NICE Guidelines Research Articles

854 Bridging the Communication Gap in Surgery: A Quality Improvement Initiative to Improve Surgical Juniors’ Confidence in Navigating Difficult Conversations and Documentation

Abstract Aim In response to the challenges faced by surgical juniors in communicating with critically ill patients and their families, particularly after emergency surgery, we initiated a comprehensive two-pronged QIP. Our aims were 1) to enhance skills and confidence of surgical juniors in navigating difficult conversations, and 2) to improve documentation of post-operative patient and NOK discussions after ITU step-down to ward, in-line with NICE guidelines (CG83-1.13). Method A retrospective analysis of 14 laparotomy patients in September 2023, revealed that only 36% had documented NOK discussions 3-5 days post-operatively, falling short of best practice guidelines recommending documentation within 12 hours. Only 33% of the 10 patients requiring ITU admission, received documented NOK updates post-step-down to the ward. Interventions to address this included developing a communication skills workshop and implementing colored cards in notes folders to visually identify patients needing NOK discussions. Results Pre- and post-workshop surveys, utilizing a 1-to-5 scale, measured confidence levels of junior doctors for difficult discussions, with 13 and 9 respondents, respectively. High confidence scores (4 or 5) for different discussion types showed substantial improvement post-workshop: DNACPR (31% vs. 89%), end-of-life (31% vs. 55%), emotionally charged (31% vs. 78%). Furthermore, 100% of participants post-workshop were highly likely (4 or 5) to utilizing communication frameworks e.g., SPIES. Conclusions Our interventions have demonstrated a significant improvement in the confidence of surgical juniors when navigating challenging conversations. Our ongoing efforts include expanding our ‘communication in surgery’ workshop series, which we hope to present, and a re-audit of NOK discussion documentation to objectively measure positive changes post-intervention.

1086 Tetanus Bedside Immuno-Assay. A Quality Improvement Study

Abstract Aim ProTetanus immunoassay is a bedside test used to determine if a patient has tetanus antibodies. It has been proven to be sensitive and specific at determining tetanus vaccination status. Although it is available on NHS Supply Chain, it is not widely used. Our aim was to prevent unnecessary Revaxis booster administrations as well as reduce the associated cost. Method Using a visual protocol based on trust and NICE guidelines, we determined which patients with tetanus prone wounds would otherwise require vaccination due to uncertainty of their previous immunisation. ProTetanus test was used to assess their immune status. If no immunity was shown, a booster was administered. A simple questionnaire was used to collect data on the test result, ease of use, and time required to perform the test. Results 18 responses were recorded over 2 months. 2 patients were unnecessarily tested but all patients were treated correctly. In terms of cost efficiency, Revaxis costs £10.16 per vial and ProTetanus £4.15 per test. Therefore, a negative test costs £14.31 and a positive test costs £4.15. In our unit, without ProTetanus, 17 doses of Revaxis would have been administered, costing £172.72. With ProTetanus, 8 doses were prevented, dropping the cost to £161.99. Conclusions The introduction of ProTetanus, prevents unnecessary tetanus booster administrations for our patients, improves the level of clinical care, and provides a cost reduction. We have demonstrated that the use of the immunoassays becomes easier with use and minimise reliance on registered nurses. We strongly advocate its use into other departments and units.

564 The Assessment and Management of Anaemia in Patients Who Underwent an Emergency Laparotomy

Abstract Aim Emergency Laparotomies (EmLap) carry a significant risk of morbidity and mortality. Peri and post-operative anaemia are associated with higher complication rates, delayed healing, and lethargy. This study aimed to assess the occurrence of anaemia in EmLap patients upon admission and discharge, as well as to evaluate its management. Method Data was collected from 260 participants undergoing EmLap from 2016 to 2019 that completed a follow up questionnaire in 2020, as part of PEEL 2 (Patients Experience of Emergency Laparotomy) in Cardiff, a retrospective cohort study. 34% of patients (n=90) had a Haemoglobin (Hb) level on admission and discharge and were included into the study. Information on transfusions and prescriptions of ferrous fumarate tablets during admission and on discharge were obtained from electronic records. Results 46.7% (n=42) were anaemic at time of admission and further 19 patients were anaemic after surgery. 61 patients (68%) were discharged with anaemia post EmLap. Of the 61 patients discharged with anaemia only 10 (16%) were given treatment; 7 (11%) were offered a blood transfusion, 2 (3%) were prescribed ferrous fumarate tablets and 1 (1.6%) received a combination of both. Discharge summaries did not highlight the issue and follow up advice was not given to GPs. Conclusions 2/3 of EmLap patients were discharged with anaemia and was not addressed. A greater understanding is needed to appreciate the impact of anaemia on EmLap patients’ such as fatigue levels. It can be avoided if a closer look at patients’ blood results is conducted and treated aligning with the NICE guidelines.

