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Wiggins T, Markar SR, Mackenzie H, et al., 2018, Evolution in the management of acute cholecystitis in the elderly: population-based cohort study, Surgical Endoscopy, Vol: 32, Pages: 4078-4086, ISSN: 0930-2794
BACKGROUND: Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates. METHODS: Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year. RESULTS: 47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy. CONCLUSION: Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients inc
Markar SR, Brodie B, Chin S-T, et al., 2018, Profile of exhaled-breath volatile organic compounds to diagnose pancreatic cancer, British Journal of Surgery, Vol: 105, Pages: 1493-1500, ISSN: 1365-2168
BACKGROUND: Pancreatic cancer has a very poor prognosis as most patients are diagnosed at an advanced stage when curative treatments are not possible. Breath volatile organic compounds (VOCs) have shown potential as novel biomarkers to detect cancer. The aim of the study was to quantify differences in exhaled breath VOCs of patients with pancreatic cancers compared with cohorts without cancer. METHODS: Patients were recruited to an initial development cohort and a second validation cohort. The cancer group included patients with localized and metastatic cancers, whereas the control group included patients with benign pancreatic disease or normal pancreas. The reference test for comparison was radiological imaging using abdominal CT, ultrasound imaging or endoscopic ultrasonography, confirmed by histopathological examination as appropriate. Breath was collected from the development cohort with steel bags, and from the validation cohort using the ReCIVA™ system. Analysis was performed using gas chromatography-mass spectrometry. RESULTS: A total of 68 patients were recruited to the development cohort (25 with cancer, 43 no cancer) and 64 to the validation cohort (32 with cancer, 32 no cancer). Of 66 VOCs identified, 12 were significantly different between groups in the development cohort on univariable analysis. Receiver operating characteristic (ROC) curve analysis using significant volatile compounds and the validation cohort produced an area under the curve of 0·736 (sensitivity 81 per cent, specificity 58 per cent) for differentiating cancer from no cancer, and 0·744 (sensitivity 70 per cent, specificity 74 per cent) for differentiating adenocarcinoma from no cancer. CONCLUSION: Breath VOCs may distinguish patients with pancreatic cancer from those without cancer.
Kamal F, Kumar S, Singanayagam A, et al., 2018, Volatile organic compound (VOC) analysis to differentiate between bacterial and viral respiratory infections in COPD, 28th International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Leusink A, Markar SR, Wiggins T, et al., 2018, Laparoscopic surgery for perforated peptic ulcer: an English national population-based cohort study, Surgical Endoscopy, Vol: 32, Pages: 3783-3788, ISSN: 0930-2794
BACKGROUND: Randomized controlled trials have shown that laparoscopic approach to surgery for perforated peptic ulcer (PPU) is associated with improved short-term outcomes; however, there is limited evidence concerning national practice. The aim of this investigation was to evaluate the effect of laparoscopic approach to PPU surgery upon mortality and morbidity in England. METHODS: Patients with a primary diagnosis of PPU, admitted as an emergency to a hospital in England, and receiving surgical intervention, between 2005 and 2012 were identified from the Hospital Episode Statistics database. Outcomes analyzed included 30-day and 90-day mortality, 30-day complications, and length of hospital stay. Univariate and multivariate analyses were used to identify patient, hospital, and treatment-related factors associated with use of laparoscopy and mortality. RESULTS: The study included 13,022 patients who underwent emergency surgery for PPU in England over an 8-year period. From 2005 to 2012, the utilization of laparoscopic surgery for PPU increased from 0 to 13% and was more commonly used in high volume emergency centers. Laparoscopic surgery was associated with significant reductions in 30-day (7% vs. 15.7%; P < 0.001) and 90-day mortality (8.9% vs. 19.6%; P < 0.001), pneumonia (6% vs. 10.1%; P < 0.001), ischemic cardiac events (1% vs. 2.4%; P = 0.007), as well as length of hospital stay (median 5 vs. 7 days; P < 0.001). Factors associated with a reduced utilization of laparoscopic surgery included age ≥ 70 years (Odds ratio (OR) = 0.58 (95% CI) 0.49-0.68) and Charlson Comorbidity Index score ≥ 2 (OR = 0.73; 95% CI 0.57-0.94). CONCLUSION: The rate of laparoscopic repair of PPU is increasing at a national level and more common in high volume emergency centers. It is associated with reduced rates of mortality; pneumonia and s
