Imperial College London

MrPashaNormahani

Faculty of MedicineDepartment of Surgery & Cancer

Clinical Lecturer
 
 
 
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p.normahani

 
 
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Norfolk PlaceSt Mary's Campus

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Publications

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62 results found

Malik-Tabassum K, Lamb JN, Seewoonarain S, Ahmed M, Normahani P, Pandit H, Aderinto J, Rogers Bet al., 2023, Women in trauma and orthopaedics: are we losing them at the first hurdle?, Ann R Coll Surg Engl, Vol: 105, Pages: 653-663

INTRODUCTION: Diversity in the healthcare workforce is associated with improved performance and patient-reported outcomes. Gender disparity in Trauma and Orthopaedics (T&O) is well recognised. The aim of this study was to compare factors that influence career choice in T&O between male and female final-year students. Furthermore, the trend of representation of women in T&O over the last decade was also compared with other surgical specialities. METHODS: An online survey of final-year students who attended nationally advertised T&O courses over a 2-year period was conducted. Data from NHS digital was obtained to assess gender diversity in T&O compared with other surgical specialities. RESULTS: A total of 414 students from 13 UK medical schools completed the questionnaire. Compared with male students (34.2%), a significantly higher proportion of women (65.8%) decided against a career in T&O, p<0.001. Factors that dissuaded a significantly higher percentage of women included gender bias, technical aspects of surgery, unsociable hours, on-call commitments, inadequate undergraduate training and interest in another specialty (p<0.05). Motivating factors for choosing a career in T&O were similar between both sexes. T&O was the surgical specialty with the lowest proportion of women at both consultant and trainee level over the last decade. CONCLUSION: T&O remains an unpopular career choice among women. To enhance recruitment of women in T&O, future strategies should be directed toward medical students. Universities, orthopaedic departments and societies must work collaboratively to embed culture change, improve the delivery of the undergraduate curriculum, and facilitate students' exposure to operating theatres and female role models.

Journal article

Patel K, Sounderajah V, Hanna L, Acharya A, Chidambaram S, Normahani P, Markar SR, Bicknell Cet al., 2023, Quantifying the burden of survivorship associated with infrarenal abdominal aortic aneurysms, JOURNAL OF VASCULAR SURGERY, Vol: 78, Pages: 549-+, ISSN: 0741-5214

Journal article

Poushpas S, Normahani P, Kisil I, Szubert B, Mandic DP, Jaffer Uet al., 2023, Tensor decomposition and machine learning for the detection of arteriovenous fistula stenosis: An initial evaluation, PLOS ONE, Vol: 18, ISSN: 1932-6203

Journal article

Elghazaly H, Howard T, Sharan S, Mohamed O, Sounderajah V, Mehar Z, Davies A, Jaffer U, Normahani Pet al., 2023, Evaluating the prognostic performance of bedside tests used for peripheral arterial disease diagnosis in the prediction of diabetic foot ulcer healing, BMJ Open Diabetes Research and Care, Vol: 11, Pages: 1-11, ISSN: 2052-4897

Introduction:Diabetic foot ulceration (DFU) is a common and challenging complication of diabetes. Risk stratification can guide further management. We aim to evaluate the prognostic performance of bedside tests used for peripheral arterial disease (PAD) diagnosis to predict DFU healing.Research Design and Methods:TrEAD was a prospective observational study comparing the diagnostic performance of commonly-used tests for PAD diagnosis. We performed a secondary analysis assessing whether these could predict DFU healing. Follow-up was performed prospectively for 12-months. The primary outcome was sensitivity for predicting ulcer healing. Secondary endpoints were specificity, predictive values, and likelihood ratios for ulcer healing.Results:123 of TrEAD participants with DFU were included. In 12-months, 52.8% of ulcers healed. The best negative diagnostic likelihood ratio was observed for the PAD-scan (mono or biphasic with adverse features) (NDLR 0.35, 95% CI 0.14-0.90). The highest positive likelihood ratios were observed for TBPI of 0.2 (PDLR 7.67, 95% CI 0.91-64.84) and TcPO2 of 20mmHg (PDLR 2.68, 95% CI 0.54-13.25). Cox proportional hazard modelling demonstrated significantly greater probabilities of healing with triphasic waveforms (HR = 2.54, 95% CI 1.23 – 5.3, p=0.012) and biphasic waveforms with non-adverse features (HR = 13.67, 95% CI 4.78 – 39.1, p<0.001) on PAD-scan. Conclusions:No single test performed well enough to be used in isolation as a prognostic marker for the prediction of DFU healing.