435 Post ERCP Pancreatitis at a Tertiary Centre - a Retrospective Incidence and Causal Analysis

Abstract Background Post Endoscopic Retrograde Cholangio Pancreatography (ERCP) pancreatitis (PEP) is a serious and potentially life-threatening complication of ERCP. The overall incidence of PEP varies between 3.5% and 9.7% as per the recent meta-analyses in 2014. We aim to evaluate the incidence of PEP, conduct a causal analysis and financial implications at our hospital for general surgical patients. Method All General Surgical patients who had ERCP done between 01/10/2022 and 31/03/2023 were included in the analysis. The patient records on TrakCare® were analysed for demographic details, admission records, ERCP details, pre-procedural laboratory values and length of stay. The successful ERCPs defined as cannulation of the common bile duct were divided into the PEP and the non-PEP groups. Results A total of 155 patients had ERCP attempted but only 131 were successful. Of these 131, 13 (9.92%) developed PEP. Females in their 60s were predominantly affected. Three out of six patients undergoing ERCP for malignant biliary obstructions were affected (50%). Patients with grossly deranged Liver Function Tests (mean bilirubin levels >=134.92µmol/L) had a higher risk of developing PEP (p-value=0.021). The mean overall hospital stay was 3.5 days longer (2-49 days) for patients who developed PEP costing an extra £20,475 - £35,763 over 6 months to the NHS. There were no mortalities recorded. Conclusions Patients with gallstone disease should receive prompt cholecystectomy adhering to NICE guidelines to reduce the risk of developing gallstone-related complications. This in turn would lead to a reduction in PEP and positively affect the financial implications for the NHS.

612 A Quality Improvement Project of Management of Acute Pancreatitis in a District General Hospital; How Well Are We Doing Against NICE Guidelines?

612 A Quality Improvement Project of Management of Acute Pancreatitis in a District General Hospital; How Well Are We Doing Against NICE Guidelines?

Aspirin 162 mg vs 81 mg for preeclampsia prophylaxis in high-risk obese individuals: a comparative effectiveness open-label randomized trial (ASPREO)

In the United States, leading medical societies recommend 81 mg of aspirin daily for the prevention of preeclampsia in women at risk, whereas the NICE guidelines in the United Kingdom recommend a dose as high as 150 mg of aspirin. Recent data also suggest that in the obese population, inadequate dosing or aspirin resistance may impact the efficacy of aspirin at the currently recommended doses. We evaluated whether daily administration of 162 mg aspirinwould be more effective compared with 81 mg in decreasing the rate ofpreeclampsia with severe features in high-risk obese pregnant individuals. We performed a randomized trial between May 2019 and November 2022. Individuals at 12-20 weeks of gestational age with a body mass index ≥30 kg/m2 at the time of enrollment and at least 1 of 3 high-risk factors: history of preeclampsia in a prior pregnancy, at least stage I hypertension documented in the index pregnancy, pregestational diabetes or gestational diabetes diagnosed before 20 weeks of gestational age were randomized to either 162 mg or 81 mg of aspirin daily till delivery, participants were not blinded to treatment allocation. Exclusion criteria were multifetal gestation, known major fetal anomalies, seizure disorder, baseline proteinuria, on aspirin because of other indications, or contraindication to aspirin. The primary outcome was preeclampsia with severe features (preeclampsia or superimposed preeclampsia with severe features; eclampsia; or hemolysis, elevated liver enzymes, low platelet count syndrome). Secondary outcomes included rates of preterm birth because of preeclampsia, small for gestational age, postpartum hemorrhage, abruption, and medication side effects. A sample size of 220 was needed using a preplanned Bayesian analysis of the primary outcome to estimate the posterior probability of benefit or harm with a neutral informative prior. Approximately 220/343 (64.1%) individuals were randomized. The primary outcome was available for 209/220 (95%) individuals. Baseline characteristics were similar between groups, with the median gestational age at enrollment being 15.9 weeks in the 162 mg aspirin group and 15.6 weeks in the 81 mg aspirin group. Enrollment before 16 weeks occurred in 55 of 110of those assigned to 162 mg and 58 of 110 of those assigned to 81 mg ofaspirin. The primary outcome occurred in n of d individuals (35%) in the 162mg aspirin group and n of d individuals (40%) in the 81 mg aspirin group (posterior relative risk, 0.88; 95% credible interval, 0.64-1.22). Bayesian analysis indicated a 78% probability of a reduction in the primary outcome with 162 mg aspirin compared with 81 mg aspirin dose. Rates of indicated pretermbirth because of preeclampsia (21% vs 21%), small for gestational age (6.5% vs 2.9%), abruption (2.8% vs 3.0%), and postpartum hemorrhage (10.0% vs 8.8%) were similar between groups. Medication adverse effects were also similar. Among high-risk obese individuals, there was a 78% probability of benefit that 162 mg aspirin compared with 81 mg will decrease the rate of preeclampsia with severe features. With the best estimate of a 12% reduction when using 162 mg of aspirin compared with 81 mg of aspirin in this population. This trial supports doing a larger multicenter trial.