Obermair A, Graves N, Coleman M, et al., 2018, The Implementation of a Standardised Surgical Training Program for Specialist Gynaecologists to Decrease the Rate of Open, Abdominal Hysterectomy, Publisher: WILEY, Pages: 23-23, ISSN: 0004-8666
Francis NK, Curtis NJ, Conti JA, et al., 2018, EAES classification of intraoperative adverse events in laparoscopic surgery, SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, Vol: 32, Pages: 3822-3829, ISSN: 0930-2794
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Romano A, Doran S, Belluomo I, et al., 2018, High-Throughput Breath Volatile Organic Compound Analysis UsingThermal Desorption Proton Transfer Reaction Time-of-Flight MassSpectrometry, Analytical Chemistry, ISSN: 0003-2700
Boshier PR, Fehervari M, Markar SR, et al., 2018, Variation in exhaled acetone and other ketones in patients undergoing bariatric surgery: a prospective cross-sectional study, Obesity Surgery, Vol: 28, Pages: 2439-2446, ISSN: 0960-8923
BACKGROUND: Dietary restriction together with alteration of the gastrointestinal tract results in major metabolic changes and significant weight loss in patients undergoing bariatric surgery. Current methods of measuring these changes are often inaccurate and lack a molecular basis. The objective of this study was to determine the role of exhaled ketones as non-invasive markers of nutritional status in patients undergoing surgical treatment of obesity. METHODS: Patients at different stages of treatment for obesity were recruited to this single-centre cross-sectional study. The sample time points were as follows: (i) at the time of initial attendance prior to dietary or surgical interventions, (ii) on the day of surgery following a low carbohydrate diet, and (iii) > 3 months after either Roux-en-Y gastric bypass or sleeve gastrectomy. The concentrations of ketones within breath samples were analysed by selected ion flow tube mass spectrometry. RESULTS: Forty patients were recruited into each of the three study groups. Exhaled acetone concentrations increased significantly following pre-operative diet (1396 ppb) and bariatric surgery (1693 ppb) compared to the start of treatment (410 ppb, P < 0.0001). In comparison, concentrations of heptanone (6.5 vs. 4.1 vs. 1.4 ppb, P = 0.021) and octanone (3.0 vs. 1.4 vs. 0.7 ppb, P = 0.021) decreased significantly after dieting and surgical intervention. Exhaled acetone (ρ - 0.264, P = 0.005) and octanone (ρ 0.215, P = 0.022) concentrations were observed to correlate with excess body weight at the time of sampling. Acetone and octanone also correlated with neutrophil and triglyceride levels (P < 0.05). CONCLUSION: Findings confirm breath ketones, particularly acetone, to be a potentially clinically useful method of non-invasive nutritional assessment in obese patients.
Wiggins T, Markar SR, MacKenzie H, et al., 2018, The influence of hospital volume upon clinical management and outcomes of esophageal achalasia: an English national population-based cohort study., Dis Esophagus
Management of achalasia is potentially complex. Previous studies have identified equivalence between pneumatic dilatation and surgical cardiomyotomy in terms of clinical outcomes. However, previous research has not investigated whether a management strategies and outcomes are different in high-volume achalasia centers. This national population-based cohort study aimed to identify the treatment modalities utilized in centers, which regularly manage achalasia and those which manage it infrequently. This study also assessed rates of re-intervention and complications to establish if a volume-outcome relationship exists for the management of achalasia in England. In this study, the Hospitals Episode Statistics database was used to identify all patients treated for achalasia in England from 2002 to 2012. Primary treatment was defined as surgical cardiomyotomy, sequential pneumatic dilatation, or botulinum toxin therapy. Primary outcome measure was reintervention. Centers were divided into regular achalasia centers (≥5.7 cases per annum) and infrequent achalasia centers (<5.7 cases per annum), and were analyzed according to tertiary cancer center status. In total, there were 7,487 patients treated for achalasia. Out of 1,947 cases (26%) were treated in regular achalasia centers, with 5,540 (74%) treated in infrequent centers. In binary logistic regression modeling regular centers treated a similar proportion of patients with primary surgical cardiomyotomy (OR: 1.11 (95% CI 0.98-1.27)) and had similar rates of re-intervention to infrequent achalasia centers (HR: 1.03 (0.94-1.12)). RA-CUSUM analysis demonstrated no relationship between total hospital volume and reintervention rates. Tertiary cancer centers treated more achalasia patients with primary surgical cardiomyotomy (OR: 1.51 (95% CI 1.31-1.73)) but there was no significant difference in reintervention rates (OR: 1.05 (95% CI 0.95-1.16)). In conclusion, this analysis failed to demonstrate a volume-outcome relati
