University Hospital of North Durham

Topical menthol application improves thermal perception and enhances performance but reduces sweat production in hot environments. In the aquatic environment, where sweat evaporation is of limited thermoregulatory benefit (ie,minimal evaporation) and leads to dehydration and cardiovascular strain, downregulating thermoregulatory sweating may have little consequence. However, it may preserve hydration status and improve subsequent performance, especially in air (ie,after first transition in triathlon); we tested this hypothesis. Eight trained triathletes (age 36 [5]y; height 1.77 [0.1]m; mass 73.9 [8.0]kg) completed 2 experimental conditions with prior whole-body application of menthol GEL (40g, 3.5% menthol) contrasted to NO-GEL. The protocol comprised 30 minutes ofswimming (at 85% of400-m personal best) in tropical water (29 °C) followed by a 20-km self-paced cycling time trial. Measures were deep body temperature (gastrointestinal pill), skin temperature, sweat production, rating of perceived exertion, thermal sensation, and thermal comfort. Paired t test and analysis of variance compared the data (.05 alpha level). Wet-bulb globe temperature equated to "red flag" conditions-heat-injury potential for all participants. Terminal gastrointestinal temperature was 38.8 °C (0.3 °C) and 38.8 °C (0.7 °C)and time-trial performance was 39:36 (04:31) and 40:53 (05:53) minutes in the GEL and NO-GEL conditions, respectively (P = .340; 95% CI, -222 to 88s; d = -0.22). Sweat production increased in the GEL condition (1140 [257]mL) compared to the NO-GEL condition (961 [202]mL) (t = 2.482, P = .042; 95% CI, 08 to 349mL; d = 0.77). Menthol improved perception but increased thermoregulatory sweating and did not enhance performance (partial hypothesis support).

Digital papillary adenocarcinoma (DPAC) is a rare malignant tumour of the sweat glands, usually in the digits. It has a high rate of recurrence and metastasis, yet there's a lack of guidelines for its diagnosis and management. Therefore, this report aims to evaluate procedures that provide the best outcomes, which will help create a consensus for its management. This case report presents a 47-year old male who had a painless hyperkeratotic patch on his left index finger, with an additional cystic lesion underlying it. This was diagnosed as a hidradenoma, which later changed to DPAC. His finger was amputated through the head of the middle phalanx. A positive sentinel lymph node biopsy led to a left axillary lymph node dissection, which revealed micrometastasis. The patient declined radiotherapy and was on a melanoma follow-up plan. To date there is no evidence of recurrence. Reviewing studies supported the use of immunohistochemical analysis to identify specific markers, especially HPV42. Sentinel lymph node biopsy and radical excision or amputation had the lowest rate of recurrence and thus should be common practice alongside long-term follow-up. Specific follow-up criteria are debated, yet this case may offer a solution by following the melanoma criteria. Histological and immunohistochemical analysis (including HPV42 detection), SLNB, and radical excision or amputation are optimal for DPAC management. Long-term follow-up, possibly using melanoma criteria, is crucial. Further research is needed to establish definitive guidelines.

IntroductionFunctional bowel disorders (FBDs) are multi-dimensional diseases varying in demographics, symptomology, lifestyle, mental health, and susceptibility to treatment. The patient lived experience is an integration of these factors, best understood with appropriately multivariate models.MethodsIn a large patient cohort (n=1175), we developed a machine learning framework to better understand the lived experience of FBDs. Iterating through 59 factors available from routine clinical care, spanning patient demography, diagnosis, symptomatology, life-impact, mental health indices, healthcare access requirements, COVID-19 impact, and treatment effectiveness, machine models were used to quantify the predictive fidelity of one feature from the remainder. Bayesian stochastic block models were used to delineate the network community structure underpinning the lived experience of FBDs.ResultsMachine models quantified patient personal health rating (R2 0.35), anxiety and depression severity (R2 0.54), employment status (balanced accuracy 96%), frequency of healthcare attendance (R2 0.71), and patient-reported treatment effectiveness variably (R2 range 0.08–0.41). Contrary to the view of many healthcare professionals, the greatest determinants of patient-reported health and quality-of-life were life-impact, mental wellbeing, employment status, and age, rather than nosology (diagnostic group) and symptom severity (figure 1). Patients responsive to one treatment were more likely to respond to another, leaving many others refractory to all.ConclusionsThe assessment of patients with FBD should be less concerned with diagnostic classification than with the wider life impact of illness, including mental health and employment. The stratification of treatment response (and resistance) has implications for clinical practice and trial design, in need of further research. O62 Figure 1A generative network community structure for the lived experience of functional bowel disorders. Radial network of the nested, generative Bayesian stochastic block model community structure of patient factors. Nodes (circles) are sized according to their importance in predicting all other target nodes. Edges (connections) are weighted by the directional feature importance in predicting one feature over another, where edge width and colour is proportional to the key.

