Publications
269 results found
Muthuswamy K, Fisher R, Petrou F, et al., 2019, Axillary lymph node dissection training in a post‐Z0011 era: A survey of UK breast surgery trainees, The Breast Journal, Vol: 25, Pages: 1037-1041, ISSN: 1075-122X
Modi HN, Singh H, Fiorentino F, et al., 2019, Association of residents' neural signatures with stress resilience during surgery, JAMA Surgery, Vol: 154, 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. Design, Setting, and Participants: Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake. Exposures: Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-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 [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin 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: Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral P
Ahmed M, Wood S, Leff D, 2019, An evaluation of access to critical breast oncoplastic patient information within a regional autologous free-flap reconstruction service, ECANCERMEDICALSCIENCE, Vol: 13, ISSN: 1754-6605
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Berthelot M, Henry FP, Hunter J, et al., 2019, Pervasive wearable device for free tissue transfer monitoring based on advanced data analysis: clinical study report, Journal of Biomedical Optics, Vol: 24, Pages: 067001-1-067001-8, ISSN: 1083-3668
Free tissue transfer (FTT) surgery for breast reconstruction following mastectomy has become a routineoperation with high success rates. Although failure is low, it can have a devastating impact on patient recovery,prognosis and psychological well-being. Continuous and objective monitoring of tissue oxygen saturation (StO2) hasshown to reduce failure rates through rapid detection time of postoperative vascular complications. We have developeda pervasive wearable wireless device that employs near infrared spectroscopy (NIRS) to continuously monitor FTTviaStO2measurement. Previously tested on different models, this paper introduces the results of a clinical study. Thegoal of the study is to demonstrate the developed device can reliably detectStO2variations in a clinical setting: 14patients were recruited. Advanced data analysis were performed on theStO2variations, the relativeStO2gradientchange, and, the classification of theStO2within different clusters of blood occlusion level (from 0% to 100% at 25%step) based on previous studies made on a vascular phantom and animals. The outcomes of the clinical study concurwith previous experimental results and the expected biological responses. This suggests the device is able to correctlydetect perfusion changes and provide real-time assessment on the viability of the FTT in a clinical setting.
Teoh V, Tasoulis MK, Leff DR, et al., 2019, Evaluation of the Role of Neoadjuvant Radiotherapy in the Management of Patients Treated with Mastectomy and Immediate Autologous Breast Reconstruction., J Reconstr Microsurg
Modi H, Singh H, Fiorentino F, et al., 2019, 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
Grant Y, Al-Khudairi R, St John E, et al., 2019, Patient-level costs in margin re-excision for breast-conserving surgery, British Journal of Surgery, Vol: 106, Pages: 384-394, ISSN: 1365-2168
BackgroundHigh rates of reoperation following breast‐conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re‐excision costs and compare the direct patient‐level costs between patients undergoing successful BCS versus reoperations after BCS.MethodsThe study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient‐Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.ResultsThe median QHES score was 47 (i.q.r. 32·5–79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234–11786 and $655–9136 respectively. Over a 12‐month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752–18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).ConclusionThe systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high‐quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.
Chidambaram S, Erridge S, Leff D, et al., 2019, A randomized controlled trial of skills transfer: from touch surgery to laparoscopic cholecystectomy, Journal of Surgical Research, Vol: 234, Pages: 217-223, ISSN: 0022-4804
BackgroundSurgical training has traditionally involved teaching trainees in the operating room. However, intraoperative training is time-intensive and exposes patients to greater risks. Touch Surgery (TS) is an application that uses animation to provide simulation training via cognitive task analysis as an adjunct to intraoperative training.MethodsForty students were recruited and randomly allocated to either a control or intervention group. Each group received the same preparation before intervention, including a 10-min introduction to laparoscopic equipment and a 15-min educational tutorial on laparoscopic cholecystectomies. The participants then received training via either TS (intervention) or written information (control). Their performance was compared using a validated scoring tool on a porcine laparoscopic cholecystectomy model. Significance was defined as P < 0.050.ResultsIn total, n = 22 and n = 18 participants were randomly assigned to intervention and control groups, respectively. There was no significant difference between age (P = 0.320), year of medical school (P = 0.322), handedness (P = 1.000), or gender (P = 0.360) of the groups. The overall mean performance score was higher for intervention (mean ± SD = 41.9 ± 22.5) than control (mean ± SD = 24.7 ± 19.6; P = 0.016). There was no significant difference between scores for each intraoperative segment between the intervention and control group (P > 0.050).ConclusionsThis study demonstrates that TS is effective for providing cognitive training in laparoscopic cholecystectomies to medical students. It is likely that this effect will be seen across modules and other platforms that use cognitive task analysis alongside high-fidelity animation. Further work is necessary to extend this to other surgical procedures for evaluating its longitudinal effectiveness.
