The Centricity Score: A Novel Measurement to Aid in Conservative Breast Cancer Surgery

Introduction: This study describes an intra-operative scoring system to advise the surgeon of the?centricity of the tumour in the excised specimen. Methods: Spatial estimations were prospectively made in 10 consecutive patients undergoing wide local excision (WLE) using Bioptics intra-operative digital specimen imaging. The centricity score was defined as 100 – (ICD/SD?×?100), where ICD is the inter-centre distance between the specimen’s centre and the tumour’s centre. Results: 10 patients with invasive breast cancer (T1b to T4a), mean age 56 years (range 44 - 71) were studied. The mean tumour and specimen diameter was 24 mm ± 10 (range 12 - 48) and 101 mm ± 22 (range 64 - 140). The mean centricity score was 86 ± 9 (range 65 - 95). Conclusion:?This study successfully?describes an intraoperative radiological spatial scoring system for patients undergoing WLE. Tumours were well centered in specimens with an overall score of 86/100. The centricity score could?be used to guide excision and potentially set benchmarks for conservative breast surgery.

The Keys to Optimising Breast Wounds: A Meta-Analysis

Background: Breast disease and breast cancer management form a major part of healthcare delivery. Surgical site occurrence (SSO) poses septic and oncological risks to patients. This study undertook a meta-analysis to identify key risk factors and interventions that may alter the incidence of SSO in patients undergoing breast surgery. Methods: An ethically approved, PROSPERO-registered meta-analysis following PRISMA guidelines and Cochrane Handbook for Systematic Reviews was undertaken of all published English articles using electronic databases from 2010 to 2017 incorporating MeSH terms “risk factors”, “surgical site infections”, “breast surgery”, and “interventions”. Articles scoring > 10 for non-comparative studies and >15 for comparative studies, using MINORS criteria were included. The OR or RR using random-effects, Mantel-Haenszel method were computed for each risk factor and intervention respectively with RevMan 5. Results: The pre-operative factors affecting breast surgery SSO were diabetes mellitus (OR = 2.52, CI = 1.78 - 3.59, p < 0.001), smoking (OR = 2.39, CI = 1.57 - 3.63, p < 0.001), ASA ≥ III (OR = 2.37, CI = 1.51 - 3.74, p < 0.001), obese versus non-obese (OR = 1.84, CI = 1.52 - 2.24, p < 0.001), over-weight/obese versus normal BMI (OR = 1.70, CI = 1.36 - 2.13, p < 0.001), hypertension (OR = 1.63, CI = 1.39 - 1.90, p < 0.001), and antibiotics prophylaxis (RR = 0.58, CI = 0.36 - 0.95, p = 0.03). The intraoperative factors were surgical wound classifications 3 - 4 (OR = 6.16, CI = 2.52 - 15.02, p < 0.001), surgical drains (OR = 2.80, CI = 1.06 - 7.38, p = 0.04), and axillary lymph node dissection (OR = 1.46, CI = 1.18 - 1.80, p < 0.001). The post-operative factors were adjuvant radiotherapy (OR = 1.77, CI = 1.26 - 2.50, p = 0.001), re-operated patients (OR = 1.65, CI = 1.01 - 2.70, p = 0.05), post-operative antibiotics (RR = 0.57, CI = 0.33 - 0.98, p = 0.04), and drain antisepsis care (RR = 0.15, CI = 0.03 - 0.82, p = 0.03). Conclusions: This study identified key factors associated with increased risk of breast surgery wound occurrence. It will facilitate the development of a peri-operative breast wound bundle to optimize outcomes.

Failure to Engage in Breast Screening and Risk Assessment Results in More Advanced Stage at Diagnosis

Background: Although well established, population based screening and family risk assessment for breast cancer have come under increasing scrutiny. The concept of over diagnosis is increasingly cited in cancer publications. This study assessed the impact of failure to screen or risk assess patients attending with a new diagnosis of breast cancer. Methods: A retrospective review was undertaken of 200 consecutive patients diagnosed with breast cancer between January 2010 and September 2012 at Letterkenny Hospital. Appropriate screening was defined as biennial in those aged 50 - 66 and in those 40 - 49 with moderate/high family history risk (NICE criteria or IBIS criteria). Patient demographics, screening history, diagnosis date and stage (TNM) were?documented. Patients with previous breast cancer were not included (n = 17). Results: 200 consecutive patients, whose mean age was 61 (range 28 - 99), were studied. 112/200 (56%) met no criteria for screening or family history assessment, and 88/200 (44%) met criteria for either screening (in 56) or family history assessment (in 32). 61/88 (69.3%) meeting criteria did not have a mammogram or risk assessment. The stage of breast cancer was significantly earlier in those screened appropriately, with early stage cancer in n = 111/139 (79.9 %) and late in n = 28/139 (20.1%), compared with 38/61 (62.3%) and 23/61 (37.7%) in those failing to be screened appropriately (p = 0.01?χ2?df1). Conclusion:?Failure to engage in breast screening and risk assessment resulted in more advanced stage at diagnosis.