Rational Use of Proton Pump Inhibitors among Patients Admitted in a Tertiary Care Hospital

Background: The prevalent usage of proton pump inhibitors (PPIs) is a testament to the effectiveness of this class of medications, but it also introduces risk associated with inappropriate prescriptive and consumptive practices. Because of the negative effect of incorrect usage and overdose of PPIs, it is very important for physicians to only prescribe these drugs when needed. However, recent studies showed some concerns about long-term PPIs consumption. The rational prescription of medications is vital to ensuring the optimal use of medical resources, providing effective therapy and minimizing adverse drug reactions. Methods: This observational study was conducted in the department of Pharmacology and therapeutics, Sylhet M.A.G. Osmani medical college, Sylhet, in collaboration with the department of Medicine, Surgery, Gastroenterology, Obstetrics and gynaecology, Sylhet M.A.G. Osmani medical college hospital, Sylhet, from July 2022 to June 2023. The sample size for this study was 600. Usage of PPIs was considered to be appropriate on the basis NICE guidelines and recommendations by Scarpignato et al. (2016) committees on behalf of three Italian scientific societies. Result: For 600 PPIs prescriptions, total 705 case sheets were reviewed. The mean age of the study patients was 42.94±17.16 years. Female were found more 359(59.8%) than male 241(40.2%). Out of 600 patients, based on the indications of PPI usage, 287 (47.8%) of prescriptions were found appropriate, whereas inappropriate prescriptions were found in 313 (52.2%) cases. Out of 287 patients who were prescribed PPIs in an appropriate indication, 175 (61%) patients were given PPIs in an appropriate dose, whereas inappropriate dose was found in 112 (39%) of patients. Again, among 175 patients who were prescribed PPIs for appropriate dose, 24 (13.7%) patients were given PPIs in an appropriate frequency, whereas inappropriate frequency was found in 151 (86.3%) of patients. Finally, 24/600 (4%) patients were prescribed in an appropriate indication with an appropriate dose and frequency, whereas inappropriate prescription were found in 576/600 (96%) patients. PPIs were used as prophylaxis for NSAIDs in highest number 147(51.2%) of patients. Oral was the most common 348(58%) route of prescribing PPIs. Omeprazole was the highest 577(96.2%) prescribed PPIs. Conclusion: Based on this study result, it could be concluded that in most of the patients PPIs prescriptions were not following appropriate indications, dose and frequency recommended by reference guidelines. Like any other drugs, PPIs should be prescribed for a clear indication, the minimum dose needed for the expected effect and medication halted when no longer necessary upon re-evaluation.

1083 Assessment of Antibiotic Prescribing Compliance: Are We Adhering to NICE Guidelines for Recording Stop/Review Dates in Surgical Wards- A Closed Loop Audit

1083 Assessment of Antibiotic Prescribing Compliance: Are We Adhering to NICE Guidelines for Recording Stop/Review Dates in Surgical Wards- A Closed Loop Audit

Is the NICE Guideline for maintenance fluid therapy in adults in hospital appropriate?