Leiloglou M, Chalau V, Kedrzycki M, et al., 2019, Fluorescence Intensity Image Guided Breast Conserving Surgery (BCS)., European Molecular Imaging Meeting
Hall A, Leff D, Wojdecka A, et al., 2019, Beyond the healthcare paradigm: Co-creating a new model for collaborative transdisciplinary healthcare design education
Although healthcare has long been a focus for design research dating from the 1960’s and Bruce Archer’s Industrial Design (Engineering) research unit, there remain very few academic programmes in the field of healthcare design and even fewer that go beyond classic user driven models. This paper reports on a unique collaboration between the Royal College of Art and Imperial College in London to develop an innovative partnership and programme structure between two diverse collaborating institutions. Moreover, the partnership has shown how new design and healthcare research methods have been used for innovative practice-based healthcare design projects. We reflect on the diverse skill sets and approaches that have evolved through collaborative teamwork between healthcare practitioners, designers and diverse disciplinary backgrounds. Our conclusions illustrate how a context driven programme provides evidence of a new ‘post-disciplinary’ mindset and explores implications for research and practice for the future of healthcare design.
Leiloglou M, Chalau V, Kedrzycki M, et al., 2019, Snapshot Fluorescence Hyperspectral System for Breast Cancer Surgery Guidance, Hamlyn Symposium Advanced Biophotonics Workshop
Kedrzycki M, Leiloglou M, Chalau V, et al., 2019, Highlighting Breast Cancer: First-in-Human Testing of the Imperial Camera System for Fluorescence Guided Breast Cancer Surgery, London Surgery Symposium
Hall A, Leff D, Wojdecka A, et al., 2019, Beyond the healthcare paradigm: Co-creating a new model for collaborative transdisciplinary healthcare design education
© 2019 Institution of Engineering Designers, The Design Society. All rights reserved. Although healthcare has long been a focus for design research dating from the 1960’s and Bruce Archer’s Industrial Design (Engineering) research unit, there remain very few academic programmes in the field of healthcare design and even fewer that go beyond classic user driven models. This paper reports on a unique collaboration between the Royal College of Art and Imperial College in London to develop an innovative partnership and programme structure between two diverse collaborating institutions. Moreover, the partnership has shown how new design and healthcare research methods have been used for innovative practice-based healthcare design projects. We reflect on the diverse skill sets and approaches that have evolved through collaborative teamwork between healthcare practitioners, designers and diverse disciplinary backgrounds. Our conclusions illustrate how a context driven programme provides evidence of a new ‘post-disciplinary’ mindset and explores implications for research and practice for the future of healthcare design.
Hall A, Leff D, Wojdecka A, et al., 2019, Beyond the healthcare paradigm: Co-creating a new model for collaborative transdisciplinary healthcare design education
© 2019 Institution of Engineering Designers, The Design Society. All rights reserved. Although healthcare has long been a focus for design research dating from the 1960’s and Bruce Archer’s Industrial Design (Engineering) research unit, there remain very few academic programmes in the field of healthcare design and even fewer that go beyond classic user driven models. This paper reports on a unique collaboration between the Royal College of Art and Imperial College in London to develop an innovative partnership and programme structure between two diverse collaborating institutions. Moreover, the partnership has shown how new design and healthcare research methods have been used for innovative practice-based healthcare design projects. We reflect on the diverse skill sets and approaches that have evolved through collaborative teamwork between healthcare practitioners, designers and diverse disciplinary backgrounds. Our conclusions illustrate how a context driven programme provides evidence of a new ‘post-disciplinary’ mindset and explores implications for research and practice for the future of healthcare design.