An Evaluation of FaHRAS Computer Programmes’ Utility in Family History Triage of Breast Cancer

Introduction: Rapid and appropriate family risk assessment and triage of patients are essential for patients presenting to a symptomatic breast unit and international criteria for review are well established. Family History Risk Assessment Software (FaHRAS) is a computerized program, involving different modalities of risk assessment, which is available but has not been widely assessed. Aims: This study evaluated the FaHRAS software scoring of family history risk. Its analysis was compared to multi-tool family history risk assessment models in a cohort of 353 patients on a historic family history waiting list. Methods: A recent published pilot study assessed and categorized family history risk in 353 patients on a historic family history waiting list, according to international guidelines including NICE criteria, Gail and IBIS risk estimates. The current study involved a reassessment of all 353 patients using the FaHRAS software program to determine its accuracy and ease of use. Patient demographics and time required to perform the analysis were documented. Results: FaHRAS identified 73 (20.7%) patients had an IBIS family history score of 17% or greater and 89 (25.2%) patients met the NICE guidelines criteria for management beyond primary care. In the previous study, this was 79 (22.4%) and 112 (31.7%) respectively. Using the largest denominator (NICE guidelines), 264/353 (74.8%) patients could be discharged to primary care using FaHRAS. Using this largest denominator, FaHRAS also identified a total of 28 (7.9%) patients requiring referral to tertiary care while the previous study identified 3 (0.8%). Conclusion: This is one of the first studies to validate FaHRAS, which is accurate and easy to use. FaHRAS system can enable clinicians to become more efficient gatekeepers to genetic services.

Combined Patients and Medical Related Cosmetic Breast Cancer Outcomes—A Preferred Approach to Outcomes Assessment

Introduction: Reducing positive margins and need for re-excision yet maintaining cosmesis is key in breast cancer surgery. This study describes the evaluation of early outcomes of a combined cosmetic assessment programme following breast conservation surgery (BCS). Methods: An ethically approved prospective study was conducted at Letterkenny University Hospital and a 15-month timeframe was chosen. All consecutive patients undergoing conservative breast surgery with complete local excision, from July 2015 to October 2016, were entered into the study. Patients undergoing mastectomy and reconstruction with either implant or autologous tissue were not included. 41 patients undergoing BCS were analysed. Objective and subjective cosmetic evaluations were carried out. Assessments used were the Breast Cancer Conservative Treatment—cosmetic results [BCCT.core 2.0] Software, a panel of 4 experts in breast surgery and the Breast Cancer Treatment Outcome Scale (BCTOS). Demographic and pathological data, breast excision weight, % breast volume excised (BVE), margin positivity, complications and re-excision were documented. Data was expressed as mean and standard deviation for normally distributed data and medians and inter quartile range for non-normal data. Scores were also dichotomised to excellent/good and fair/poor and results were analysed. Results: 41 patients’ mean age is 55 ± 13 years. Mean breast volume was 768.3 cm3 ± 440;BVE weighed 78.6g ± 42.6 (18.9 - 214.4) and %BVE 11.3% ± 5.2% (5.1 - 23.3). Re-excision rate was 2/41 (4.9%) all for positive margins. 0/41 infections or haematomas occurred. Cosmetic status of 10 - 14 days post surgery was excellent or good by BCCT.core Software 78%, Expert panel 82.9%, BCTOS scale (92.7%), and fair or poor in 22%, 17.1% and 7.3% respectively. Conclusion: This study successfully evaluated objective and subjective cosmetic related outcomes following breast conserving surgery, incorporating both patient and surgeon in these assessments. The encouraging results show that despite low re-excision rates, acceptable cosmetic outcomes were achieved.

Are Family Doctors Compliant with Breast Family History Guidelines?