Markar S, Wiggins T, Antonowicz S, et al., 2018, Assessment of a noninvasive exhaled breath test for the diagnosis of oesophagogastric cancer, JAMA Oncology, Vol: 4, Pages: 970-976, ISSN: 2374-2445
Importance Early esophagogastric cancer (OGC) stage presents with nonspecific symptoms.Objective The aim of this study was to determine the accuracy of a breath test for the diagnosis of OGC in a multicenter validation study.Design, Setting, and Participants Patient recruitment for this diagnostic validation study was conducted at 3 London hospital sites, with breath samples returned to a central laboratory for selected ion flow tube mass spectrometry (SIFT-MS) analysis. Based on a 1:1 cancer:control ratio, and maintaining a sensitivity and specificity of 80%, the sample size required was 325 patients. All patients with cancer were on a curative treatment pathway, and patients were recruited consecutively. Among the 335 patients included; 172 were in the control group and 163 had OGC.Interventions Breath samples were collected using secure 500-mL steel breath bags and analyzed by SIFT-MS. Quality assurance measures included sampling room air, training all researchers in breath sampling, regular instrument calibration, and unambiguous volatile organic compounds (VOCs) identification by gas chromatography mass spectrometry.Main Outcomes and Measures The risk of cancer was identified based on a previously generated 5-VOCs model and compared with histopathology-proven diagnosis.Results Patients in the OGC group were older (median [IQR] age 68 [60-75] vs 55 [41-69] years) and had a greater proportion of men (134 [82.2%]) vs women (81 [47.4%]) compared with the control group. Of the 163 patients with OGC, 123 (69%) had tumor stage T3/4, and 106 (65%) had nodal metastasis on clinical staging. The predictive probabilities generated by this 5-VOCs diagnostic model were used to generate a receiver operator characteristic curve, with good diagnostic accuracy, area under the curve of 0.85. This translated to a sensitivity of 80% and specificity of 81% for the diagnosis of OGC.Conclusions and Relevance This study shows the potential of breath analysis in noninvasive diagn
Markar SR, Mackenzie H, Askari A, et al., 2018, Population-based cohort study of surgical myotomy and pneumatic dilatation as primary interventions for oesophageal achalasia, British Journal of Surgery, Vol: 105, Pages: 1028-1035, ISSN: 1365-2168
BackgroundThe aim of this national population‐based cohort study was to compare rates of reintervention after surgical myotomy versus sequential pneumatic dilatation for the primary management of oesophageal achalasia.MethodsPatients with oesophageal achalasia diagnosed between 2002 and 2012, and without an intervention in the preceding 5 years were identified from the Hospital Episode Statistics database. Patients were divided into two groups based on the primary treatment, and propensity score matching was used to compensate for differences in baseline characteristics.ResultsSome 14 705 patients were diagnosed with oesophageal achalasia, of whom 7487 (50·9 per cent) received interventional treatment: 1742 (23·3 per cent) surgical myotomy, 4534 (60·6 per cent) pneumatic dilatation and 1211 (16·2 per cent) endoscopic botulinum toxin injection. As age increased, the proportion of patients receiving myotomy decreased and the proportion undergoing dilatation increased. Patients who underwent surgical myotomy were younger (mean age 44·8 years versus 58·5 years among those who had pneumatic dilatation; P < 0·001), a greater proportion had a Charlson co‐morbidity index score of 0 (90·1 versus 87·7 per cent; P = 0·003) and they were more commonly men (55·6 versus 51·8 per cent; P = 0·020). Following propensity score matching, the safety of the two initial treatment approaches was equivalent, with no difference in incidence of oesophageal perforation (1·3 and 1·4 per cent after myotomy and dilatation respectively; P = 0·750). However, dilatation was associated with increased need for reintervention (59·6 versus 13·8 per cent; P < 0·001) and frequency of reinterventions (mean 0·34 versus 0·06 per year; P < 0·001
Murray AC, Markar S, Mackenzie H, et al., 2018, An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK, Surgical Endoscopy, Vol: 32, Pages: 3055-3063, ISSN: 0930-2794
BACKGROUND: Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS: In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS: Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION: This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.
