Plymouth Hospital

Patients with suspected malignant pleural effusions (MPE) are often in need of both a confirmatory diagnosis and symptom control. Therapeutic options include talc pleurodesis via chest drain, poudrage during medical thoracoscopy, or alternatively an indwelling pleural catheter (IPC). Combining the diagnostic and therapeutic efficacy of medical thoracoscopy and poudrage with the ambulatory benefits of an IPC has not been studied within a randomised controlled trial. The aim of the TACTIC trial was to determine whether this approach resulted in a reduced length of hospital stay and improvements in dyspnoea. This unblinded, phase 3, randomised controlled trial was undertaken in 11 UK hospitals. Patients with MPE and confirmed malignancy (during medical thoracoscopy or beforehand) received talc poudrage and were randomly assigned by a centralised web-based system to an IPC at the time of medical thoracoscopy or usual care (ie, medical thoracoscopy, poudrage, and admission with large bore tube). Co-primary outcomes were time in hospital (including initial admission for trial procedure and any subsequent readmissions over 4 weeks post procedure) and average breathlessness assessed with visual analogue scale dyspnoea scores, measuring severity of dyspnoea from 0 mm to 100 mm, over a 4-week period. All randomised patients in whom an outcome was available were included in the analysis on a modified intention-to-treat basis. TACTIC was registered with ISRCTN on Aug 8, 2021 (ISRCTN11058680). Participants were recruited from between Dec 15, 2021, and Jan 3, 2024. 124 participants were randomised: 62 to the intervention and 62 to standard care. Leading diagnoses were pleural mesothelioma (46%), lung cancer (28%), and breast cancer (10%). Co-primary outcome data were available for 102 patients for total length of hospital stay (52 in intervention group vs 50 in standard care group) and 108 patients for breathlessness (57 vs 51). Median time in hospital was 1 day (IQR 1-3, 95% CI 1-2) in the intervention group versus 2 days (IQR 1-3, 95% CI 1-2) in standard care group (p=0·26). Median visual analogue scale dyspnoea scores did not differ between groups: 14·0 mm (IQR 8·8-32·4) in the intervention group versus 19·6 mm (8·1-38·7) in standard care group (p=0·26). Participants in the intervention group required fewer additional invasive pleural procedures by 12 weeks (two [3%] of 60 vs 19 [34%] of 56, p<0·0001) Trial related adverse events rates were similar in both groups (46 [74%] of 62 vs 44 [71%] of 62, p=0·84). Three related serious adverse events were recorded, all occurring in the intervention group. The combination of medical thoracoscopy, poudrage, and IPC did not result in shorter hospital stay but was safe and resulted in similar dyspnoea control compared with standard care. For patients with symptomatic MPE undergoing medical thoracoscopy for pleurodesis who prioritise minimising the length of hospital stay or the need for further invasive pleural procedures, the addition of an IPC alongside poudrage might help to achieve this goal. National Institute of Health Research, Research for Patient Benefit.

SummaryIntroductionDay‐case surgical activity is increasing in the UK yet there is a lack of data on the prevalence of chronic post‐surgical pain in this population. This study uses data from the POPPY study to estimate the prevalence of chronic post‐surgical pain after day‐case surgery, its relationship with quality of life and also explores associated factors.MethodsData were collected from eligible consenting adults having day‐case surgery in 199 sites across the UK. Baseline data were collected on the day of surgery, and patients were followed up by short message service‐delivered questionnaires on day 1, day 3, day 7 and day 97. Chronic post‐surgical pain was defined using pain severity scores at day 97. Multivariable logistic regression models were used to explore associations with chronic post‐surgical pain.ResultsAt day 97, 3442 patients had responded from a total of 7839 recruited. The estimated prevalence of chronic post‐surgical pain was 7.2% (95%CI 6.4–8.1%). We found the following were associated with chronic post‐surgical pain: week 1 pain scores; orthopaedic, breast and plastic surgical specialities; non‐surgical site chronic pain at baseline; deprivation; and ethnicity. Patients with chronic post‐surgical pain had a mean (SD) decrease of 0.137 (0.205) in health‐related quality of life score compared with baseline.DiscussionThis is the first large UK multicentre, prospective observational study exploring chronic post‐surgical pain after day‐case surgery. Multivariable modelling highlighted several associated factors. Chronic post‐surgical pain is common after day‐case surgery and is associated with reduced quality of life.

Abstract Aim This study assessed the educational value of a novel, low-cost virtual reality headset system designed for stereoscopic 3D viewing of robotic upper gastrointestinal surgery, targeting medical students and junior doctors. Method Ten participants observed robotic surgical procedures using a prototype 3D video streaming system in combination with a phone-based VR headset. Following the experience, participants completed a structured questionnaire evaluating immersion, ease of use, comfort, spatial understanding, and overall educational value. Responses were collected using Likert scales and open-text feedback. Results Ninety per cent of participants (9/10) rated the VR experience as highly immersive (score ≥4/5), with the same proportion reporting an improved understanding of robotic surgical procedures. All participants preferred the VR system over traditional 2D displays, particularly for conveying spatial awareness and depth perception. Key educational benefits included a clearer appreciation of the surgeon’s perspective and enhanced visualisation of anatomical depth. While 70 per cent found the headset comfortable to use, some noted limitations such as reduced image resolution and occasional latency. Despite these minor drawbacks, all participants supported the continued use of VR in surgical training, with 60 per cent strongly endorsing its integration. Suggested improvements focused on increasing image quality and enhancing headset ergonomics to further enrich the learning experience. Conclusions A low-cost VR headset system offers a highly immersive and educationally effective tool for observing robotic upper GI surgery. Its affordability and minimal setup requirements support its potential for broader adoption in surgical education.

Exosomes, lipid bilayer-enclosed extracellular vesicles, transfer bioactive molecules to mediate intercellular communication and tumour progression. Melanoma differentiation-associated gene 9 (MDA-9/Syntenin) regulates exosome biogenesis, but its role in glioma-derived exosomes remains poorly understood, with prior studies focusing primarily on MDA-9's intracellular functions in glioma cells. Here, we investigate MDA-9-mediated exosomal contributions to glioma pathogenesis. We found that MDA-9 is upregulated in glioma tissues, correlating with poor prognosis in glioma patients. Exosomes from MDA-9-overexpressing glioma cells significantly enhanced recipient glioma cell proliferation and invasion compared to controls. Mechanistically, these exosomes activated the PI3K-AKT pathway, upregulating MMP9 and c-MYC to drive cell proliferation and invasion. These findings reveal a novel role of the exosomal MDA-9-PI3K-AKT-MMP9/c-MYC axis in glioma progression, highlighting MDA-9 as a promising therapeutic target.