Staff Publication

Breast cancer surgery without suction drainage and impact of mastectomy flap fixation in reducing seroma formation (2017)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Zaidi S.; *Hinton C.

Citation:
European Journal of Surgical Oncology; May 2017; vol. 43 (no. 5)

Abstract:
Background: One of the most invalidating complications after breast cancer surgery is seroma formation. The incidence of seroma formation after breast surgery varies from 3% to 85%. Seroma formation and inadequate drainage of seroma may lead to infections, pain, hospitalization and delay in treatment. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants. Aim: To determine the effect of a 'no drains' policy on seroma formation and other complications in women undergoing breast cancer surgery and to evaluate the effect of obliteration of dead space by suture fixation of the mastectomy flaps to the underlying chest wall, on the amount and duration of postoperative fluid drainage and incidence of seroma formation after breast surgery. Materials and methods: A retrospective analysis was performed on a consecutive series of patients that had been treated with mastectomy with or without axillary surgery for breast cancer for the last 1 year. Patients divided into Group 1 the wound was closed in the conventional method at the edges and closed suction drains are used. Group 2; after completing the mastectomy procedure, using absorbable sutures (vicryl), continuous stitches 3 cm apart were taken, in rows, between the subcutaneous tissues of the skin flaps and the underlying muscles. Special attention is taken to the obliteration of the largest potential dead space, the empty axillary apex. Closed suction drains are used. Group 3 similar procedure but no drain used. The patient characteristics collected were: age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage and length of hospital stay. Definitions: Postoperative haematoma: clear postoperative haematoma formation in the area of the operation, for which intervention is necessary. Wound infection: clinical signs of infection (pain, swelling, erythema, fever, exudate, delayed wound healing or breakdown), purulent discharge or a positive microbiological culture. Seroma production: palpable fluid collection, with serous consistency, produced subcutaneous in the area of operation or axilla Results: 113 women were included in the study. Women underwent modified radical mastectomy (MRM) and ALND , MRM +/- sentinel lymph node biopsy (SLNB) /axillary node sampling (ANS) and simple Mx. There was no significant difference between the studied groups concerning the age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage. There were six patients with evacuation of haematoma postoperatively and belong to group 1 and 2 with drains. The number (and percentage) of women with wound infection was none in the group 1, 8 in gp 2 and 2 among gp 3 patients. Seroma formation was 10 in gp 1, 9 in gp 2 and 4 in gp 3. The length of hospital stays (days) was 2.7 in gp 1, 2.6 in gp 2 and 1.3 days in gp 3 patients with no drains (ND). Conclusion: This study investigated that wound drainage following mastectomy could be avoided by suturing flaps to the underlying chest wall, thereby facilitating early discharge with no associated increase in surgical morbidity. This study suggests that MRM +/- ALND/SLNB/ANS can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a 'nodrains' policy may also contribute to earlier hospital discharge.

Link to full-text: http://www.ejso.com/article/S0748-7983(17)30225-1/abstract

NHSBSP Guidelines and use of VAE for B3 pathology saves money and reduces patient pathway (2017)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Lake B.; *Williams S.; *Usman T.; *Burrows C.

Citation:
European Journal of Surgical Oncology; May 2017; vol. 43 (no. 5)

Abstract:
Introduction: B3 or indeterminate breast pathology combines a variety of heterogeneous pathological entities, with varying malignant potential and often cause a treatment dilemma. Recent NHSBSP guidelines help to delineate the treatment pathway following B3 diagnosis. Recommendations include for certain B3 pathology the use of second line Vacuum Assisted Excision(VAE), which decreases the need for open surgical biopsy. The aim of this audit was to assess current practice compared to guidelines and the potential cost saving from implementation. Method: A 5 year audit of all B3 pathologies at Shrewsbury and Telford NHS Trust was performed from 2010 to 2015. Data was recorded from the Clinical Portal and included initial pathology, subsequent procedures, subsequent pathology, upgrade and downgrade rates. Cost saving analysis was performed to see how much would have been saved if the new NHSBSP guidelines had been followed. Results: 297 B3 pathologies were identified; repeat B3 biopsy and B4 pathology were excluded. Commonest initial B3 pathology was Papilloma or Papillary lesion without atypia 24%. 140 patients (47%) had excision as second line procedure. Upgrade rate was 22% and downgrade rate was 29%. Cost saving analysis showed that if VAE was available as a second line procedure, 115 patients (39%) could have had this instead of excision saving 80,960.In addition 10% of patients would have had reduced clinical pathway. Conclusion: New guidelines recommend for selected B3 pathology the use of VAE. This audit demonstrates not only does this save money but also reduces the steps in the patient's pathway.