Introduction: Optimizing breast cancer care involves accurate risk assessment. Referrals to secondary care need to be appropriate both in terms of healthcare resource utilisation and the reduction of unnecessary patient anxiety. Aim: This study undertook an evaluation of family doctors compliance with NICE guidelines for asymptomatic family history referrals to a breast unit. Methods: A retrospective audit of general practice in County Donegal was carried out between January 2010 and May 2011. NICE guidelines and IBIS computerised model were used to assess whether referrals were appropriate. Results: 77.6% (90/116) met a criterion for secondary care referral. 51.7% (60/116) met the NICE criteria and 64.7% (75/116) met the IBIS criteria for referral to secondary care. 38.8% (45/116) met both. 6 were of low risk, 45 were of moderate risk and 1 was of high risk. 80.4% (45/56) of the patients who did not meet the NICE criteria, failed to do so because they had one 1st degree relative with breast cancer who was over the age of 40. Conclusion: 77.6% of referrals complied with international criteria for referral to secondary care. A greater understanding of what constitutes appropriate referral of 1st degree relatives would enhance the referral process.

Immediate and long-term outcomes after treat-all among people living with HIV in China:an interrupted time series analysis

Background In 2003,China implemented free antiretroviral therapy(ART)for people living with HIV(PLHIV),establishing an eligibility threshold of CD4<200 cells/μl.Subsequently,the entry criteria were revised in 2012(eligibility threshold:CD4≤350 cells/μl),2014(CD4≤500 cells/μl),and 2016(treat-all).However,the impact of treat-all policy on HIV care and treatment indicators in China is unknown.We aimed to elucidate the immediate and long-term impact of the implementation of treat-all policy in China.Methods Anonymized programmatic data on ART initiation and collection in PLHIV who newly started ART were retrieved between 1 January 2015 and 31 December 2019,from two provincial and municipal Centers for Disease Control and Prevention and ten major infectious disease hospitals specialized in HIV care in China.We used Poisson and quasi-Poisson segmented regression models to estimate the immediate and long-term impact of treat-all on three key indicators:monthly proportion of 30-day ART initiation,mean CD4 counts(cells/μl)at ART initiation,and mean estimated time from infection to diagnosis(year).We built separate models according to gender,age,route of transmission and region.Results Monthly data on ART initiation and collection were available for 75,516 individuals[gender:83.8%males;age:median 39 years,interquartile range(IQR):28-53;region:18.5%Northern China,10.9%Northeastern China,17.5%Southern China,49.2%Southwestern China].In the first month of treat-all,compared with the contemporaneous counterfactual,there was a significant increase in proportion of 30-day ART initiation[+12.6%,incidence rate ratio(IRR)=1.126,95%CI:1.033-1.229;P=0.007]and mean estimated time from infection to diagnosis(+7.0%,IRR=1.070,95%CI:1.021-1.120;P=0.004),while there was no significant change in mean CD4 at ART initiation(IRR=0.990,95%CI:0.956-1.026;P=0.585).By December 2019,the three outcomes were not significantly different from expected levels.In the stratified analysis,compared with the contemporaneous counterfactual,mean CD4 at ART initiation showed significant increases in Northern China(+3.3%,IRR=1.033,95%CI:1.001-1.065;P=0.041)and Northeastern China(+8.0%,IRR=1.080,95%CI:1.003-1.164;P=0.042)in the first month of treat-all;mean estimated time from infection to diagnosis showed significant increases in male(+5.6%,IRR=1.056,95%CI:1.010-1.104;P=0.016),female(+14.8%,IRR=1.148,95%CI:1.062-1.240;P<0.001),aged 26-35(+5.3%,IRR=1.053,95%CI:1.001-1.109;P=0.048)and>50(+7.8%,IRR=1.078,95%CI:1.000-1.161;P=0.046),heterosexual transmission(+12.4%,IRR=1.124,95%CI:1.042-1.213;P=0.002)and Southwestern China(+12.9%,IRR=1.129,95%CI:1.055-1.208;P<0.001)in the first month of treat-all.Conclusions The implementation of treat-all policy in China was associated with a positive effect on HIV care and treatment outcomes.To advance the work of rapid ART,efforts should be made to streamline the testing and ART initiation process,provide comprehensive support services,and address the issue of uneven distribution of medical resources.

Hesitancy to Receive the Booster Doses of COVID-19 Vaccine Among Cancer Patients in China:A Multicenter Cross-Sectional Survey—Four PLADs,China,2022

Summary What is already known about this topic?Cancer patients are more vulnerable and have higher mortality rates from severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)than the general population;however,coverage for booster doses of the coronavirus disease 2019(COVID-19)vaccine was low among cancer patients in China.What is added by this report?Overall,32.0%and 56.4%of cancer patients from four Provincial Level Administrative Divisions(PLADs)expressed hesitancy toward the first and second booster doses,respectively.Factors negatively associated with hesitancy to receive booster doses included positive attitudes,perceived support,and higher exposure to COVID-19 vaccination information.Conversely,postvaccination fatigue was positively associated with vaccine hesitancy.What are the implications for public health practice?Improved COVID-19 vaccination coverage is needed to promote health for cancer patients.