Clinical management relies on a diagnostic label as the primary guide to treatment. However, individual patient lived experiences vary more widely than standard diagnostic categories reflect. This is especially true for functional bowel disorders (FBDs), a heterogeneous and challenging group of gastrointestinal disorders where no definitive diagnostic tests, clinical biomarkers, or universally effective treatments exist. Characterising the link between disease and lived experience - in the face of marked patient heterogeneity - requires deep phenotyping of the interactions between multiple characteristics plausibly achievable only with complex modelling approaches. In a large patient cohort (n=1175), we developed a machine learning and Bayesian generative graph framework to better understand the lived experience of FBDs. Iterating through 59 factors available from routine clinical care, spanning patient demography, diagnosis, symptomatology, life impact, mental health indices, healthcare access requirements, COVID-19 impact, and treatment effectiveness, machine models were used to quantify the predictive fidelity of one feature from the remainder. Bayesian stochastic block models were used to delineate the network community structure underpinning the heterogeneous lived experience of FBDs. Machine models quantified patient personal health rating (R2 0.35), anxiety and depression severity (R2 0.54), employment status (balanced accuracy 96%), frequency of healthcare attendance (R2 0.71), and patient-reported treatment effectiveness variably (R2 range 0.08-0.41). Contrary to the view of many healthcare professionals, the greatest determinants of patient-reported health and quality-of-life were life impact, mental well-being, employment status, and age, rather than diagnostic group and symptom severity. Patients responsive to one treatment were more likely to respond to another, leaving many others refractory to all. Clinical assessment of patients with FBDs should be less concerned with diagnostic classification than with the wider life impact of illness, including mental health and employment. The stratification of treatment response (and resistance) has implications for clinical practice and trial design, in need of further research.

Abstract Aim Skin cancer is the most common cancer in the UK. 95% of complete excision is considered the national average and achieving this is important for our patients and our practice. The aims of our study were to evaluate our complete excision rates, sensitivity, and specificity in diagnosing and excising Non-Melanoma Skin Cancers (NMSC) as a department. Method We conducted a retrospective audit of adult patients undergoing excision of NMSC in our department in July 2022. Data was collected on age, gender, clinical and pathological diagnosis, surgeon grade, complications, site and subtype of lesion excised. Results Of the 100 cases identified, 43% of lesions excised were BCC and 22% were SCC. 72% of procedures were carried out by registrars. 98% of excisions were complete with 2 incomplete excisions and 13 excisions with narrow margins. 86% of specimens with narrow margins or incomplete excision were excised from craniofacial areas. Clinical diagnosis sensitivity for BCC was 79% and 86% for SCC, whereas specificity was 79% for BCC and 58% for SCC. The overall clinical diagnosis sensitivity for NMSC was 81% and negative predictive value was 88%. Conclusions Our complete excision rate and sensitivity is above the national average, however our ability to distinguish benign from cancerous lesions has room for improvement. This may reflect surgeon grade and concerns over prolonged waiting times delaying treatment. We therefore recommend regular skin cancer teaching and encourage all grades to use loupes, dermatoscopes and adequate lighting in clinic and theatre to ensure adequate margins and adherence to national guidelines.

Typing and grading of endometrial carcinomas (ECs) on small biopsy specimens is crucial to determine the need for full surgical staging. Histological subtype and grade are key factors available for risk stratification before surgery. However, this can be diagnostically challenging on small biopsy specimens, especially when morphologic features are subtle or overlapping. The aims of this audit were to assess concordance of endometrial carcinomas on biopsy specimens with hysterectomy specimens and to determine if the immunohistochemistry (IHC) panel being used in our practice was adequately subtyping ECs. The audit was approved by the Clinical Effectiveness Team of the Royal College of Pathologists (UK) as meeting all the criteria and standards set out by the College. Biopsies from 67 cases of EC were compared for histological subtype and grade of endometrioid carcinoma with resection specimens. A re-audit was carried out on 59 cases after implementation of changes recommended by the initial audit. Two of 35 (6%) tumours defined as G1 on biopsy were upgraded (to G2) on final pathology, as was one of 7 (14%) G2 tumours (to G3). One of these cases had solid areas just amounting to more than 6% on resection. In the second case, a comment was made that assessment had been difficult as the specimen was suboptimally fixed, but nuclei appeared atypical. Of seven G2 biopsies, one case was upgraded to grade 3 on final pathology based on proportion of solid areas. Our data show lower rates of discordance as compared to previous studies and on re-audit, the concordance between endometrioid and nonendometrioid serous carcinoma improved with the addition of immunohistochemistry (IHC) for Phosphatase and tensin homolog (PTEN) to biopsies. PTEN IHC can complement other stains and aid in the distinction of grade 3 endometrioid carcinoma from serous carcinoma on endometrial biopsies.