Link to more details or full-text: http://www.ejso.com/article/S0748-7983(17)30204-4/abstract

 

Multidisciplinary team meetings in primary care: Could they help to attract the GPs of tomorrow? (2017)

Posted on by

Type of publication:
Journal article

Author(s):
Coventry J.; *Coventry C.; Coventry P.

Citation:
British Journal of General Practice; Jun 2017; vol. 67 (no. 659); p. 267

Abstract:
It is well recognised that there is currently a crisis in recruiting medical students and doctors to a career in general practice. Around 12% of training posts were vacant for the 2015 application year.1 When research has enquired as to why these groups decide against general practice many reasons have been given including ‘wanting to work in acute care’, ‘wanting to specialise’, but one that caught our eye was ‘wanting to work in a team’.2 Many GPs would argue that at practice meetings and business meetings you are part of a team. However, if we think about what the students see on placement it is quite often a GP sitting in their room facing whatever comes…

Term admissions to neonatal units in England: A role for transitional care? A retrospective cohort study (2017)

Posted on by

Type of publication:
Journal article

Author(s):
Battersby C.; Michaelides S.; Upton M.; Rennie J.M.; Babirecki M.; Harry L.; Rackham O.; Wickham T.; Hamdan S.; Gupta A.; Wigfield R.; Wong L.; Mittal A.; Nycyk J.; Simmons P.; Singh A.; Seal S.; Hassan A.; Schwarz K.; Thomas M.; Foo A.; Shastri A.; Whincup G.; Brearey S.; Chang J.; Gad K.; Hasib A.; Garbash M.; Allwood A.; Adiotomre P.; Ahmed J.S.; Deketelaere A.; Khader K.A.; Shephard R.; Mallik A.; Abuzgia B.; Jain M.; Pirie S.; Zengeya S.; Watts T.; Jampala C.; Seagrave C.; Cruwys M.; Dixon H.; Aladangady N.; Gaili H.; James M.; Lal M.; Ambadkar; Rao P.; Hickey A.; Dave D.; Pai V.; Lama M.; Miall L.; Cusack J.; Kairamkonda V.; Jayachandran; Kollipara; Kefas J.; Yoxall B.; Whitehead G.; Krishnamurthy; Soe A.; Misra I.; Pillay T.; Ali I.; Dyke M.; Selter M.; Panasa N.; Alsford L.; Spencer V.; Gupta S.; Nicholl R.; Wardle S.; McBride T.; Shettihalli N.; Adams E.; Babiker S.; Crawford M.; Gibson D.; Khashu M.; Toh C.; Hall M.; Sleight E.; Groves C.; Godambe S.; Bosman D.; Rewitzky G.; Banjoko O.; Kumar N.; Manzoor A.; Lopez W.; D'Amore A.; Mattara S.; Zipitis C.; De Halpert P.; Settle P.; Munyard P.; McIntyre J.; Bartle D.; Yallop K.; Fedee J.; Maddock N.; Gupta R.; *Deshpande S.; Moore A.; Godden C.; Amess P.; Jones S.; Fenton A.; Mahadevan; Brown N.; Mack K.; Bolton R.; Khan A.; Mannix P.; Huddy C.; Yasin S.; Butterworth S.; Edi-Osagie N.; Cairns P.; Reynolds P.; Brennan N.; Heal C.; Salgia S.; Abu-Harb M.; Birch J.; Knight C.; Clark S.; Van Sommen V.; Murthy V.; Paul S.; Kisat H.; Kendall G.; Blake K.; Kuna J.; Kumar H.; Vemuri G.; Rawlingson C.; Webb D.; Bird; Narayanan S.; Gane J.; Eyre E.; Evans I.; Sanghavi R.; Sullivan C.; Amegavie L.; Leith W.; Vasu V.; Gallagher A.; Vamvakiti K.; Eaton M.; Millman G.

