St. Mary’s Hospital

Low-grade B-cell lymphomas (LGBCLs) account for approximately 40% of non-Hodgkin lymphomas with low progression. LGBCL is divided into subgroups, which share common complications. Analyzing prognostic factors and mortality causes could improve patient survival; however, currently available models present limitations in discriminating the cause of death. Therefore, this study aimed to compare the prognostic factors and causes of death, such as secondary malignancies (SMs), aggressive histologic transformation (HT), and infectious complications, including coronavirus disease 2019 (COVID-19), in LGBCLs using a competing risk analysis. This retrospective analysis included 1,047 adults with LGBCLs (follicular lymphoma, 689; marginal zone lymphoma, 312; mantle cell lymphoma [MCL], 46) diagnosed between January 2011 and December 2022 across seven centers. Competing risk models were employed to estimate cumulative incidence rates of lymphoma progression-related and non-lymphoma-related mortality. Patients with SMs (3.8%) exhibited poorer overall survival than those without SMs, whereas HT and COVID-19 status did not impact survival outcomes in multivariate analysis. Analysis revealed an association of SMs, age > 60 years, male sex, pleural effusion, and elevated lactate dehydrogenase levels with worse non-lymphoma-related mortality. Moreover, age > 60 years, MCL, nodal MZL, and anemia were linked to poorer outcomes for lymphoma progression-related death. The management of non-lymphoma-related risk factors, such as through early SM detection, is crucial for improving the survival of patients with LGBCLs.

Leiomyosarcoma (LMS) is a malignant tumor of smooth muscle origin that is most frequently found in the uterus and gastrointestinal tract. LMS involving the head and neck is rare, accounting for only 2.3% of all cases. In this region, LMS tends to be more aggressive and is associated with a poorer prognosis compared to its gastrointestinal counterparts. Furthermore, LMS of the nasal cavity and paranasal sinuses is extremely rare. Here, we present a case of malignant transformation of a leiomyoma originating from the inferior turbinate, which was successfully treated with endoscopic tumor resection followed by postoperative radiotherapy.

Consenting patients for surgery is a vital process with ethical and legal implications. The use of a standardised consent form may provide a solution to issues related to poor communication surrounding the consenting process. To date, there is no standardised consent form available for use specifically for transoral robotic surgery (TORS) across robotic centres. In an attempt to improve the consenting process relating specifically to TORS, this study aims to develop a standardised consent form using a modified Delphi process. A modified Delphi process was employed to define consensus for complications to be used in a standardised consent form for TORS. An initial iteration was devised using a literature search with experts rating each item using a Likert scale. The process was repeated until consensus was reached for all items. Two rounds were completed with seven experts detailing key risks to be included on a standardised TORS consent form. This study is the first to propose a standardised consent form for use specifically in TORS. The authors agree with other literature that suggests that the use of standardised consent forms provide numerous advantages over handwritten forms. Future studies are needed to evaluate its implementation across multiple centres in order to assess the proposed benefits to both clinicians and patients.

IntroductionGBA1 variants are significant genetic risk factors for Parkinson’s disease (PD). Accurately measuring glucocerebrosidase (GCase) activity is crucial for understanding disease progression and developing targeted therapies. This study aimed to validate strategies for measuring blood GCase activity in patients with GBA1-associated PD (GBA-PD).MethodsWe recruited 25 GBA-PD patients and 27 matched PD patients without GBA1 variants (non-GBA-PD). GCase activity from fresh blood was quantified using the 4-methylumbelliferyl β-D-glucopyranoside leukocyte assay (GCaseRaw). The GCase patient/normal control ratio (GCase ratio) was calculated for consistency. GCase activity in dried blood spot (DBS) specimens (GCaseDBS) and plasma glucosylsphingosine (GluSph) levels were measured using LC–MS/MS. The diagnostic accuracy was assessed using area under the curve (AUC) values.ResultsNo significant differences in demographics or disease characteristics were found between GBA-PD and non-GBA-PD patients. GCase activity was significantly lower in patients with GBA-PD (p < 0.001). The GCase ratio exhibited a higher diagnostic accuracy (AUC, 0.93) than GCaseRaw (AUC, 0.88) or GCaseDBS (AUC, 0.78). Plasma GluSph levels were higher in GBA-PD patients and were negatively correlated with the GCase ratio (r = −0.326; p < 0.01).DiscussionThe relative ratio of GCase activity showed a strong discriminatory potential, distinguishing between GBA-PD and non-GBA-PD.