Journal article

Normahani P, Epstein DM, Gaggero A, Davies AH, Sounderajah V, Jaffer Uet al., 2023, Cost-effectiveness of Diagnostic Tools to Establish the Presence of Peripheral Arterial Disease in People With Diabetes, ANNALS OF SURGERY, Vol: 277, Pages: E184-E191, ISSN: 0003-4932

Journal article

Normahani P, Burgess L, Norrie J, Epstein D, Kandiyil N, Saratzis A, Khunti K, Edmonds M, Ahluwalia R, Coward T, Hartshorne T, Ashwell S, Shalhoub J, Pigott J, Davies A, Jaffer Uet al., 2022, Study protocol for a multicentre comparative diagnostic accuracy study of tools to establish the presence and severity of Peripheral Arterial Disease in people with Diabetes Mellitus: the DM PAD study, BMJ Open, Vol: 12, Pages: 1-9, ISSN: 2044-6055

Introduction:Peripheral arterial disease (PAD) is a key risk factor for cardiovascular disease, foot ulceration and lower limb amputation in people with diabetes. Early diagnosis of PAD can enable optimisation of therapies to manage these risks. Its diagnosis is fundamental though challenging in the context of diabetes. Although a variety of diagnostic bedside tests are available, there is no agreement as to which is the most accurate in routine clinical practice. The aim of this study is to determine the diagnostic performance of a variety of tests (audible waveform assessment, visual waveform assessment, ankle brachial pressure index (ABPI), exercise ABPI and toe brachial pressure index (TBPI)) for the diagnosis of PAD in people with diabetes as determined by a reference test (computed tomography angiography (CTA) or magnetic resonance angiography (MRA)). In selected centres, we also aim to evaluate the performance of a new point-of-care duplex ultrasound scan (PAD-scan).Methods and analysis:A prospective multicentre diagnostic accuracy study (ClinicalTrials.gov Identifier NCT05009602). We aim to recruit 730 people with diabetes from 18 centres across the United Kingdom (UK), covering primary and secondary healthcare. Consenting participants will undergo the tests under investigation. Reference tests (CTA or MRA) will be performed within six weeks of the index tests. Imaging will be reported by blinded consultant radiologists at a core imaging lab, using a validated scoring system, which will also be used to categorise PAD severity. The presence of one or more arterial lesions of 50% stenosis, or tandem lesions with a combined value of 50%, will be used as the threshold for the diagnosis of PAD. The primary outcome measure of diagnostic performance will be test sensitivity.Ethics and Dissemination: The study has received approval from the National Research Ethics Service (NRES) (REC reference 21/PR/1221). Results will be disseminated through research presentatio

Journal article

Powezka K, Pettipher A, Hemakom A, Adjei T, Normahani P, Mandic DP, Jaffer Uet al., 2022, A Pilot Study of Heart Rate Variability Synchrony as a Marker of Intraoperative Surgical Teamwork and Its Correlation to the Length of Procedure, SENSORS, Vol: 22

Journal article

Normahani P, Poushpas S, Alaa M, Bravis V, Sounderajah V, Aslam M, Jaffer Uet al., 2022, Diagnostic Accuracy of Point-of-care Tests Used to Detect Arterial Disease in Diabetes TEsting for Arterial Disease in Diabetes (TrEAD) Study, ANNALS OF SURGERY, Vol: 276, Pages: E605-E612, ISSN: 0003-4932

Journal article

Normahani P, Sounderajah V, Mandic D, Jaffer Uet al., 2022, Machine learning-based classification of arterial spectral waveforms for the diagnosis of peripheral artery disease in the context of diabetes: A proof-of-concept study, VASCULAR MEDICINE, Vol: 27, Pages: 450-456, ISSN: 1358-863X

Journal article

Wallace W, Chan C, Chidambaram S, Hanna L, Iqbal FM, Acharya A, Normahani P, Ashrafian H, Markar SR, Sounderajah V, Darzi Aet al., 2022, The diagnostic and triage accuracy of digital and online symptom checker tools: a systematic review, npj Digital Medicine, Vol: 5, ISSN: 2398-6352

Digital and online symptom checkers are an increasingly adopted class of health technologies that enable patients to input their symptoms and biodata to produce a set of likely diagnoses and associated triage advice. However, concerns regarding the accuracy and safety of these symptom checkers have been raised. This systematic review evaluates the accuracy of symptom checkers in providing diagnoses and appropriate triage advice. MEDLINE and Web of Science were searched for studies that used either real or simulated patients to evaluate online or digital symptom checkers. The primary outcomes were the diagnostic and triage accuracy of the symptom checkers. The QUADAS-2 tool was used to assess study quality. Of the 177 studies retrieved, 10 studies met the inclusion criteria. Researchers evaluated the accuracy of symptom checkers using a variety of medical conditions, including ophthalmological conditions, inflammatory arthritides and HIV. 50% of the studies recruited real patients, while the remainder used simulated cases. The diagnostic accuracy of the primary diagnosis was low across included studies (range: 19% to 37.9%) and varied between individual symptom checkers, despite consistent symptom data input. Triage accuracy (range: 48.8% to 90.1%) was typically higher than diagnostic accuracy. Overall, the diagnostic and triage accuracy of symptom checkers are variable and of low accuracy. Given the increasing push towards adopting this class of technologies across numerous health systems, this study demonstrates that reliance upon symptom checkers could pose significant patient safety hazards. Large scale primary studies, based upon real world data, are warranted to demonstrate adequate performance of these technologies in a manner that is and non-inferior to current best practice. Moreover, an urgent assessment of how these systems are regulated and implemented is required.