Hall A, Leff D, Wojdecka A, et al., 2019, BEYOND THE HEALTHCARE PARADIGM: CO-CREATING A NEW MODEL FOR COLLABORATIVE TRANSDISCIPLINARY HEALTHCARE DESIGN EDUCATION, 21st International Conference on Engineering and Product Design Education (E and PDE), Publisher: DESIGN SOC
Ashcroft J, Patel R, Singh H, et al., 2018, The Impact of Transcranial direct current stimulation (tDCS) on a surgical knot-tying task, Surgery and Cancer Research Afternoon Abstract
Leff DR, Patani N, Finn M, et al., 2018, A ‘best practice’ care pathway improves management of mastitis and breast abscess, British Journal of Surgery, Vol: 105, Pages: 1615-1622, ISSN: 1365-2168
Background: As a result of surgical sub-specialisation, mastitis and breast abscess may be managed with unnecessary hospitalisation, prolonged admission, variable antibiotic prescribing, incision and drainage rather than aspiration, and loss to follow-up. Objective: To evaluate a ‘best-practice’ algorithm to improve management across a multi-site NHS Trust; focusing on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of stay, intervention by aspiration or incision and drainage, and follow-up. Methods: Management was initially evaluated in a retrospective cohort (Phase-I: “PRE-pathway”, n=53) and subsequently compared to two prospective cohorts (Phase II and III = “POST-pathway”, n=141), one immediately following pathway introduction (Phase II n=61), and a further loop-closing audit (Phase-III, n=80) to assess sustainability of quality improvements. Results: The management pathway and referral proforma improved compliance with antibiotic guidelines (Pre=34.0% vs. Post=58.2%, p<0.01), which was maintained (Phase-II=54.1% vs. III=61.3%, p=0.68) and sustainably increased ultrasound assessment (Pre=37.7% vs. Post=77.3%, p<0.001; Phase-II=75.4% vs. III=78.8%, p=0.89). Reductions in rates of incision and drainage (Pre=7.5% vs. Post=0.7%, p<0.01) were maintained (Phase-II=0% vs. III=1.3%, p=0.38), and follow-up consistently improved (Pre=43.4% vs. Post=95.7%, p<0.001; Phase-II=91.8% vs. III=98.8%, p=0.12). Reduced hospital admission (Pre=30.2% vs. Post=20.6%, p=0.25) and median length of stay [Pre=2 days (range=1-5) vs. Post=1 day (range=1-6), p=0.07] were not statistically significant.
Modi H, Singh H, Yang G, et al., 2018, Neural correlates of stress resilience in the operating room, Journal of The American College of Surgeons, Vol: 227, Pages: e208-e208, ISSN: 1072-7515
IntroductionIntraoperative stressors can increase surgeons’ mental demands, precipitating technical performance decline and risking patient safety. However, the neural signatures of stress resilience among surgeons remain unknown. We aimed to compare activation in the prefrontal cortex (PFC)–important for attention and concentration–between residents demonstrating performance stability and those exhibiting performance decline when operating under time pressure.MethodsThirty-three surgical residents [median age (range) = 33 years (29 to 56), 27 males] performed a laparoscopic suturing task under ‘self-paced’ (no time restriction) and ‘time pressure’ (2-minute per knot time restriction) conditions. A composite deterioration score was calculated based on between-condition differences in technical performance, and subjects were divided into quartiles reflecting performance stability (Q1) and decline (Q4). Changes in oxygenated haemoglobin concentration (HbO2) measured at 24 prefrontal locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Subjective workload was quantified using the Surgical Task Load Index (SURG-TLX).ResultsUnder time pressure, Q1 residents demonstrated task-induced increases in HbO2 in the bilateral ventrolateral PFC (VLPFC), whereas Q4 residents demonstrated HbO2 decreases. The amplitude of activation (ΔHbO2) was significantly greater in Q1 than Q4 in the bilateral VLPFC (left VLPFC: Q1=0.44±1.36μM, Q4=-0.03±1.83μM; right VLPFC: Q1=0.49±1.70μM, Q4=-0.32±2.00μM). There were no significant between-group differences in SURG-TLX scores.ConclusionsResilience to intraoperative stress is associated with sustained prefrontal activation indicating preserved attention and concentration. In contrast, sensitivity to stress is marked by prefrontal deactivation suggesting task disengagement. Future work will aim to develop interventions that recr
Singh H, Modi HN, Ranjan S, et al., 2018, Robotic surgery improves technical performance and enhances prefrontal activation during high temporal demand, Annals of Biomedical Engineering, Vol: 46, Pages: 1621-1636, ISSN: 0090-6964
Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons’ brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = − 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = − 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.