Citation:
BMJ Open; May 2017; vol. 7 (no. 5)

Abstract:
Objective: To identify the primary reasons for term admissions to neonatal units in England, to determine risk factors for admissions for jaundice and to estimate the proportion who can be cared for in a transitional setting without separation of mother and baby. Design: Retrospective observational study using neonatal unit admission data from the National Neonatal Research Database and data of live births in England from the Office for National Statistics. Setting: All 163 neonatal units in England 2011-2013. Participants: 133 691 term babies born >=37 weeks gestational age and admitted to neonatal units in England. Primary and secondary outcomes: Primary reasons for admission, term babies admitted for the primary reason of jaundice, patient characteristics, postnatal age at admission, total length of stay, phototherapy, intravenous fluids, exchange transfusion and kernicterus. Results: Respiratory disease was the most common reason for admission overall, although jaundice was the most common reason for admission from home (22% home vs 5% hospital). Risk factors for admission for jaundice include male, born at 37 weeks gestation, Asian ethnicity and multiple birth. The majority of babies received only a brief period of phototherapy, and only a third received intravenous fluids, suggesting that some may be appropriately managed without separation of mother and baby. Admission from home was significantly later (3.9 days) compared with those admitted from elsewhere in the hospital (1.7 days) (p<0.001). Conclusion: Around two-thirds of term admissions for jaundice may be appropriately managed in a transitional care setting, avoiding separation of mother and baby. Babies with risk factors may benefit from a community midwife postnatal visit around the third day of life to enable early referral if necessary. We recommend further work at the national level to examine provision and barriers to transitional care, referral pathways between primary and secondary care, and community postnatal care

Link to full-text [open access - no password required]

Altmetric Attention Score

Border-line coeliac serology in children - Outcome and correlation with histology (2017)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Fox H.; Cheng J.H.; *Singh R.; *Ayub N.

Citation:
Journal of Pediatric Gastroenterology and Nutrition; Apr 2017; vol. 64 ; Supplement 1, p. 18

Abstract:
Objectives and study: Coeliac disease is an immune-mediated condition that affects the lining of the intestine when exposed to gluten. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition guideline on Coeliac Disease (2013) recommends that patients with Tissue Transglutaminase antibodies (TTG) less than 10 times normal should undergo duodenal biopsy to confirm a diagnosis of Coeliac Disease. However, there is a paucity of data on how often this correlates with a final diagnosis of Coeliac disease. This study is to measure the sensitivity of borderline Tissue Transglutaminase Antibody (TTG) levels (greater than normal but less than 10 times of normal values) in diagnosing Coeliac disease. Methods: The Study Population was children aged 1-16 years with TTG levels less than 10 times of normal seen at The Shrewsbury & Telford Hospitals NHS Trust. The study period was from January 2010 to September 2016. Patients were identified from the biochemistry database. Relevant data including the clinical symptoms, TTG levels, IgA levels, HLA status and histology results were collected using the hospital data base. The histology results were classified according to the Modified Marsh Criteria. Results: A total of 52 patients had TTG levels between 2 – 19.9 U/ml which is less than ten times of the normal range used by our biochemistry laboratory. The median age of presentation was 10 years while the median TTG value was 4.2U/ml. 10 patients with Type 1 Diabetes Mellitus were detected to have border-line positive coeliac serology on routine testing. Thirty-nine patients underwent endoscopy with duodenal biopsies. Ten patients had neither endoscopy nor HLA testing performed because of various reasons including parental choice, symptom resolution prior to endoscopy while still on a normal diet, or repeat TTG levels within the normal range. 29 children (56%) out of the cohort of 52 had histological changes consistent with coeliac disease and were diagnosed as such. Seven of these (24%) had Grade 1 Marsh criteria, 3 children (10%) had Grade 2 Marsh criteria and 19 (66%) had Grade 3 Marsh criteria. There was no significant difference in symptomatology between the children who were diagnosed with coeliac disease and those with normal biopsies, apart from recurrent abdominal pain which was commoner in coeliac disease. Conclusion: 56% of children with borderline TTG levels were diagnosed with coeliac disease based on biopsy changes. Symptomatology was of poor discriminatory value apart from recurrent abdominal pain which was commoner in coeliac disease. Children with border-line positive coeliac serology should have duodenal biopsies to confirm a diagnosis of coeliac disease.