Journal article

Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AHet al., 2022, Prevention and management strategies for diabetic neuropathy, Life, Vol: 12, Pages: 1185-1185, ISSN: 2075-1729

Diabetic neuropathy (DN) is a common complication of diabetes that is becoming an increasing concern as the prevalence of diabetes rapidly rises. There are several types of DN, but the most prevalent and studied type is distal symmetrical polyneuropathy, which is the focus of this review and is simply referred to as DN. It can lead to a wide range of sensorimotor and psychosocial symptoms and is a major risk factor for diabetic foot ulceration and Charcot neuropathic osteoarthropathy, which are associated with high rates of lower limb amputation and mortality. The prevention and management of DN are thus critical, and clinical guidelines recommend several strategies for these based on the best available evidence. This article aims to provide a narrative review of DN prevention and management strategies by discussing these guidelines and the evidence that supports them. First, the epidemiology and diverse clinical manifestations of DN are summarized. Then, prevention strategies such as glycemic control, lifestyle modifications and footcare are discussed, as well as the importance of early diagnosis. Finally, neuropathic pain management strategies and promising novel therapies under investigation such as neuromodulation devices and nutraceuticals are reviewed.

Journal article

Wallace W, Chan C, Chidambaram S, Hanna L, Iqbal FM, Acharya A, Normahani P, Ashrafian H, Markar S, Sounderajah V, Darzi Aet al., 2022, The diagnostic and triage accuracy of digital and online symptom checker tools: a systematic review, Publisher: MedArxiv

<h4>ABSTRACT</h4> <h4>Objective</h4> To evaluate the accuracy of digital and online symptom checkers in providing diagnoses and appropriate triage advice. <h4>Design</h4> Systematic review. <h4>Data sources</h4> Medline and Web of Science were searched up to 15 February 2021. <h4>Eligibility criteria for study selection</h4> Prospective and retrospective cohort, vignette, or audit studies that utilised an online or application-based service designed to input symptoms and biodata in order to generate diagnoses, health advice and direct patients to appropriate services were included. <h4>Main outcome measures</h4> The primary outcomes were (1) the accuracy of symptom checkers for providing the correct diagnosis and (2) the accuracy of subsequent triage advice given. <h4>Data extraction and synthesis</h4> Data extraction and quality assessment (using the QUADAS-2 tool) were performed by two independent reviewers. Owing to heterogeneity of the studies, meta-analysis was not possible. A narrative synthesis of the included studies and pre-specified outcomes was completed. <h4>Results</h4> Of the 177 studies retrieved, nine cohort studies and one cross-sectional study met the inclusion criteria. Symptom checkers evaluated a variety of medical conditions including ophthalmological conditions, inflammatory arthritides and HIV. 50% of the studies recruited real patients, while the remainder used simulated cases. The diagnostic accuracy of the primary diagnosis was low (range: 19% to 36%) and varied between individual symptom checkers, despite consistent symptom data input. Triage accuracy (range: 48.8% to 90.1%) was typically higher than diagnostic accuracy. Of note, one study found that 78.6% of emergency ophthalmic cases were under-triaged. <h4>Conclusions</h4> The diagnostic and triage accuracy of symptom checkers are variable and of low accuracy. Given the increasin

Working paper

Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AHet al., 2022, Pathogenesis of distal symmetrical polyneuropathy in diabetes, Life, Vol: 12, Pages: 1-16, ISSN: 2075-1729

Distal symmetrical polyneuropathy (DSPN) is a serious complication of diabetes associated with significant disability and mortality. Although more than 50% of people with diabetes develop DSPN, its pathogenesis is still relatively unknown. This lack of understanding has limited the development of novel disease-modifying therapies and left the reasons for failed therapies uncertain, which is critical given that current management strategies often fail to achieve long-term efficacy. In this article, the pathogenesis of DSPN is reviewed, covering pathogenic changes in the peripheral nervous system, microvasculature and central nervous system (CNS). Furthermore, the successes and limitations of current therapies are discussed, and potential therapeutic targets are proposed. Recent findings on its pathogenesis have called the definition of DSPN into question and transformed the disease model, paving the way for new research prospects.