Leff DR, de Silva T, Henry F, et al., 2018, Streamlining decision making in contralateral risk-reducing mastectomy: impact of PREDICT and BOADICEA computations, Annals of Surgical Oncology, Vol: 25, Pages: 3057-3063, ISSN: 1068-9265
Introduction.Patients with sporadic breast cancer (BC)have low contralateral breast cancer risk (CLBCR;approximately 0.7% per annum) and contralateral pro-phylactic mastectomy (CPM) offers no survival advantage.CPM with autologous reconstruction (AR) has majormorbidity and resource implications.Objective.The aim of this study was to review the impactof PREDICT survival estimates and lifetime CLBCRscores on decision making for CPM in patients with uni-lateral BC.Methods.Ofn= 272 consecutive patients undergoingmastectomy and AR, 252 were included. Five- and 10-yearsurvival was computed with the PREDICT(V2) onlineprognostication tool, using age and clinicopathologicalfactors. Based on family history (FH) and tumor biology,CLBCR was calculated using validated BODICEA web-based software. Survival scores were correlated againstCLBCR estimates to identify patients receiving CPM with‘low’ CLBCR (\30% lifetime risk) and poor prognosis (5-year survival\80%). Patients with ‘high’ CLBCRreceiving unilateral mastectomy (UM) were similarlyidentified (UK National Institute of Health and CareExcellence [NICE] criteria for CPM,C30% lifetime BCrisk). Justifications motivating CPM were investigated.Results.Of 252 patients, 215 had UM and 37 had bilateralmastectomy and AR. Only 23 (62%) patients receivingCPM fulfilled the NICE criteria. Of 215 patients, 5 (2.3%)failed to undergo CPM despite high CLBCR and goodprognosis. CPMs were performed, at the patient’s request,for no clear justification (n= 8), contralateral non-invasivedisease, and/or FH (n= 5), FH alone (n= 4) and ipsilateralcancer recurrence-related anxiety (n= 3).Conclusion.In the absence of prospective risk estimatesof CLBCR and prognosis, certain patients receive CPMand reconstruction despite modest CLBCR, yet a propor-tion of patients with good prognoses and substantial riskare not undergoing CPM
Cutress RI, McIntosh SA, Potter S, et al., 2018, Opportunities and priorities for breast surgical research, The Lancet Oncology, Vol: 19, Pages: e521-e533, ISSN: 1470-2045
Singh H, Modi H, Yang G, et al., 2018, Impact of escalating cognitive workload and temporal demands on surgeons cognitive function, 2nd International Neuroergonomics Conference, Publisher: Frontiers Media, ISSN: 1662-5161
Singh H, Modi H, Darzi A, et al., 2018, Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand, Ara Darzi
Athanasiou Award Presentation
Osborne-Grinter M, Patel R, Modi H, et al., 2018, Enhancing Surgical Performance Through Mental Rehearsal: An fNIRS Study, society of functional Near Infra-red Spectroscopy, Biennial meeting of society of functional Near Infra-red Spectroscopy (fNIRS-2018)
Background: Mental rehearsal (MR) is the cognitive rehearsal of a skill without movement to produce genuine sensory experiences. Mandates for new approaches to surgical skill acquisition have led to increased interest in MR as a method of practical learning supplementation. However, the neurophysiological mechanisms underpinning the psychomotor benefits of MR are poorly understood.Objective: To delineate the neural mechanisms that underpin mental imagery-related improvements in surgical performance.Methods: Twelve surgical trainees performed a laparoscopic suturing (LS) task (pre-intervention) followed by randomization to either MR (n=6) or textbook reading (TR; n=6). The LS task was repeated (post-intervention). Subjective workload was quantified using the Surgical Task Load Index and Spielberg State-Trait Anxiety Index. Mental imagery ability was assessed using a mental imagery questionnaire. Continuous heart rate (HR) monitoring captured stress responses. Cortical activation was recorded with optical neuroimaging (ETG-4000, Hitachi Medical Corp., Japan). Technical skill was assessed using progression scores (au), performance scores (units) and leak volumes (mL). Results: There were no baseline differences in demographics, mental imagery ability or laparoscopic performance between the two groups. MR significantly improved post-intervention performance scores (53.10 ± 28.00 a.u. vs. -61.32 ± 40.78 a.u., p=0.04) and reduced leak volume (3.48 ±0.44ml vs. 4.81 ± 0.61ml, p=0.04) when compared to TR. MR also led to significant improvement in subjective imagery ability (41.50 ± 4.59 a.u. vs 31.17 ± 9.11 a.u, P=0.009). There were no differences in subjective or objective stress measures between the two groups. Cortical activation was defined by a significant (p < 0.05) rise in oxygenated haemoglobin with a concurrent fall in deoxygenated haemoglobin. During MR, activation was demonstrated in the left supplementary motor area (S
Deligianni F, Singh H, Modi H, et al., 2018, Expertise Related Disparity in Prefrontal-Motor Brain Connectivity, Hamlyn Symposium on Medical Robotics
Fisher R, Muthuswamy K, Petrou F, et al., 2018, The impact of the American College of Surgeons Oncology Group Z0011 Trial on axillary lymph node dissection cases worldwide: A systematic review, 19th Annual Meeting of the American-Society-of-Breast-Surgeons, Publisher: Springer (part of Springer Nature), Pages: 434-434, ISSN: 1068-9265
Muthuswamy K, Fisher R, Petrou F, et al., 2018, Specialist trainee experiences in axillary lymph node dissection in a post-Z11-era survey indicates declining exposure and confidence, 19th Annual Meeting of the American-Society-of-Breast-Surgeons, Publisher: SPRINGER, Pages: 393-394, ISSN: 1068-9265
Thiruchelvam P, Fisher C, Leff DR, et al., 2018, Pervasive genetic testing, Lancet, Vol: 391, Pages: 2089-2091, ISSN: 0140-6736
Grant Y, Al-Khudairi R, St John E, et al., 2018, Patient level costs of margin excision and re-excision for breast conserving surgery, Association of Breast Surgery 2018
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