Woodfield G, Belluomo I, Lin G, et al., 2018, BREATH TESTING FOR GI CANCERS-SCALING UP FOR CLINICAL PRACTICE, Meeting of the International-Digestive-Disease-Forum (IDDF), Publisher: BMJ PUBLISHING GROUP, Pages: A268-A268, ISSN: 0017-5749
Woodfield G, Belluomo I, Lin G, et al., 2018, BREATH TESTING FOR COLORECTAL POLYPS AND CANCER- A LOAD OF HOT AIR?, Meeting of the International-Digestive-Disease-Forum (IDDF), Publisher: BMJ PUBLISHING GROUP, Pages: A206-A207, ISSN: 0017-5749
Boshier PR, Adam ME, Doran S, et al., 2018, Effects of intraoperative pyloric stretch procedure on outcomes after esophagectomy., Dis Esophagus
Various methods have been described to aid pyloric drainage in patients undergoing esophagectomy with gastric reconstruction. These techniques are intended to prevent delayed gastric empting following esophagectomy that can be associated with early morbidity and long-term functional complaints. The current study aims to review the safety and efficacy of a pyloric stretch procedure performed at the time of esophagectomy. To achieve this, a retrospective review of 100 consecutive patients undergoing esophagectomy during the period 2011-2016 was performed. Until May 2013, no patients received intraoperative pyloric intervention. After May 2013, all patients (N = 50) underwent intraoperative pyloric stretch procedure that involved bidirectional mechanical dilatation of the pylorus. Postoperative outcomes including result of routine oral contrast swallow and early morbidity were evaluated. Intraoperative pyloric stretching was performed safely and without local complications in all patients. Delayed gastric emptying was observed significantly less frequently in patients who received intraoperative pyloric stretching (48% vs. 22%, P = 0.006). No significant differences were observed in postoperative outcomes. When considering all patients as a single cohort, the presence of delayed gastric emptying was associated with significantly higher rates of postoperative pneumonia (71% vs. 45%, P = 0.010), cardiac complications (57% vs. 25%, P = 0.001) as well as longer hospital say (12 vs. 15 days, P < 0.001) and delay to free oral fluid intake (7 vs. 9 days, < 0.001). Binary logistic regression identified age and postoperative delayed gastric emptying as independent risk factors for postoperative pneumonia. In conclusion, this study has demonstrated the safety and efficacy an intraoperative pyloric stretch procedure for the prevention of delayed gastric emptying following esophagectomy.
Visser E, Markar SR, Ruurda JP, et al., 2018, Prognostic Value of Lymph Node Yield on Overall Survival in Esophageal Cancer Patients: A Systematic Review and Meta-analysis., Ann Surg
OBJECTIVE: This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy. BACKGROUND: Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy. METHODS: An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed. RESULTS: A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group [hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74-0.87; P < 0.01]. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62-0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73-0.92; P < 0.01). CONCLUSION: This meta-analysis demonstrates the benefit of an increased lymph node yi
Romano A, Hanna G, 2018, Identification and quantification of VOCs by Proton Transfer Reaction Time of Flight Mass Spectrometry: an experimental workflow for the optimization of specificity, sensitivity and accuracy, Journal of Mass Spectrometry, Vol: 53, Pages: 287-295, ISSN: 1076-5174
Proton Transfer Reaction Time of Flight Mass Spectrometry (PTR-ToF-MS) is a direct injection MS technique, allowing for the sensitive and real-time detection, identification and quantification of volatile organic compounds (VOCs). When aiming to employ PTR-ToF-MS for targeted VOC analysis some methodological questions must be addressed, such as the need to correctly identify product ions, or evaluating the quantitation accuracy. This work proposes a workflow for PTR-ToF-MS method development, addressing the main issues affecting the reliable identification and quantification of target compounds. We determined the fragmentation patterns of 13 selected compounds (aldehydes, fatty acids, phenols). Experiments were conducted under breath-relevant conditions (100% humid air), and within an extended range of reduced electric field values (E/N = 48-144 Td), obtained by changing drift tube voltage. Reactivity was inspected using H3O+, NO+ and O2+ as primary ions. The results show that a relatively low (< 90 Td) E/N often permits to reduce fragmentation enhancing sensitivity and identification capabilities, particularly in the case of aldehydes using NO+, where a 4-fold increase in sensitivity is obtained by means of drift voltage reduction. We developed a novel calibration methodology, relying on diffusion tubes used as gravimetric standards. For each of the tested compounds, it was possible to define suitable conditions whereby experimental error, defined as difference between gravimetric measurements and calculated concentrations, was 8% or lower.