Journal article

Normahani P, Boyle JJ, Cave L, Brookes P, Woollard KJ, Jaffer Uet al., 2022, Peripheral blood mononuclear cell gene expression and cytokine profiling in patients with intermittent claudication who exhibit exercise induced acute renal injury., PLoS One, Vol: 17, Pages: 1-15, ISSN: 1932-6203

BACKGROUND: Intermittent claudication (IC) is a common manifestation of peripheral arterial disease. Some patients with IC experience a rise in Urinary N-acetyl-β-D-Glucosaminidase (NAG)/ Creatinine (Cr) ratio, a marker of renal injury, following exercise. In this study, we aim to investigate whether peripheral blood mononuclear cells (PBMC) from patients with IC who exhibit a rise in urinary NAG/ Cr ratio following exercise exhibit differential IL-10/ IL-12 ratio and gene expression compared to those who do not have a rise in NAG/ Cr ratio. METHODS: We conducted a single center observational cohort study of patients diagnosed with IC. Blood and urine samples were collected at rest and following a standardised treadmill exercise protocol. For comparative analysis patients were separated into those with any rise in NAG/Cr ratio (Group 1) and those with no rise in NAG/Cr ratio (Group 2) post exercise. Isolated PBMC from pre- and post-exercise blood samples were analysed using flow cytometry. PBMC were also cultured for 20 hours to perform further analysis of IL-10 and IL-12 cytokine levels. RNA-sequencing analysis was performed to identify differentially expressed genes between the groups. RESULTS: 20 patients were recruited (Group 1, n = 8; Group 2, n = 12). We observed a significantly higher IL-10/IL-12 ratio in cell supernatant from participants in Group 1, as compared to Group 2, on exercise at 20 hours incubation; 47.24 (IQR 9.70-65.83) vs 6.13 (4.88-12.24), p = 0.04. 328 genes were significantly differentially expressed between Group 1 and 2. The modulated genes had signatures encompassing hypoxia, metabolic adaptation to starvation, inflammatory activation, renal protection, and oxidative stress. DISCUSSION: Our results suggest that some patients with IC have an altered immune status making them 'vulnerable' to systemic inflammation and renal injury following exercise. We have identified a panel of genes which are differentially expressed in this group of

Journal article

Sounderajah V, Ashrafian H, Karthikesalingam A, Markar SR, Normahani P, Collins GS, Bossuyt PM, Darzi Aet al., 2022, Developing Specific Reporting Standards in Artificial Intelligence Centred Research, ANNALS OF SURGERY, Vol: 275, Pages: E547-E548, ISSN: 0003-4932

Journal article

Sounderajah V, 2022, Quality assessment standards in artificial intelligence diagnostic accuracy systematic reviews: a meta-research study, npj Digital Medicine, Vol: 5, Pages: 1-13, ISSN: 2398-6352

Artificial intelligence (AI) centred diagnostic systems are increasingly recognized as robust solutions in healthcare delivery pathways. In turn, there has been a concurrent rise in secondary research studies regarding these technologies in order to influence key clinical and policymaking decisions. It is therefore essential that these studies accurately appraise methodological quality and risk of bias within shortlisted trials and reports. In order to assess whether this critical step is performed, we undertook a meta-research study evaluating adherence to the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool within AI diagnostic accuracy systematic reviews. A literature search was conducted on all studies published from 2000 to December 2020. Of 50 included reviews, 36 performed quality assessment, of which 27 utilised the QUADAS-2 tool. Bias was reported across all four domains of QUADAS-2. 243 of 423 studies (57.5%) across all systematic reviews utilising QUADAS-2 reported a high or unclear risk of bias in the patient selection domain, 110 (26%) reported a high or unclear risk of bias in the index test domain, 121 (28.6%) in the reference standard domain and 157 (37.1%) in the flow and timing domain. This study demonstrates incomplete uptake of quality assessment tools in reviews of AI-based diagnostic accuracy studies and highlights inconsistent reporting across all domains of quality assessment. Poor standards of reporting act as barriers to clinical implementation. The creation of an AI specific extension for quality assessment tools of diagnostic accuracy AI studies may facilitate the safe translation of AI tools into clinical practice.

