence had sensitivity of 94.4% (84.0%-99.1% CI) and specificity of 50.9% (13.2%-88.8% CI). Endomicroscopy had sensitivity of 93.6% (85.3%-98.3% CI) and specificity of 92.5% (81.8%-98.1% CI). Computer-aided diagnosis had sensitivity of 88.9% (74.2%-96.7% CI) and specificity of 80.4% (52.6%-95.7% CI). Prediction confidence and endoscopist experience alone did not significantly improve any technology. The only subgroup to demonstrate a negative predictive value for adenoma above 90% was digital chromoendoscopy, making high confidence predictions of diminutive recto-sigmoid polyps. Chronologic meta-analyses show a

JOURNAL ARTICLE

Warren L, Clarke J, Arora S, Barahona M, Arebi N, Darzi Aet al., Transitions of care across hospital settings in patients with inflammatory bowel disease, World Journal of Gastroenterology, ISSN: 1007-9327

BACKGROUNDInflammatory bowel disease (IBD) is a chronic, inflammatory disorder characterised by both intestinal and extra-intestinal pathology. Patients may receive both emergency and elective care from several providers, often in different hospital settings. Poorly managed transitions of care between providers can lead to inefficiencies in care and patient safety issues. To ensure that the sharing of patient information between providers is appropriate, timely, accurate and secure, effective data-sharing infrastructure needs to be developed. To optimise inter-hospital data-sharing for IBD patients, we need to better understand patterns of hospital encounters in this group.AIMTo determine the type and location of hospital services accessed by IBD patients in England.METHODSThis was a retrospective observational study using Hospital Episode Statistics, a large administrative patient data set from the National Health Service in England. Adult patients with a diagnosis of IBD following admission to hospital were followed over a 2-year period to determine the proportion of care accessed at the same hospital providing their outpatient IBD care, defined as their ‘home provider’. Secondary outcome measures included the geographic distribution of patient-sharing, regional and age-related differences in accessing services, and type and frequency of outpatient encounters.RESULTSOf 95055 patients accessed hospital services on 1760156 occasions over a 2-year follow-up period. The proportion of these encounters with their identified IBD ‘home provider’ was 73.3%, 87.8% and 83.1% for accident and emergency, inpatient and outpatient encounters respectively. Patients living in metropolitan centres and younger patients were less likely to attend their ‘home provider’ for hospital services. The most commonly attended specialty services were gastroenterology, general surgery and ophthalmology.CONCLUSIONTransitions of care between secondary care sett

JOURNAL ARTICLE

Camara M, Dawda S, Mayer E, Darzi A, Pratt Pet al., 2019, Subject-specific modelling of pneumoperitoneum: model implementation, validation and human feasibility assessment, International Journal of Computer Assisted Radiology and Surgery, ISSN: 1861-6429

PURPOSE: The aim of this study is to propose a model that simulates patient-specific anatomical changes resulting from pneumoperitoneum, using preoperative data as input. The framework can assist the surgeon through a real-time visualisation and interaction with the model. Such could further facilitate surgical planning preoperatively, by defining a surgical strategy, and intraoperatively to estimate port positions. METHODS: The biomechanical model that simulates pneumoperitoneum was implemented within the GPU-accelerated NVIDIA FleX position-based dynamics framework. Datasets of multiple porcine subjects before and after abdominal insufflation were used to generate, calibrate and validate the model. The feasibility of modelling pneumoperitoneum in human subjects was assessed by comparing distances between specific landmarks from a patient abdominal wall, to the same landmark measurements on the simulated model. RESULTS: The calibration of simulation parameters resulted in a successful estimation of an optimal set parameters. A correspondence between the simulation pressure parameter and the experimental insufflation pressure was determined. The simulation of pneumoperitoneum in a porcine subject resulted in a mean Hausdorff distance error of 5-6 mm. Feasibility of modelling pneumoperitoneum in humans was successfully demonstrated. CONCLUSION: Simulation of pneumoperitoneum provides an accurate subject-specific 3D model of the inflated abdomen, which is a more realistic representation of the intraoperative scenario when compared to preoperative imaging alone. The simulation results in a stable and interactive framework that performs in real time, and supports patient-specific data, which can assist in surgical planning.

JOURNAL ARTICLE

Poynter L, Mirnezami R, Galea D, Veselkov K, Nicholson J, Takats Z, Darzi A, Kinross J, Mirnezami Aet al., 2019, Network mapping of molecular biomarkers influencing radiation response in rectal cancer, Clinical Colorectal Cancer, ISSN: 1533-0028

IntroductionPre-operative radiotherapy (RT) has an important role in the management of locally advanced rectal cancer (RC). Tumour regression following RT shows marked variability and robust molecular methods are needed with which to predict likely response. The aim of this study was to review the current published literature and employ Gene Ontology (GO) analysis to define key molecular biomarkers governing radiation response in RC.MethodsA systematic review of electronic bibliographic databases (MEDLINE, Embase) was performed for original articles published between 2000 and 2015. Biomarkers were then classified according to biological function and incorporated into a hierarchical GO tree. Both significant and non-significant results were included in the analysis. Significance was binarized based on uni- and multivariate statistics. Significance scores were calculated for each biological domain (or node), and a direct acyclic graph was generated for intuitive mapping of biological pathways and markers involved in rectal cancer radiation response.Results72 individual biomarkers, across 74 studies, were identified through review. On highest order classification, molecular biomarkers falling within the domains of response to stress, cellular metabolism and pathways inhibiting apoptosis were found to be the most influential in predicting radiosensitivity.ConclusionsHomogenising biomarker data from original articles using controlled GO terminology demonstrates that cellular mechanisms of response to radiotherapy in RC - in particular the metabolic response to radiotherapy - may hold promise in developing radiotherapeutic biomarkers with which to predict, and in the future modulate, radiation response.

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