Link to more details or full-text: http://pdfs.journals.lww.com/jpgn/2017/04001/50th_ESPGHAN_Annual_Meeting_.1.pdf

Addition of gemcitabine to paclitaxel, epirubicin, and cyclophosphamide adjuvant chemotherapy for women with early-stage breast cancer (tAnGo): final 10-year follow-up of an open-label, randomised, phase 3 trial (2017)

Posted on by

Type of publication:
Randomised controlled trial

Author(s):
Earl, Helena M; Hiller, Louise; Howard, Helen C; Dunn, Janet A; Young, Jennie; Bowden, Sarah J; McDermaid, Michelle; Waterhouse, Anna K; Wilson, Gregory; *Agrawal, Rajiv; O'Reilly, Susan; Bowman, Angela; Ritchie, Diana M; Goodman, Andrew; Hickish, Tamas; McAdam, Karen; Cameron, David; Dodwell, David; Rea, Daniel W; Caldas, Carlos; Provenzano, Elena; Abraham, Jean E; Canney, Peter; Crown, John P; Kennedy, M John; Coleman, Robert; Leonard, Robert C; Carmichael, James A; Wardley, Andrew M; Poole, Christopher J; tAnGo trial collaborators

Citation:
The Lancet. Oncology, Volume 18, No. 6, p755–769, June 2017

Abstract:
BACKGROUND The tAnGo trial was designed to investigate the potential role of gemcitabine when added to anthracycline and taxane-containing adjuvant chemotherapy for early breast cancer. When this study was developed, gemcitabine had shown significant activity in metastatic breast cancer, and there was evidence of a favourable interaction with paclitaxel. METHOD StAnGo was an international, open-label, randomised, phase 3 superiority trial that enrolled women aged 18 years or older with newly diagnosed, early-stage breast cancer who had a definite indication for chemotherapy, any nodal status, any hormone receptor status, Eastern Cooperative Oncology Group performance status of 0-1, and adequate bone marrow, hepatic, and renal function. Women were recruited from 127 clinical centres and hospitals in the UK and Ireland, and randomly assigned (1:1) to one of two treatment regimens: epirubicin, cyclophosphamide, and paclitaxel (four cycles of 90 mg/m2 intravenously administered epirubicin and 600 mg/m2 intravenously administered cyclophosphamide on day 1 every 3 weeks, followed by four cycles of 175 mg/m2 paclitaxel as a 3 h infusion on day 1 every 3 weeks) or epirubicin, cyclophosphamide, and paclitaxel plus gemcitabine (the same chemotherapy regimen as
the other group, with the addition of 1250 mg/m2 gemcitabine to the paclitaxel cycles, administered intravenously as a 0·5 h infusion on days 1 and 8 every 3 weeks). Patients were randomly assigned by a central computerised deterministic minimisation procedure, with stratification by country, age, radiotherapy intent, nodal status, and oestrogen receptor and HER-2 status. The primary endpoint was disease-free survival and the trial aimed to detect 5% differences in 5-year disease-free survival between the treatment groups. Recruitment completed in 2004 and this is the final, intention-to-treat analysis. This trial is registered with EudraCT (2004-002927-41), ISRCTN (51146252), and ClinicalTrials.gov (NCT00039546).FINDINGS Between Aug 22, 2001, and Nov 26, 2004, 3152 patients were enrolled and randomly assigned to epirubicin, cyclophosphamide, paclitaxel, and gemcitabine (gemcitabine group; n=1576) or to epirubicin, cyclophosphamide, and paclitaxel (control group; n=1576). 11 patients (six in the gemcitabine group and five in the control group) were ineligible because of pre-existing metastases and were therefore excluded from the analysis. At this protocol-specified final analysis (median follow-up 10 years [IQR 10-10]), 1087 disease-free survival events and 914 deaths had occurred. Disease-free survival did not differ significantly between the treatment groups at 10 years (65% [63-68] in the gemcitabine group vs 65% [62-67] in the control group), and median disease-free survival was not reached (adjusted hazard ratio 0·97 [95% CI 0·86-1·10], p=0·64). Toxicity, dose intensity, and a detailed safety substudy showed both regimens to be safe, deliverable, and tolerable. Grade 3 and 4 toxicities were reported at expected levels in both groups. The most common were neutropenia (527 [34%] of 1565 patients in the gemcitabine group vs 412 [26%] of 1567 in the control group), myalgia and arthralgia (207 [13%] vs 186 [12%]), fatigue (207 [13%] vs 152 [10%]), infection (202 [13%] vs 141 [9%]), vomiting (143 [9%] vs 108 [7%]), and nausea (132 [8%] vs 102 [7%]).INTERPRETATION The addition of gemcitabine to anthracycline and taxanebased adjuvant chemotherapy at this dose and schedule confers no therapeutic advantage in terms of disease free survival in early breast cancer, although it can cause increased toxicity. Therefore, gemcitabine has not been added to standard adjuvant chemotherapy in breast cancer for any subgroup.FUNDING Cancer Research UK core funding for Clinical Trials Unit at the University of Birmingham, Eli Lilly, Bristol-Myers Squibb, and Pfizer.