Journal article

Sounderajah V, Normahani P, Aggarwal R, Jayakumar S, Markar SR, Ashrafian H, Darzi Aet al., 2022, Reporting Standards and Quality Assessment Tools in Artificial Intelligence-Centered Healthcare Research, Artificial Intelligence in Medicine, Pages: 385-395, ISBN: 9783030645724

The practice of incomplete study reporting is rife within scientific literature. It hinders the adoption of technologies, introduces considerable “research waste, " and represents a significant moral hazard. In order to combat this issue, there has been a shift towards the use of reporting standards and quality assessment tools, a move that has been endorsed by major biomedical journals as well as other key stakeholders. These instruments help [1] to improve the quality and completeness of study reporting as well as [2] to aid researchers in their assessment of a study’s risk of bias and applicability. These instruments are carefully created through a multistep evidence generation process and are specific to individual study designs or specialties. Recently, it has been noted that many of the existing instruments are poorly suited to aid the reporting and assessment of artificial intelligence (AI)- based studies on account of their niche study considerations. As such, there has been a concerted effort to produce AI-specific extensions to preexisting instruments, such as CONSORT, SPIRIT, STARD, TRIPOD, QUADAS, and PROBAST. This chapter expands upon why AI-specific amendments to these instruments are required in addition to highlighting their contents and proposed scope.

Book chapter

Normahani P, Shalhoub J, 2022, Diabetic foot disease, Surgery (Oxford), Vol: 40, Pages: 53-61, ISSN: 0263-9319

Diabetic foot disease, or ulceration, is prevalent and is associated with high rates of lower limb amputation and mortality. Its underlying aetiology is complex and multifactorial. However, neuropathy and peripheral arterial disease represent two important precipitating risk factors. Regular, comprehensive foot examinations are important in the prevention of ulceration and cardiovascular complications as they provide an opportunity to assess risk, modify risk factors and deliver patient education. Charcot neuropathic osteoarthropathy is commonly misdiagnosed and should always be suspected in an individual with diabetes presenting with a hot and swollen foot. Diabetic foot ulcers are challenging to manage. The key to optimizing outcomes includes early diagnosis with referral for coordinated multidisciplinary care where prompt treatment of infection and peripheral arterial disease, as well as appropriate wound care and offloading can be initiated and monitored.

Journal article

Guni A, Normahani P, Davies A, Jaffer Uet al., 2021, Harnessing machine learning to personalize web-based health care content, Journal of Medical Internet Research, Vol: 23, ISSN: 1438-8871

Web-based health care content has emerged as a primary source for patients to access health information without direct guidance from health care providers. The benefit of this approach is dependent on the ability of patients to access engaging high-quality information, but significant variability in the quality of web-based information often forces patients to navigate large quantities of inaccurate, incomplete, irrelevant, or inaccessible content. Personalization positions the patient at the center of health care models by considering their needs, preferences, goals, and values. However, the traditional methods used thus far in health care to determine the factors of high-quality content for a particular user are insufficient. Machine learning (ML) uses algorithms to process and uncover patterns within large volumes of data to develop predictive models that automatically improve over time. The health care sector has lagged behind other industries in implementing ML to analyze user and content features, which can automate personalized content recommendations on a mass scale. With the advent of big data in health care, which builds comprehensive patient profiles drawn from several disparate sources, ML can be used to integrate structured and unstructured data from users and content to deliver content that is predicted to be effective and engaging for patients. This enables patients to engage in their health and support education, self-management, and positive behavior change as well as to enhance clinical outcomes.

Journal article

Sounderajah V, Ashrafian H, Rose S, Shah NH, Ghassemi M, Golub R, Kahn CE, Esteva A, Karthikesalingam A, Mateen B, Webster D, Milea D, Ting D, Treanor D, Cushnan D, King D, McPherson D, Glocker B, Greaves F, Harling L, Ordish J, Cohen JF, Deeks J, Leeflang M, Diamond M, McInnes MDF, McCradden M, Abramoff MD, Normahani P, Markar SR, Chang S, Liu X, Mallett S, Shetty S, Denniston A, Collins GS, Moher D, Whiting P, Bossuyt PM, Darzi Aet al., 2021, A quality assessment tool for artificial intelligence-centered diagnostic test accuracy studies: QUADAS-AI, NATURE MEDICINE, Vol: 27, Pages: 1663-1665, ISSN: 1078-8956

Journal article

Oktay LA, Abuelgasim E, Abdelwahed A, Houbby N, Lampridou S, Normahani P, Peters N, Jaffer Uet al., 2021, Factors affecting engagement in web-based health care patient information: narrative review of the literature, Journal of Medical Internet Research, Vol: 23, ISSN: 1438-8871