The National Institute for Health and Care Excellence's (NICE) Guideline for Maintenance Fluid Therapy in Adults in Hospital is widely used, but the recommendations have not been evaluated properly. In this study, we investigated whether the recommendation of providing 25-30mL/kg/day of fluid and 1mmol/kg each of sodium and potassium is sufficient for human needs. First, we calculated the distribution of fluid between the extracellular fluid volume (ECV) and intracellular fluid volume (ICV) during a cross-over infusion experiment where 12 volunteers received 25mL/kg/day of either a high-sodium (154mmol/L) or low-sodium (54mmol/L) solution over 48h. Second, urine samples from 719 volunteers and clinical patients were used to quantify their renal water conservation and excretion of sodium and potassium. Third, retrospective analysis of a diet study was used to extrapolate how large the fluid intake and the electrolyte excretion likely had been in the 719 volunteers and hospital patients who delivered urine. The high-sodium fluid maintained the ECV but the ICV had decreased by 1.3L after 48h. The low-sodium fluid resulted in a volume deficit of 1.7L that equally affected the ECV and the ICV. Regression equations based on the diet study suggested that the daily intake of water in the 719 subjects averaged 2.6L and that 2mmol/kg of sodium and 1mmol/kg of potassium was excreted. The NICE guideline recommends too little water and sodium for a human to adequately maintain the ECV and ICV. EudraCT 2016-001846-24 and ISRCTN 12215472.

Economic Analysis of Cochlear Implants in Adults With Bilateral Severe-to-Profound Hearing Loss. A Systematic Review of the Literature.

To determine the cost-effectiveness or cost-utility of cochlear implants (CI) in adults with severe to profound bilateral hearing loss. PubMed (Medline), The Cochrane Library, Embase via Elsevier, EBSCOhost CINAHL, and Scopus. The study included adult participants with severe to profound bilateral neurosensory hearing loss. The analysis encompassed quality of life improvements, costs, cost-effectiveness, cost-utility, cost-benefit, quality-adjusted life year (QALY), incremental cost-effectiveness ratio (ICER), and incremental cost-utility ratio (ICUR). Systematic reviews, meta-analyses, case series, and prospective or retrospective cohort studies published in English between 2010 and 2023 were retrieved. Exclusion criteria included incomplete studies, abstracts, clinical cases, editorials, letters, studies involving pediatric populations, single-side deafness, methodology research, noneconomic aspects of CI, mixed child and adult data, and studies published before 2010. The risk of bias was assessed following the criteria outlined in Appendix I of the economic evaluation's quality assessment as per the NICE Guideline Development Method. Ten articles met the criteria and were included in the qualitative synthesis. One study conducted a prospective cost-utility analyses, one carried out a cost-benefit analyses, one was a randomized controlled clinical trial focusing on cost-utility, and another was a clinical trial addressing cost-effectiveness. Six studies employed Markov models, and one study utilized uniquely the Monte Carlo method. None quantified the economic impact of improved hearing on cognitive function. The heterogeneity of sources impacted data quality. Unilateral and sequential bilateral CI appeared to be cost-effective when compared with bilateral hearing aids or nontechnological support. When properly indicated, simultaneous bilateral CIs are cost-effective compared to no interventions and to unilateral cochlear implantation through differential discounting or variations from the base cases, especially with a life expectancy of 5-10 years or longer.