Boshier PR, Ziff C, Adam ME, et al., 2018, Effect of perioperative blood transfusion on the long-term survival of patients undergoing esophagectomy for esophageal cancer: a systematic review and meta-analysis, DISEASES OF THE ESOPHAGUS, Vol: 31, ISSN: 1442-2050
Markar SR, Mackenzie H, Jemal S, et al., 2018, Emergency presentation of esophagogastric cancer predictors and long-term prognosis, Annals of Surgery, Vol: 267, Pages: 711-715, ISSN: 0003-4932
Objective: To identify patient factors that are associated with emergency presentation of esophageal and gastric cancer, and further to evaluate long-term prognosis in this cohort.Background: The incidence of emergency presentation is variable, with the prognosis of patients stabilized and discharged to return for elective surgery unknown.Methods: The primary admission of patients with esophageal or gastric cancer within the Hospital Episode Statistics database (1997–2012) was used to classify as emergency or elective diagnosis. Multivariate regression analyses were used to identify patient factors associated with emergency diagnosis and prognosis.Results: A total of 35,807 (29.4%) and 45,866 (39.6%) patients with esophageal and gastric cancer presented as an emergency over the study period. Age ≥70, female sex, non-white ethnicity, Charlson comorbidity index score ≥3 and more deprived Townsend index were independent predictors of emergency cancer diagnosis. Emergency diagnosis was an independent predictor of increased 5-year mortality for all patients with esophageal cancer [hazard ratio (HR) = 1.63, 95% confidence interval (CI) 1.61–1.65] and gastric cancer (HR = 1.20, 95% CI 1.16–1.23). Specifically patients receiving surgery on an elective follow-up admission with an initial emergency diagnosis had a poorer prognosis (esophageal cancer: HR = 1.35, 95% CI 1.27–1.44, gastric cancer: HR = 1.13. 95% CI 1.04–1.22), with a significant increase in liver recurrence (esophageal cancer: 7.1% vs 4.9%; P < 0.001, gastric cancer: 7.0% vs 4.8%; P < 0.001) compared to patients referred electively.Conclusions: Emergency presentation of esophageal and gastric cancer is associated with a poor prognosis, due to the increased incidence of metastatic disease at diagnosis and a higher recurrence rate after surgery.
Chin S-T, Romano A, Doran SLF, et al., 2018, Cross-platform mass spectrometry annotation in breathomics of oesophageal-gastric cancer, SCIENTIFIC REPORTS, Vol: 8, ISSN: 2045-2322
Disease breathomics is gaining importance nowadays due to its usefulness as non-invasive early cancer detection. Mass spectrometry (MS) technique is often used for analysis of volatile organic compounds (VOCs) associated with cancer in the exhaled breath but a long-standing challenge is the uncertainty in mass peak annotation for potential volatile biomarkers. This work describes a cross-platform MS strategy employing selected-ion flow tube mass spectrometry (SIFT-MS), high resolution gas chromatography-mass spectrometry (GC-MS) retrofitted with electron ionisation (EI) and GC-MS retrofitted with positive chemical ionisation (PCI) as orthogonal analytical approaches in order to provide facile identification of the oxygenated VOCs from breath of cancer patients. In addition, water infusion was applied as novel efficient PCI reagent in breathomics analysis, depicting unique diagnostic ions M+ or [M-17]+ for VOC identification. Identity confirmation of breath VOCs was deduced using the proposed multi-platform workflow, which reveals variation in breath oxygenated VOC composition of oesophageal-gastric (OG) cancer patients with dominantly ketones, followed by aldehydes, alcohols, acids and phenols in decreasing order of relative abundance. Accurate VOC identification provided by cross-platform approach would be valuable for the refinement of diagnostic VOC models and the understanding of molecular drivers of VOC production.