BACKGROUND: Web-based content is rapidly becoming the primary source of health care information. There is a pressing need for web-based health care content to not only be accurate but also be engaging. Improved engagement of people with web-based health care content has the potential to inform as well as influence behavioral change to enable people to make better health care choices. The factors associated with better engagement with web-based health care content have previously not been considered. OBJECTIVE: The aims of this study are to identify the factors that affect engagement with web-based health care content and develop a framework to be considered when creating such content. METHODS: A comprehensive search of the PubMed and MEDLINE database was performed from January 1, 1946, to January 5, 2020. The reference lists of all included studies were also searched. The Medical Subject Headings database was used to derive the following keywords: "patient information," "online," "internet," "web," and "content." All studies in English pertaining to the factors affecting engagement in web-based health care patient information were included. No restrictions were set on the study type. Analysis of the themes arising from the results was performed using inductive content analysis. RESULTS: The search yielded 814 articles, of which 56 (6.9%) met our inclusion criteria. The studies ranged from observational and noncontrolled studies to quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments, which made quantitative assessment difficult. Consensus among all authors of this study resulted in six categories that formed the basis of a framework to assess the factors affecting engagement in web-based health care content: easy to understand, support, adaptability, accessibility, visuals and content, and credibility and completeness. CONCLUSIONS: There is a p

Journal article

Jaffer U, 2021, Factors affecting engagement in online healthcare patient information: a narrative review of the literature, Journal of Medical Internet Research, Vol: 23, ISSN: 1438-8871

Background:The online world is rapidly becoming the primary source of healthcare information. There is a pressing need for online healthcare content not only to be accurate but also engaging. Improved engagement of people with online healthcare content has the potential to inform but also to influence behavioural change to make healthier choices. Factors associated with better engagement with online healthcare content have previously not been well considered.Objective:To identify factors which may improve engagement with online healthcare content and develop a framework to be considered when creating such content.Methods:The Pubmed and MEDLINE databases were searched up to January 2020 and manual cross checking of reference lists of relevant articles was performed. No restrictions on the study type were put. Abstracts and titles were reviewed by two authors independently for relevance. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.Results:Our search returned a total of 814 articles, 56 of which met our inclusion criteria. Studies tended to be observational, non-controlled studies, and a few quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments making quantitative assessment difficult. Consensus of all authors resulted in seven categories forming the basis of a framework to assess quality of engagement in online healthcare content : 1. Textual information; 2. Discussion groups; 3. Video content; 4. Visuals/ Pictograph; 5. Accessibility; 6. Stage of patient journey; 7. Credibility and completeness of information.Conclusions:Healthcare providers should recognise barriers to understanding as well as barrier to adherence with treatment. When producing online healthcare patient information, healthcare providers should consider the categories described which may improve engagement with the content being created.

Journal article

Chan C, Sounderajah V, Daniels E, Acharya A, Clarke J, Yalamanchili S, Normahani P, Markar S, Ashrafian H, Darzi Aet al., 2021, The reliability and quality of YouTube videos as a source of public health information regarding COVID-19 vaccination: cross-sectional study, JMIR Public Health and Surveillance, Vol: 7, ISSN: 2369-2960

Background: Recent emergency authorization and rollout of COVID-19 vaccines by regulatory bodies has generated global attention. As the most popular video-sharing platform globally, YouTube is a potent medium for the dissemination of key public health information. Understanding the nature of available content regarding COVID-19 vaccination on this widely used platform is of substantial public health interest.Objective: This study aimed to evaluate the reliability and quality of information on COVID-19 vaccination in YouTube videos.Methods: In this cross-sectional study, the phrases “coronavirus vaccine” and “COVID-19 vaccine” were searched on the UK version of YouTube on December 10, 2020. The 200 most viewed videos of each search were extracted and screened for relevance and English language. Video content and characteristics were extracted and independently rated against Health on the Net Foundation Code of Conduct and DISCERN quality criteria for consumer health information by 2 authors.Results: Forty-eight videos, with a combined total view count of 30,100,561, were included in the analysis. Topics addressed comprised the following: vaccine science (n=18, 58%), vaccine trials (n=28, 58%), side effects (n=23, 48%), efficacy (n=17, 35%), and manufacturing (n=8, 17%). Ten (21%) videos encouraged continued public health measures. Only 2 (4.2%) videos made nonfactual claims. The content of 47 (98%) videos was scored to have low (n=27, 56%) or moderate (n=20, 42%) adherence to Health on the Net Foundation Code of Conduct principles. Median overall DISCERN score per channel type ranged from 40.3 (IQR 34.8-47.0) to 64.3 (IQR 58.5-66.3). Educational channels produced by both medical and nonmedical professionals achieved significantly higher DISCERN scores than those of other categories. The highest median DISCERN scores were achieved by educational videos produced by medical professionals (64.3, IQR 58.5-66.3) and the lowest median scores by indep

Journal article

Patel K, Sounderajah V, Normahani P, Acharya A, Ashrafian H, Bicknell Cet al., 2021, Quantifying the burden of survivorship associated with infra-renal abdominal aortic aneurysm repair: a systematic review, Publisher: OXFORD UNIV PRESS, ISSN: 0007-1323