Neonatal Outcomes in Intrapartum Pathological CTG in Low-risk Pregnancies

Objective: The study aimed to investigate the neonatal outcomes of intrapartum pathological CTG patterns in low-risk women during labor. Methodology: This retrospective cohort study included 120 low-risk pregnant women who experienced pathological CTG patterns during labor. This study was conducted over a period of 12 months, from May 2023 to April 2024, in PAF hospital, Islamabad. Low-risk women were defined as those without pre-existing medical conditions or obstetric complications. Pathological CTG patterns were identified and categorized based NICE guideline [NG229]. Data on neonatal outcomes, including Apgar scores, neonatal resuscitation, admission to NICU, and perinatal mortality, were collected from medical records. Statistical analysis was performed to determine the association between pathological CTG patterns and neonatal outcomes. Results: The study was comprised of 120 low-risk females having the mean age of 28.4 ± 4.2 years. Pathological CTG patterns were classified into three categories: bradycardia, tachycardia, and variable decelerations. Among the study cohort, 45% (n=54) exhibited bradycardia, 30% (n=36) exhibited tachycardia, and 25% (n=30) exhibited variable decelerations. Neonatal outcomes revealed that 20% (n=24) of neonates had an Apgar score of <7 at 1 minute, while 10% (n=12) had an Apgar score of <7 at 5 minutes. Neonatal resuscitation was required in 15% (n=18) of cases. Statistical analysis showed that bradycardia was significantly related with low Apgar scores at 1 minute (p=0.03) and 5 minutes (p=0.04). Tachycardia was significantly associated with the need for neonatal resuscitation (p=0.02) and NICU admission (p=0.01). Conclusion: Intrapartum pathological CTG patterns in low-risk women were found to be associated with low Apgar scores, the need for neonatal resuscitation, and NICU admission. Bradycardia and tachycardia, in particular, were significant predictors of these adverse outcomes.

Obstructive sleep apnoea/hypopnoea syndrome: a feasibility study to review NICE guidelines

Obstructive sleep apnoea/hypopnoea syndrome: a feasibility study to review NICE guidelines

Preconception lipid profile and the subsequent risk of pregnancy disorders characterized by uteroplacental dysfunction in a multi-ethnic population: the linked HELIUS–PERINED study

BackgroundUnfavorable lipid profile is associated with pregnancy disorders characterized by uteroplacental dysfunction, including hypertensive disorders of pregnancy, preterm birth and fetal growth restriction. None of current tools used to predict the risk of pregnancy complications include lipid levels. Objective(s)In this study, we examined the association of preconception lipid profile with pregnancy disorders characterized by uteroplacental dysfunction in a multi-ethnic population, aiming to improve the identification of women at high risk for uteroplacental dysfunction using current prediction models. Study designWe conducted a linkage study combining lipid profile collected in the multi-ethnic HELIUS study (Amsterdam, 2011–2015), linked with national perinatal registry data on pregnancy complications after inclusion until 2019. We included 1177 women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, and Moroccan origin. Associations were studied using Poisson regression. The discriminative ability was assessed for different pregnancy complications of significantly associated lipid parameters when added to commonly used prediction tools for preeclampsia. ResultsPreconception triglyceride level was associated with prevalence of hypertensive disorders of pregnancy (e^triglyceride level (mmol/L) adjusted prevalence ratio 1.07, 95% CI 1.00 to 1.14). Age-adjusted prevalence of hypertensive disorders of pregnancy was also higher among women with high LDL-C level, high TC/HDL-C or ≥4 adverse lipid parameters, but most of these findings were not statistically significant when adjusted for demographic, lifestyle and medical characteristics. Addition of triglyceride level and other lipid parameters to the NICE guideline criteria and to the EXPECT prediction tool did not improve discriminative ability for hypertensive disorders of pregnancy, preterm birth or fetal growth restriction. Conclusion(s)Lipid profile did not aid in the identification of women at high risk for pregnancy disorders characterized by uteroplacental dysfunction. Further studies are needed to improve preconception prediction models for hypertensive disorders of pregnancy and other pregnancy disorders characterized by uteroplacental dysfunction using biomarkers or other easily available measurements.

Evaluating adherence to ECG monitoring protocols for methadone patients in primary care.