Abstract Introduction Recent studies have demonstrated that early rhythm control for first-line treatment of atrial fibrillation (AF) improved cardiovascular outcomes. However, there is limited data regarding the long-term outcome of patients who failed antiarrhythmic drugs and who refuse radiofrequency catheter ablation (RFCA). Methods Patients with AF who were refractory to antiarrhythmic drugs and had refused further rhythm control attempts via RFCA were retrospectively identified and propensity-score matched with who had been treated with RFCA. The primary outcome of interest was all-cause mortality or ischemic stroke. Results A total of 169 patients who refused rhythm control with RFCA and propensity-score matched 169 patients who had been treated with RFCA were included for analysis. During a mean follow-up of 4.3[2.3;6.9] years, maintenance of sinus rhythm was more achieved in RFCA group (7 [4.1%] in Refuse group vs. 133 [78.7%] in RFCA group, p&amp;lt;0.001). the incidence of ischemic stroke was significantly higher in patients who refused RFCA compared with patients who underwent RFCA (24 [14.2%] vs. 6 [3.5%], log-rank p&amp;lt;0.001), but all-cause mortality was not significantly different (log-rank p=0.8). Refusal of attempted rhythm control via RFCA was an independent risk factor for ischemic stroke on multivariate Cox analysis (hazard ratio 3.2; 95% confidence interval 1.2 to 8.53, p=0.02). The risk of major adverse cardiovascular events (MACE) were also significantly higher in Refuse group (31 [18.3%] vs. 12 [7.1%], HR 3.83, 95% CI 1.57-9.37, p=0.003). Conclusion In patients with antiarrhythmic drug-refractory AF, maintenance of sinus rhythm was significantly different dependent on rhythm control via RFCA, therefore the risk of stroke was significantly higher in patients who refused rhythm control via RFCA compared with that of those treated with RFCA.

Abstract Introduction Heart failure (HF) is a significant global health concern, and sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as dapagliflozin and empagliflozin, have emerged as important therapeutic options. However, their comparative effectiveness in a real-world population remains uncertain. Purpose The purpose of this multicenter, population-based cohort study was to investigate and compare the outcomes associated with dapagliflozin and empagliflozin use in patients with heart failure. We sought to understand whether these SGLT2 inhibitors had differential effects on cardiovascular events in a real-world setting. Methods We analysed data from a clinical data warehouse encompassing seven medical centers. Subjects diagnosed with heart failure between January 2021 and November 2023, who were prescribed dapagliflozin or empagliflozin, were included. We conducted one-to-one propensity-score matching, ensuring that the dapagliflozin and empagliflozin groups were comparable in baseline characteristics. The primary outcome was a composite of cardiovascular (CV) death or hospitalization for HF, analysed as the first event occurring after starting each medication. Secondary outcomes included individual components, all-cause death, and CV hospitalization. Results Propensity-score matching made a balanced cohort of 6,281 patients (3,111 in the dapagliflozin group and 3,170 in the empagliflozin group). The median follow-up duration was 16.0 months. In the propensity-score matched cohort, dapagliflozin and empagliflozin showed no significant difference in the primary outcome (8.8% versus 7.8%, hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.77-1.08, p=0.276). Similar findings were observed in secondary outcomes. Subgroup analysis revealed potential benefits of empagliflozin in patients with diabetes mellitus (DM) (7.8% versus 5.6%, HR 0.73, 95% CI 0.55-0.98, p=0.039). Conclusion This study suggests that dapagliflozin and empagliflozin have similar clinical outcomes in the management of heart failure in a real-world setting. However, empagliflozin showed result in improving outcomes for HF patients with DM. Further research is warranted to validate these findings and guide clinical decision-making in the individualized management of heart failure.Baseline characteristicsSubgroup analysis

ObjectivesTo evaluate London paediatric trainee priorities and identify areas of improvement to achieve an outstanding training programme. To compare these results to previous years to monitor trends and provide up-to-date training recommendations.Methods983 London paediatric trainees were invited to complete a survey on their training experiences for their March-September 2023 rotation. The survey comprised of two separate areas for analysisClosed questions – allowing for rating and comparison between trusts and sub-specialityOpen comments – written responses on both placement positives and improvements/issuesFree text qualitative analysis was performed by DataSyrup and the Everyday Excellence subgroup of the London School of Paediatrics.Results705/778 ‘in programme’ trainees responded to the survey – a 90% completion rate. This year, 80% of trainees judged their placement to be ‘good’ or ‘excellent’ – up 2% vs 2022 but lower than pre-covid levels.What makes an excellent placement?The top three factors creating a great placement for paediatric trainees remain similar to previous years (figure 1):Variety and novelty in learning experiences, opportunities and exposureSenior support – especially engaged and supportive ConsultantsPositive team relationships and friendly working environments 6458 Figure 1Trainees were asked two open questions: (1) What were the BEST THINGS about this placement? What worked well and enabled you to learn and to enjoy the placement? (2) And what are the AREAS OF IMPROVEMENT that you would advise for the placement. Trainees were then asked to self-classify their comments by theme as shown in the bar chartWhat are the most pressing areas for improvement?Rota issues and staffing levels continue to dominate concerns -they are mentioned by half of trainees (figure 1); expectedly, other themes for improvement are largely the inverse of the positive aspects of placements.Results also show stage of training has more of an influence on placement satisfaction than being part time (figure 2) – Junior Registrars rate their placements lowest. 6458 Figure 2Time full than less vs time full and training of level by satisfaction placementAssessment of supporting professional activity (SPA) time was a new addition to the survey this year. With reference to the RCPCH trainee charter – 27% of trainees felt they were rostered for the recommended time or more; 23% answered: ‘no, can’t take recommended time’ and 50% were not rostered for any SPA time at all.ConclusionSenior support, team environment and learning opportunities remain the cornerstones of an excellent trainee experience. This, alongside the aforementioned areas for improvement should be the focus for departments aiming to improve trainee experience. It seems we should be paying particular attention to trainees at Junior Registrar level who show worse satisfaction scores than other stages of training. Finally, new to the survey this year, we see only 27% of trainees fulfil RCPCH recommendations for SPA time – addressing this will require both an improvement in staffing levels and recognition of the value of SPA in training.