Uptake of Heterologous or Homologous COVID-19 Booster Dose and Related Adverse Events Among Diabetic Patients:A Multicenter Cross-Sectional Study—China,2022

Summary What is already known about this topic?Although a third coronavirus disease 2019(COVID-19)vaccination(booster)dose is highly recommended for diabetic patients,the vaccination behaviors and related adverse events are unclear among diabetic patients with a COVID-19 booster dose.What is added by this report?Diabetic patients with higher postprandial blood glucose,worrying about the safety of the booster dose were less likely to get the vaccine.

Lingguizhugan Decoction, a Chinese herbal formula, improves insulin resistance in overweight/obese subjects with non-alcoholic fatty liver disease: a translational approach

Lingguizhugan Decoction(LGZG)has been investigated in basic studies,with satisfactory effects on insulin resistance in non-alcoholic fatty liver disease(NAFLD).This translational approach aimed to explore the effect and underlying mechanism of LGZG in clinical setting.A randomized,double-blinded,placebo-controlled trial was performed.A total of 243 eligible participants with NAFLD were equally allocated to receive LGZG(two groups:standard dose and low dose)or placebo for 12 weeks on the basis of lifestyle modifications.The primary efficacy variable was homeostasis model assessment of insulin resistance(HOMA-IR).Analyses were performed in two populations in accordance with body mass index(BMI;overweight/obese,BMI 24 kg/m^(2);lean,BMI<24 kg/m^(2)).For overweight/obese participants,low-dose LGZG significantly decreased their HOMA-IR level compared with placebo(0.19(1.47)versus 0.08(1.99),P=0.038).For lean subjects,neither dose of LGZG showed a superior effect compared with placebo.Methylated DNA immunoprecipitation sequencing and real-time qPCR found that the DNA N6-methyladenine modification levels of protein phosphatase 1 regulatory subunit 3A(PPP1R3A)and autophagy related 3(ATG3)significantly increased after LGZG intervention in overweight/obese population.Low-dose LGZG effectively improved insulin resistance in overweight/obese subjects with NAFLD.The underlying mechanism may be related to the regulation of DNA N6-methyladenine modification of PPP1R3A and ATG3.Lean subjects may not be a targeted population for LGZG.

Appraisal of treatment outcomes in integrative medicine using metabonomics:Taking non-alcoholic fatty liver disease with spleen deficiency syndrome as an example

Objective:Appraisal of treatment outcomes in integrative medicine is a challenge due to a gap between the concepts of Western medicine(WM)disease and traditional Chinese medicine(TCM)syndrome.This study presents an approach for the appraisal of integrative medicine that is based on targeted metabolomics.We use non-alcoholic fatty liver disease with spleen deficiency syndrome as a test case.Methods:A patient-reported outcome(PRO)scale was developed based on literature review,Delphi consensus survey,and reliability and validity test,to quantitatively evaluate spleen deficiency syndrome.Then,a metabonomic foundation for the treatment of non-alcoholic fatty liver disease with spleen deficiency syndrome was identified via a longitudinal interventional trial and targeted metabolomics.Finally,an integrated appraisal model was established by identifying metabolites that responded in the treatment of WM disease and TCM syndrome as positive outcomes and using other aspects of the metabonomic foundation as independent variables.Results:Ten symptoms and signs were included in the spleen deficiency PRO scale.The internal reliability,content validity,discriminative validity and structural validity of the scale were all qualified.Based on treatment responses to treatments for WM disease(homeostasis model assessment of insulin resistance)or TCM syndrome(spleen deficiency PRO scale score)from a previous randomized controlled trial,two cohorts comprised of 30 participants each were established for targeted metabolomics detection.Twenty-five metabolites were found to be involved in successful treatment outcomes to both WM and TCM,following quantitative comparison and multivariate analysis.Finally,the model of the integrated appraisal system was exploratively established using binary logistic regression;it included 9 core metabolites and had the prediction probability of 83.3%.Conclusion:This study presented a new and comprehensive research route for integrative appraisal of treatment outcomes for WM disease and TCM syndrome.Critical research techniques used in this research included the development of a TCM syndrome assessment tool,a longitudinal interventional trial with verified TCM treatment,identification of homogeneous metabolites,and statistical modeling.