Opioid Agonist Treatment (OAT) is the gold standard for managing Opioid Use Disorder (OUD). It is highly effective at reducing all-cause mortality and drug-related harms. Prescribing OAT, particularly methadone, is becoming increasingly complex as Scotland's OUD population ages. Older patients, with increased polypharmacy and multimorbidity, are more susceptible to QTc interval prolongation associated with methadone use. Therefore, adherence to ECG monitoring guidelines for patients prescribed methadone is crucial, though insights from substance use services indicate suboptimal compliance. Medically Assisted Treatment guidelines established by the Scottish Government advocate for shared care agreements, thus transferring OAT prescribing responsibilities to primary care. Understanding ECG monitoring guideline implementation in non-specialist services is vital for developing safe OAT services in primary care. This audit assessed adherence to NICE guidelines for ECG monitoring in OUD patients prescribed methadone in a Scottish primary care practice. The notes of patients prescribed methadone were assessed using NICE criteria to determine eligibility for ECG monitoring. Eligible patients' medical records were reviewed to identify previous ECG investigations. Of 21 patients prescribed methadone, 16 qualified for ECG monitoring. Only 25% of eligible patients received ECG monitoring per NICE guideline, meaning 75% did not. These findings highlight that the issue of poor compliance with ECG monitoring guidelines is not limited to specialist services, but also affects primary care. Further exploration of barriers to guideline implementation is essential. Perhaps more resources are needed to integrate OAT services into primary care, which has taken on increased responsibilities without corresponding investment.

Antipsychotic Prescribing for In-Patients With Dementia at University Hospital Llandough to Look for Good Prescribing Practice in Line With NICE Guidelines

Antipsychotic Prescribing for In-Patients With Dementia at University Hospital Llandough to Look for Good Prescribing Practice in Line With NICE Guidelines

Assessment of Compliance With NICE Guidelines on Safety Planning Following Self-Harm in Elderly Patients in a Mental Health Trust

Assessment of Compliance With NICE Guidelines on Safety Planning Following Self-Harm in Elderly Patients in a Mental Health Trust

#1244 Rates of eGFR and UACR testing in patients with chronic kidney disease in England: Clinical Practice Research Datalink 2010-2019

Abstract Background and Aims The NICE chronic kidney disease (CKD) treatment guidelines recommend regular laboratory measurements of both kidney function (eGFR) and damage (proteinuria) to appropriately inform efforts to prevent and treat progression of CKD. Recommendations also indicate frequency of such testing should increase with CKD progression. There are few data on rates of testing in patients with confirmed CKD with particularly paucity in patients with various stages of CKD. Method This non-interventional, observational study utilised data from primary care electronic health records from Clinical Practice Research Datalink (CPRD) AURUM. Patients aged ≥18 years with CKD registered in CPRD with at least one year of follow-up (FU) between January 1, 2010 and December 31, 2019 were identified. CKD was defined by an eGFR <60 ml/min/1.73 m2 and/or presence of a uACR measurement ≥3 mg/mmol, both confirmed by a second measurement 90-365 days later (index). Patients with eGFR <9 ml/min/1.73 m2 at index were excluded. Frequency of renal testing (eGFR and UACR) for each complete year of FU was quantified starting the day after index and patients were censored the last day of the final complete calendar year of FU after index. Frequency of renal testing per FU year was calculated overall and by CKD stage and level of albuminuria at index. Results In the 650 565 patients with CKD identified, mean age (SD) was 76.1 (11.3) years, 55.4% were female, and 88.5% White. Most (62.0%) patients had stage 3a CKD (eGFR 45-<59 ml/min/1.73 m2) at index. Among patients with UACR measurements within 1 year prior to index (54.1%), 49.3% were A1 (<3 mg/mmol), 43.4% A2 (3-30 mg/mmol) and 7.3% A3 (>30 mg/mmol) at index. During the first year of FU, 81.45% of patients had 1+ eGFR test whereas 39.2% had 1+ UACR test. Patients more frequently received 1+ eGFR per year over subsequent years of FU but the low proportion with 1+ UACR test per year remained stable for UACR. The mean (SD) number of eGFR and UACR tests performed per patient in the first year of FU was 2.09 (2.39) and 0.49 (0.70), respectively. More frequent eGFR testing was observed with lower eGFR at index and across subsequent years of FU. Frequency of UACR testing was lower at more advanced stages of CKD at index in all FU years, however, no trends in UACR testing frequency were observed by level of albuminuria at index. Conclusion This evidence from a population-based sample of patients with confirmed CKD in England, indicates that eGFR is being monitored in the majority of patients, yet UACR testing is suboptimal according to NICE guidelines regardless of level of kidney function or level of albuminuria. Although eGFR testing is more frequent at more advanced stages of CKD, UACR testing seems to become less frequent with more advanced stages of CKD. With emergence of new therapies to prevent progression of CKD, efforts to increase frequency of UACR testing are needed (particularly in earlier CKD stages) to ensure that patients who are at risk of worsening CKD and albuminuria receive appropriate management.