Conference paper

Sounderajah V, Ashrafian H, Golub RM, Shetty S, De Fauw J, Hooft L, Moons K, Collins G, Moher D, Bossuyt PM, Darzi A, Karthikesalingam A, Denniston AK, Mateen BA, Ting D, Treanor D, King D, Greaves F, Godwin J, Pearson-Stuttard J, Harling L, McInnes M, Rifai N, Tomasev N, Normahani P, Whiting P, Aggarwal R, Vollmer S, Markar SR, Panch T, Liu X, STARD-AI Steering Committeeet al., 2021, Developing a reporting guideline for artificial intelligence-centred diagnostic test accuracy studies: the STARD-AI protocol, BMJ Open, Vol: 11, ISSN: 2044-6055

Introduction Standards for Reporting of Diagnostic Accuracy Study (STARD) was developed to improve the completeness and transparency of reporting in studies investigating diagnostic test accuracy. However, its current form, STARD 2015 does not address the issues and challenges raised by artificial intelligence (AI)-centred interventions. As such, we propose an AI-specific version of the STARD checklist (STARD-AI), which focuses on the reporting of AI diagnostic test accuracy studies. This paper describes the methods that will be used to develop STARD-AI.Methods and analysis The development of the STARD-AI checklist can be distilled into six stages. (1) A project organisation phase has been undertaken, during which a Project Team and a Steering Committee were established; (2) An item generation process has been completed following a literature review, a patient and public involvement and engagement exercise and an online scoping survey of international experts; (3) A three-round modified Delphi consensus methodology is underway, which will culminate in a teleconference consensus meeting of experts; (4) Thereafter, the Project Team will draft the initial STARD-AI checklist and the accompanying documents; (5) A piloting phase among expert users will be undertaken to identify items which are either unclear or missing. This process, consisting of surveys and semistructured interviews, will contribute towards the explanation and elaboration document and (6) On finalisation of the manuscripts, the group’s efforts turn towards an organised dissemination and implementation strategy to maximise end-user adoption.Ethics and dissemination Ethical approval has been granted by the Joint Research Compliance Office at Imperial College London (reference number: 19IC5679). A dissemination strategy will be aimed towards five groups of stakeholders: (1) academia, (2) policy, (3) guidelines and regulation, (4) industry and (5) public and non-specific stakeholders. We anticipate th

Journal article

Normahani P, Mustafa C, Shalhoub J, Davies A, Norrie J, Sounderajah V, Smith S, Jaffer Uet al., 2021, A systematic review and meta-analysis of the diagnostic accuracy of point-of-care tests used to establish the presence of peripheral arterial disease in people with diabetes, Journal of Vascular Surgery, Vol: 73, Pages: 1811-1820, ISSN: 0741-5214

ObjectiveThere is currently no agreement as to which bedside test is the most useful for the diagnosis of PAD in diabetes. The aim of this systematic review and meta-analysis was to evaluate the performance of bedside tests for the detection of PAD in individuals with diabetes.Research design and methodsMEDLINE and EMBASE databases were systematically searched for studies providing data on diagnostic performance of bedside tests used for the detection of PAD in people with diabetes. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for the diagnosis of PAD.ResultsA total of 18 studies, reporting on a total of 3016 limbs of diabetic patients, were included in our qualitative review. Of these, eleven studies (1543 limbs) were included in the meta-analysis of diagnostic accuracy: ankle-brachial pressure index (ABPI, 9 studies, 1368 limbs, sensitivity 63.5% [95% CI 51.7-73.9%], specificity 89.3% [95% CI 81.1-94.2%]); toe-brachial pressure index (TBPI, 3 studies, 221 limbs, sensitivity 83.0% [95% CI 59.1-94.3%], specificity 66.3% [95% CI 41.3-84.6%]); and tibial waveform assessment (4 studies, 397 limbs, sensitivity 82.8% [95% CI 73.3-89.4%], specificity 86.8% [95% CI 75.5-93.3%]). Overall, there was a high risk of bias across studies, most frequently relating to patient selection and lack of blinding.ConclusionsTBPI, pulse oximetry and tibial arterial waveform assessment have demonstrated some promise, warranting further investigation.Key wordsDiabetesdiabetic footdiagnosisfoot ulcerperipheral arterial disease

Journal article

Chan C, Sounderajah V, Daniels E, Acharya A, Clarke J, Yalamanchili S, Normahani P, Markar S, Ashrafian H, Darzi Aet al., 2021, The Reliability and Quality of YouTube Videos as a Source of Public Health Information Regarding COVID-19 Vaccination: Cross-sectional Study (Preprint)