This study compares the stage at the presentation of patients with colorectal cancer (CRC) before and after introducing COVID-19 restrictions and the mode of presentation. This is a retrospective cohort study comparing the incidence of CRC, TNM stage and mode of presentation in the pre-COVID and COVID cohorts at a single UK Trust. All patients discussed at the CRC multidisciplinary team (MDT) from March 2017 to March 2021 were included and split into two cohorts; the pre-COVID group from 01/03/2017 to 29/02/2020 and the COVID group from 01/03/2020 to 28/02/2021. Percentages were used for descriptive statistics. Student's t-test was used for the comparison of demographic variables. Chi-squared test was used for the difference analysis for the categorical data, such as TNM and mode of presentation. P value ≤0.05 was significant. In total, 1373 patients were diagnosed with CRC during the period from March 2017 to March 2021. The pre-COVID group (2017-2020) included 1104 CRC patients, compared to 269 patients in the COVID one (2020-2021). The mean age was higher in the pre-COVID group (p = 0.001). There was a statistically significant increase in the proportion of cases presenting with T4 disease (p = 0.023) and metastatic disease (p = 0.032) in the COVID group compared to the pre-COVID group. There was also a significant increase in the rate of emergency presentations (p < 0.0001). We observed a statistically significant increase in rates of locally advanced (T4) and metastatic (distant) CRC in patients presenting after introducing the COVID-19 lockdown. There was also an increase in emergency presentations. There was no observed difference in nodal status. This may reflect disruption to cancer diagnostic services and the reluctance of patients to access medical care during a pandemic, particularly the elderly.

IntroductionFlexible bronchoscopy (FB) remains an important tool in the assessment of respiratory disease that is frequently performed within the outpatient setting. While guidelines exist concerning safety standards in FB,1 individual practice is known to vary, which may extend to patient consent and discussion of potential complications. In this study, we aimed to evaluate consent procedures for patients undergoing FB within one healthcare region, including how this relates to actual complications observed.MethodsA retrospective review of patients undergoing FB between 1stApril 2021 and 30th September 2021 was performed across five hospital sites in the North East of England. Medical records, including patient consent forms and bronchoscopy reports, were examined using a structured proforma (guided by existing BTS standards1). Specific areas of consideration included: the person obtaining consent; whether the consent form was pre-populated; the type of complication discussed; and, if any complications were observed.ResultsIn total, 312 patients were included for analysis across the five hospital sites. Medical records were either incomplete or not available for a further 33 patients. Two hospital sites (A and B) predominantly used pre-populated consent forms; the remaining three sites (C, D and E) used free-text consent forms. Most consent forms (208/312, 67%) were completed by consultants, with the majority (242/312, 78%) occurring on the day of the procedure. All sites differed in the extent of complications patients were consented for (see figure 1). Hypoxia (58/312, 19%) and bleeding (55/312, 18%) were the two most frequently observed complications, but were variably included in the consent process. One death occurred as a direct consequence of bronchoscopy, though was not stated in the consent form for this patient. P98 Figure 1Number of patients consented across study sites according to listed complications. The total number of patients (n) included at each study site is presented in parentheses. The most frequent complications consented for were: bleeding (291/312, 93%), pneumothorax (245/312, 79%) and infection (241/312, 77%). Substantial variation existed between study sites regarding the specific complications and rates of complication patients were consented for.ConclusionsThere is wide variation regarding consent procedures for FB, even within a single healthcare region. This includes the type of consent form used, the timing of consent relative to the procedure, and the specific complications (and rates of complication) consented for. Use of a standardised pre-populated consent form, which could be adopted at a regional – or national – level, would help to reduce this variability in practice.ReferenceDu Rand IA et al. Thorax, 2013;68:i1-i44.Please refer to page A214 for declarations of interest related to this abstract.

IntroductionA prospective cohort study comparing peri‐ and postoperative outcomes for patients with predominantly anterior prostate cancer (APC) identified preoperatively against non‐anterior prostate cancer (NAPC) treated via robotic‐assisted radical prostatectomy (RARP).Patients and MethodsOf the 757 RARP's completed between January 2016 and April 2018, two comparative cohorts for anterior and an equivalent group of non‐anterior prostate tumours each consisting of 152 patients were compared against each other. Data were collected on the following variables: patient age; operating consultant; preoperative PSA, ISUP grade, degree of nerve sparing; tumour staging; presence and location of positive surgical margins; PSA density, postoperative ISUP grade; treatment paradigm and postoperative PSA, erectile function, and continence outcomes with 2‐year follow‐up.ResultsAPCs were found to have significantly lower ISUP grading postoperatively; increased diagnosis via active surveillance over new diagnosis; more frequently undertaken bilateral nerve‐sparing and long‐term poorer continence outcomes at 18 and 24 months postoperatively (p < 0.05). Pre‐ and post‐op PSA levels, erectile function, PSA density, positive surgical margins (PSM), age and tumour staging showed no significant differences between the APC and NAPC cohorts (p > 0.05).ConclusionThe lower ISUP grading could indicate APC as overall being less aggressive than NAPC, whereas the poorer long‐term continence outcomes require further investigating. The non‐significant differences amongst tumour staging, PSA density, preoperative PSA levels and PSM rates suggest that APC may not be as significant as predicted in diagnostic evaluation. Overall, this study provides useful information on the growing literature of anterior prostate cancer. Being the largest comparative cohort study to date on APC post‐RARP, these results indicate the true characteristics of anterior tumours and their functional outcomes to help improve education, patient expectations and management.