Current axillary management of patients with early breast cancer and low-volume nodal disease undergoing primary surgery: results of a United Kingdom national practice survey

PurposeUK NICE guidelines recommend axillary node clearance (ANC) should be performed in all patients with biopsy-proven node-positive breast cancer having primary surgery. There is, however, increasing evidence such extensive surgery may not always be necessary. Targeted axillary dissection (TAD) may be an effective alternative in patients with low-volume nodal disease who are clinically node negative (cN0) but have abnormal nodes detected radiologically. This survey aimed to explore current management of this group to inform feasibility of a future trial.MethodsAn online survey was developed to explore current UK management of patients with low-volume axillary disease and attitudes to a future trial. The survey was distributed via breast surgery professional associations and social media from September to November 2022. One survey was completed per unit and simple descriptive statistics used to summarise the results.Results51 UK breast units completed the survey of whom 78.5% (n = 40) reported performing ANC for all patients with biopsy-proven axillary nodal disease having primary surgery. Only 15.7% of units currently performed TAD either routinely (n = 6, 11.8%) or selectively (n = 2, 3.9%). There was significant uncertainty (83.7%, n = 36/43) about the optimal surgical management of these patients. Two-thirds (n = 27/42) of units felt an RCT comparing TAD and ANC would be feasible.ConclusionsANC remains standard of care for patients with low-volume node-positive breast cancer having primary surgery in the UK, but considerable uncertainty exists regarding optimal management of this group. This survey suggests an RCT comparing the outcomes of TAD and ANC may be feasible.

OPTIMIZING WATER USAGE: THE IMPACT OF ALCOHOL HAND RUBS IN LOWER LIMB PRIMARY ARTHROPLASTY

Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications.Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled.We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters.Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices.

Abstract PS10-08: Validation of a clinical image-based AI-risk model for individualized breast cancer screening in a multi-national setting

Abstract Background: Image-derived AI risk models for breast cancer have shown high discriminatory performances compared with clinical risk models based on family history and lifestyle factors. However, little is known about their generalizability across different screening settings and clinical feasibility. Purpose: To investigate the predictive performance of a clinically used image-derived AI-based breast cancer risk model in multiple European screening populations. Methods: Four European mammographic screening populations in three countries screened between 2009-2020 for women aged 45-69 was used to perform a nested case-control study. In total, 739 women with incident breast cancers were included together with 7,812 controls matched to cases on year of study-entry. Mammographic features (density, microcalcifications, masses, left-right breast asymmetries of these features) for risk assessment were extracted using AI from full-field digital mammograms. Breast cancer occurrence was assessed after two years of follow-up. Absolute risks of breast cancer were predicted using the risk model from negative mammograms at study-entry. Adjusted Area Under the receiver operating characteristic Curves (aAUC) estimated discriminatory performance and, adjusted risk-ratios estimated the stratification performance of women at high/general risk per the clinical guidelines. Results: The overall aAUC of the AI risk model was 0.72 (95%CI 0.70-0.75), range 0.71 (95%CI 0.67-0.75) to 0.74 (95%CI 0.69-0.78) for breast cancers developed in four screening populations. In the 4.6% of women classified at high risk using the NICE guidelines thresholds, cancers were more likely diagnosed after 2 years follow-up, risk-ratio (RR) 6.7 (95%CI 5.6-8.0), compared with the 71% of women classified at general risk by the model. Similar risk-ratios were observed across tertiles of mammographic density. In the high-risk group, 22% of the 2-year future cancers were diagnosed, and 29% of stage 2 and higher cancers, p< 0.01. Conclusions: The AI risk model showed generalizable discriminatory performances across European populations and, captured ~30% of clinically relevant stage 2 and higher breast cancers in ~5% of high-risk women who were sent home with a negative mammogram. Similar results were seen in fatty and dense breasts. An image-derived AI model is feasible for personalized screening to improve screening outcomes. Citation Format: Mikael Eriksson, Marta Román, Axel Gräwingholt, Sylvia Heywang-Köbrunner, Paolo Rossi, Per Hall. Validation of a clinical image-based AI-risk model for individualized breast cancer screening in a multi-national setting [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS10-08.