Metabolic bariatric surgery tourism continues to rise and has become a growing concern for bariatric surgeons globally. With varying degrees of regulation, counselling and success, those that develop complications may have to deal with a multitude of challenges often distant from their country of operation. The aim of this study was to characterize the barriers and facilitators influencing individuals to undergo metabolic bariatric surgery tourism, in order to better understand the implications to the National Health Service and other healthcare systems. A systematic literature search, restricted to the English language, was performed to identify relevant studies. All studies were included until December 2022, the last search date. Study quality was assessed with the validated mixed-methods appraisal tool. A Braun and Clarke thematic analysis was undertaken to identify themes and subthemes. A total of five studies met the inclusion criteria. Identified themes included: availability, accessibility, cost, eligibility, reputation, and stigma; the available evidence was of varying quality. This work identifies a series of subthemes influencing the decision to undertake metabolic bariatric surgery tourism. The results highlight the limited literature available in understanding the complex motivational insights; the scale of the problem in the current healthcare system; cost and long-term outcomes. A National Emergency Bariatric Surgery audit would allow generation of more robust data to explore further the issues of clinical relationships and networks and to guide policy making.

Abstract ObjectiveTo estimate the association between several risk factors and high-grade squamous intraepithelial lesions (HSIL) treatment failure in order to identify predictors.MethodsThe study population included 1,548 Canadian women treated for HSIL who participated in a randomized control trial. HSIL treatment failure was the presence of histologically confirmed HSIL or worse during the two-year follow-up period. This nested-case control study included all 101 cases of treatment failure and controls that were matched 1:1 on treatment center and date of failure. Conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) between each potential predictor and HSIL treatment failure. Independent variables that were examined included age, parity, smoking status, number of sexual partners, condom use, method of contraception, margins, number of passes, diagnosis on conisation, genotype, and number of infecting types. Interactions between smoking and margins and genotype were evaluated.ResultsHaving positive vs. negative margins (adjusted OR=4.05, 95% CI 1.57-10.48) and being positive forHuman Papillomavirus(HPV)16 and/or HPV18 vs. any other type (adjusted OR=2.69, 95% CI 1.32-5.49) were predictors of HSIL treatment failure in multivariable models. ORs suggested that older age, more severe lesions, and single-type infections may be at a higher risk of treatment failure but were not statistically significant. The ORs for smoking status, number of sexual partners, condom use, contraception, parity, and number of passes were near the null value. We did not observe any evidence of interaction between smoking and genotype, nor between margins and genotype.ConclusionOnly positive margins and HPV16/18 positivity were predictors for being diagnosed with HSIL or worse within two years of treatment. However, we do not recommend automatic retreatment of those with positive margins because over 90% of those with positive margins did not fail treatment. The predictive value of HPV16 and HPV18 for HSIL treatment failure suggests that high coverage vaccination programs should contribute to a significant reduction in residual/recurrent disease.

The Da Vinci SP robot system was recently introduced, but its safety and feasibility for rectal cancer compared with the currently used robot system have not been reported. This was a single-centre retrospective study. Data from patients who underwent abdominal total mesorectal excision (TME) from October 2015 to October 2022 were analysed. After propensity score matching, the short-term outcomes were compared. A total of 56 patient data were analysed. Intersphincteric resection was more common in the SP group (7 cases (25%) vs. 0 case (0%), p=0.001). The operation time was significantly shorter in SP (184 vs. 227.5min, p<0.0001), but the docking time was similar. The postoperative complications were similar. There were no differences in the postoperative pain score and length of hospital stay. The SP robotic system for abdominal TME has acceptable short-term and is safe and technically feasible.