Leiloglou M, Qi J, Rees Whippey D, et al., 2018, Guiding Fluorescence-Augmented Imaging System for Breast Cancer Surgery, BMES Annual Meeting
Singh M, Nabavi E, Zhou Y, et al., 2018, Fluorescence image-guided photothermal therapy: Diagnosis and treatment of upper gastrointestinal cancer and beyond (prize winner), Global Surgery
Leiloglou M, Qi J, Rees Whippey D, et al., 2018, Guiding Fluorescence-Augmented Imaging System for Breast Cancer Surgery, EPSRC Image Guided Therapies Young Investigators
Brookes ST, Chalmers KA, Avery KNL, et al., 2018, Impact of question order on prioritisation of outcomes in the development of a core outcome set: a randomised controlled trial, Trials, Vol: 19, Pages: 66-66, ISSN: 1745-6215
BACKGROUND: Core outcome set (COS) developers increasingly employ Delphi surveys to elicit stakeholders' opinions of which outcomes to measure and report in trials of a particular condition or intervention. Research outside of Delphi surveys and COS development demonstrates that question order can affect response rates and lead to 'context effects', where prior questions determine an item's meaning and influence responses. This study examined the impact of question order within a Delphi survey for a COS for oesophageal cancer surgery. METHODS: A randomised controlled trial was nested within the Delphi survey. Patients and health professionals were randomised to receive a survey including clinical and patient-reported outcomes (PROs), where the PRO section appeared first or last. Participants rated (1-9) the importance of 68 items for inclusion in a COS (ratings 7-9 considered 'essential'). Analyses considered the impact of question order on: (1) survey response rates; (2) participants' responses; and (3) items retained at end of the survey. RESULTS: In total, 116 patients and 71 professionals returned completed surveys. Question order did not affect response rates among patients, but fewer professionals responded when clinical items appeared first (difference = 31.3%, 95% confidence interval [CI] = 13.6-48.9%, P = 0.001). Question order led to different context effects within patients and professionals. While patients rated clinical items highly, irrespective of question order, more PROs were rated essential when appearing last rather than first (difference = 23.7%, 95% CI = 10.5-40.8%). Among professionals, the greatest impact was on clinical items; a higher percentage rated essential when appearing last (difference = 11.6%, 95% CI = 0.0-23.3%). An interaction between question order and the percentage of PRO/clinical items rated essential was observed for patients (P&t
Borsci S, Uchegbu I, Buckle P, et al., 2017, Designing medical technology for resilience: Integrating health economics and human factors approaches, Expert Review of Medical Devices, Vol: 15, Pages: 15-26, ISSN: 1743-4440
INTRODUCTION: The slow adoption of innovation into healthcare calls into question the manner of evidence generation for medical technology. This paper identifies potential reasons for this including a lack of attention to human factors, poor evaluation of economic benefits, lack of understanding of the existing healthcare system and a failure to recognise the need to generate resilient products. Areas covered. Recognising a cross-disciplinary need to enhance evidence generation early in a technology's life cycle, the present paper proposes a new approach that integrates human factors and health economic evaluation as part of a wider systems approach to the design of technology. This approach (Human and Economic Resilience Design for Medical Technology or HERD MedTech) supports early stages of product development and is based on the recent experiences of the National Institute for Health Research London Diagnostic Evidence Co-operative in the UK. Expert commentary. HERD MedTech i) proposes a shift from design for usability to design for resilience, ii) aspires to reduce the need for service adaptation to technological constraints iii) ensures value of innovation at the time of product development, and iv) aims to stimulate discussion around the integration of pre- and post-market methods of assessment of medical technology.