<sec> <title>BACKGROUND</title> <p>Recent emergency authorization and rollout of COVID-19 vaccines by regulatory bodies has generated global attention. As the most popular video-sharing platform globally, YouTube is a potent medium for the dissemination of key public health information. Understanding the nature of available content regarding COVID-19 vaccination on this widely used platform is of substantial public health interest.</p> </sec> <sec> <title>OBJECTIVE</title> <p>This study aimed to evaluate the reliability and quality of information on COVID-19 vaccination in YouTube videos.</p> </sec> <sec> <title>METHODS</title> <p>In this cross-sectional study, the phrases “coronavirus vaccine” and “COVID-19 vaccine” were searched on the UK version of YouTube on December 10, 2020. The 200 most viewed videos of each search were extracted and screened for relevance and English language. Video content and characteristics were extracted and independently rated against Health on the Net Foundation Code of Conduct and DISCERN quality criteria for consumer health information by 2 authors.</p> </sec> <sec> <title>RESULTS</title> <p>Forty-eight videos, with a combined total view count of 30,100,561, were included in the analysis. Topics addressed comprised the following: vaccine science (n=18, 58%), vaccine trials (n=28, 58%), side effects (n=23, 48%), efficacy (n=17, 35%), and manufacturing (n=8, 17%). Ten (21%) videos encouraged continued public health measures. Only 2 (4.2%) videos made nonfactual claims. The content o

Working paper

Gunn LH, Vamos EP, Majeed A, Normahani P, Jaffer U, Molina G, Valabhji J, McKay AJet al., 2021, Associations between attainment of incentivised primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study, BMJ Open Diabetes Research and Care, Vol: 9, ISSN: 2052-4897

Introduction England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation.Research design and methods This population-based retrospective cohort study, spanning 2010–2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010–2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure.Results 83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4–6 vs 0–3, 7–9 vs 0–3, and 7–9 vs 4–6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator a

Journal article

Normahani P, Shalhoub J, Narayanan S, 2021, A Guytonian explanation for hemodynamic responses to interventions in superficial venous disease, Phlebology, Vol: 36, Pages: 245-250, ISSN: 0268-3555

Background:We thank Franceschi et al for their letter entitled “Transmural pressure for conceptualisation of chronic venous insufficiency management” regarding our paper wherein we have repurposed a Guytonian model of systemic venous return to explain the hemodynamic changes that occur in lower limb venous disease.1,2 This model was developed using the non-thrombotic iliac vein lesion (NIVL) as the basis for the hemodynamic response.Franceschi et al have raised queries in their communication that in our model, we have suggested venous stenting, compression therapy and superficial ablation as treatment options for the NIVL. Their concern is that superficial venous ablation will raise transmural pressures within the deep venous compartment, with a worsening of venous compliance, transmission of the higher pressures to the microcirculation leading to trophic changes of venous stasis, as well as recurrences.It is important to state at the outset that we do not advocate superficial venous ablation as a treatment for an NIVL. The NIVL has been used by us purely to develop the model for venous return, not to suggest one form of therapy or another for superficial venous disease. A detailed explanation of the responses to different interventions for superficial venous disease based on our model is now presented to address the issues raised.

Journal article

Chan C, Sounderajah V, Normahani P, Acharya A, Markar SR, Darzi A, Bicknell C, Riga Cet al., 2021, Wearable activity monitors in home based exercise therapy for patients with intermittent claudication: a systematic review, European Journal of Vascular and Endovascular Surgery, Vol: 61, Pages: 676-687, ISSN: 1078-5884

OBJECTIVE: Intermittent claudication (IC) can severely limit functional capacity and quality of life. Supervised exercise therapy is the recommended first line management; however, this is often limited by accessibility, compliance and cost. As such, there has been an increased interest in the use of wearable activity monitors (WAMs) in home based telemonitoring exercise programmes for claudicants. This review aims to evaluate the efficacy of WAM as a feedback and monitoring tool in home based exercise programmes for patients with IC. DATA SOURCES: A search strategy was devised. The databases MEDLINE, EMBASE, and Web of Science were searched through to April 2020. REVIEW METHODS: Randomised trials and prospective trials were included. Eligible trials had to incorporate WAMs as a feedback tool to target walking/exercise behaviour. The primary outcome was the change in walking ability. Study quality was assessed with risk of bias tool. RESULTS: A total of 1148 records were retrieved. Of these, eight randomised controlled trials and one prospective cohort study, all of which compared a WAM intervention against standard care and/or supervised exercise, met the inclusion criteria. Owing to heterogeneity between studies, no meta-analysis was conducted. WAM interventions improved measures of walking ability (heterogeneous outcomes such as maximum walking distance, claudication distance and six minute walk distance), increased daily walking activity (steps/day), cardiovascular metrics (maximum oxygen consumption), and quality of life. CONCLUSION: There is some evidence that home based WAM interventions are beneficial for improving walking ability and quality of life in patients with IC. However, existing studies are limited by inadequate sample size, duration, and appropriate power. Achieving consensus on outcome reporting and study methods, as well as maximising device adherence, is needed.

Journal article

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