Altmetric Attention Score

Gefitinib and EGFR Gene Copy Number Aberrations in Esophageal Cancer (2017)

Posted on by

Type of publication:
Journal article

Author(s):
Petty, Russell D; Dahle-Smith, Asa; Stevenson, David A J; Osborne, Aileen; Massie, Doreen; Clark, Caroline; Murray, Graeme I; Dutton, Susan J; Roberts, Corran; Chong, Irene Y; Mansoor, Wasat; Thompson, Joyce; Harrison, Mark; *Chatterjee, Anirban; Falk, Stephen J; Elyan, Sean; Garcia-Alonso, Angel; Fyfe, David Walter; Wadsley, Jonathan; Chau, Ian; Ferry, David R; Miedzybrodzka, Zosia

Citation:
Journal of Clinical Oncology : official journal of the American Society of Clinical Oncology; July 10;35(20):2279-2287

Abstract:
Purpose The Cancer Esophagus Gefitinib trial demonstrated improved progression-free survival with the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib relative to placebo in patients with advanced esophageal cancer who had disease progression after chemotherapy. Rapid and durable responses were observed in a minority of patients. We hypothesized that genetic aberration of the EGFR pathway would identify patients benefitting from gefitinib. Methods A prespecified, blinded molecular analysis of Cancer Esophagus Gefitinib trial tumors was conducted to compare efficacy of gefitinib with that of placebo according to EGFR copy number gain (CNG) and EGFR, KRAS, BRAF, and PIK3CA mutation status. EGFR CNG was determined by fluorescent in situ hybridization (FISH) using prespecified criteria and EGFR FISH-positive status was defined as high polysomy or amplification. Results Biomarker data were available for 340 patients. In EGFR FISH-positive tumors (20.2%), overall survival was improved with gefitinib compared with placebo (hazard ratio [HR] for death, 0.59; 95% CI, 0.35 to 1.00; P = .05). In EGFR FISH-negative tumors, there was no difference in overall survival with gefitinib compared with placebo (HR for death, 0.90; 95% CI, 0.69 to 1.18; P = .46). Patients with EGFR amplification (7.2%) gained greatest benefit from gefitinib (HR for death, 0.21; 95% CI, 0.07 to 0.64; P = .006). There was no difference in overall survival for gefitinib versus placebo for patients with EGFR, KRAS, BRAF, and PIK3CA mutations, or for any mutation versus none. Conclusion EGFR CNG assessed by FISH appears to identify a subgroup of patients with esophageal cancer who may benefit from gefitinib as a secondline treatment. Results of this study suggest that anti-EGFR therapies should be investigated in prospective clinical trials in different settings in EGFR FISH-positive and, in particular, EGFR-amplified esophageal cancer.

Managing problems with medications for type 2 diabetes (2017)

Posted on by

Type of publication:
Journal article

Author(s):
*Morris, David

Citation:
Practice Nursing; Apr 2017; vol. 28 (no. 4); p. 148-152

Abstract:
The most recent National Institue for Health and Care Excellence (NICE) and European Association for the Study of Diabetes guidelines on management of type 2 diabetes (NICE, 2015; Inzucchi et al, 2015) emphasise the need to individualise glycemic targets and treatments, and highlight that working in partnership with the person concerned should be central to decision making. In addition to assessing the likely efficacy of a treatment, consideration should be given to tolerability and safety. The possibility of medication problems and side- effects needs to be anticipated and if a medication is chosen then a means for identifying and dealing with these should be considered in advance. Most adverse drug reactions are predictable and dose- dependent, the exception being allergic reactions. This article will consider problems arising with medications used for type 2 diabetes, excluding insulin.

Overview of diabetes... This reflective account is based on NS852 Mayo P (2016) An overview of diabetes (2017)

Posted on by

Type of publication:
Journal article

Author(s):
*Ponomarenko-Jones, Rosalind

Citation:
Nursing Standard; May 2017; vol. 31 (no. 36); p. 64-65

Abstract:
The article presents a reflective account of how a continuing professional development (CPD) article improved Rosalind Ponomarenko-Jones's knowledge of the pathophysiology, symptoms and diagnosis of diabetes. Topics discussed include the nature of the CPD activity, lesson learned from the CPD activity and how she changed or improved her practice.