Doran SLF, Romano A, hanna GB, 2017, Optimisation of sampling parameters for standardised exhaled breath sampling, Journal of Breath Research, Vol: 12, ISSN: 1752-7155
The lack of standardization of breath sampling is a major contributing factor to the poor repeatability of results and hence represents a barrier to the adoption of breath tests in clinical practice. On-line and bag breath sampling have advantages but do not suit multicentre clinical studies whereas storage and robust transport are essential for the conduct of wide-scale studies. Several devices have been developed to control sampling parameters and to concentrate volatile organic compounds (VOCs) onto thermal desorption (TD) tubes and subsequently transport those tubes for laboratory analysis. We conducted three experiments to investigate (i) the fraction of breath sampled (whole vs. lower expiratory exhaled breath); (ii) breath sample volume (125, 250, 500 and 1000ml) and (iii) breath sample flow rate (400, 200, 100 and 50 ml/min). The target VOCs were acetone and potential volatile biomarkers for oesophago-gastric cancer belonging to the aldehyde, fatty acids and phenol chemical classes. We also examined the collection execution time and the impact of environmental contamination. The experiments showed that the use of exhaled breath-sampling devices requires the selection of optimum sampling parameters. The increase in sample volume has improved the levels of VOCs detected. However, the influence of the fraction of exhaled breath and the flow rate depends on the target VOCs measured. The concentration of potential volatile biomarkers for oesophago-gastric cancer was not significantly different between the whole and lower airway exhaled breath. While the recovery of phenols and acetone from TD tubes was lower when breath sampling was performed at a higher flow rate, other VOCs were not affected. A dedicated ‘clean air supply’ reduces the contamination from ambient air, but the breath collection device itself can be a source of contaminants. In clinical studies using VOCs to elicit potential biomarkers of gastro-oesophageal cancer, the optimum parameter
Boshier PR, Knaggs AL, Hanna GB, et al., 2017, Perioperative changes in exhaled nitric oxide during oesophagectomy, JOURNAL OF BREATH RESEARCH, Vol: 11, ISSN: 1752-7155
Ahmad T, Bouwman RA, Grigoras I, et al., 2017, In-hospital clinical outcomes after upper gastrointestinal surgery: Data from an international observational study, EJSO, Vol: 43, Pages: 2324-2332, ISSN: 0748-7983
Borsci S, Buckle P, Huddy J, et al., 2017, Usability study of pH strips for nasogastric tube placement, PLoS ONE, Vol: 12, Pages: 1-14, ISSN: 1932-6203
Aims(1) To model the process of use and usability of pH strips (2) to identify, through simulation studies, the likelihood of misreading pH strips, and to assess professional’s acceptance, trust and perceived usability of pH strips.MethodsThis study was undertaken in four phases and used a mixed method approach (an audit, a semi-structured interview, a survey and simulation study). The three months audit was of 24 patients, the semi-structured interview was performed with 19 health professionals and informed the process of use of pH strips. A survey of 134 professionals and novices explored the likelihood of misinterpreting pH strips. Standardised questionnaires were used to assess professionals perceived usability, trust and acceptance of pH strip use in a simulated study.ResultsThe audit found that in 45.7% of the cases aspiration could not be achieved, and that 54% of the NG-tube insertions required x-ray confirmation. None of those interviewed had received formal training on pH strips use. In the simulated study, participants made up to 11.15% errors in reading the strips with important implications for decision making regarding NG tube placement. No difference was identified between professionals and novices in their likelihood of misinterpreting the pH value of the strips. Whilst the overall experience of usage is poor (47.3%), health professionals gave a positive level of trust in both the interview (62.6%) and the survey (68.7%) and acceptance (interview group 65.1%, survey group 74.7%). They also reported anxiety in the use of strips (interview group 29.7%, survey group 49.7%).ConclusionsSignificant errors occur when using pH strips in a simulated study. Manufacturers should consider developing new pH strips, specifically designed for bedside use, that are more usable and less likely to be misread.
Markar SR, Mackenzie H, Wiggins T, et al., 2017, Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions, British Journal of Surgery, Vol: 105, Pages: 113-120, ISSN: 1365-2168
BackgroundIn England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.MethodsThe Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997–2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed.ResultsOver the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia.ConclusionCentralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.
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