Utilisation of after-hours telephone support in a home-based hospice service.

BACKGROUND: After-hours support from hospice providers is instrumental to patients with serious illness who choose to remain at home, particularly at end of life. Utilisation of out-of-hours support has been much characterised in terms of frequency and nature of calls, but more needs to be known to inform service customisation and resource allocation to optimise care. To this end, we stratify reasons for using the after-hours helpline according to time sensitivity, and to explore disease and person factors associated with urgent calls. METHOD: Electronic medical records for incoming calls from external parties outside workhours within a large home hospice in Singapore were analysed inductively, to identify patterns and associations along study objectives. Individual code books for caller type and call reasons were created and tested in vivo, and later administered to extracted data. Patients that accessed the helpline were tracked for different outcomes, including hospital admissions and on-call home visits. Logistic regression modelling was performed to categorise call reasons by urgency and to identify disease and person factors associated with time sensitive calls. RESULTS: More than 5,000 calls to the helpline were made over a two-year period (2019-2020), predominantly by family caregivers (88.4%). These were in relation to 2,303 unique patients (38.9% of total patients served). After-hours calls were made an average of 2.3 times by patients across various lengths of service. Only 11.9% of calls were deemed time sensitive or urgent, requiring home visits by on-call staff (4%) or resulting in admission to hospital (7.9%). The majority were managed by primary care teams on the next workday (65.1%) and the remainder sorted during the after-hours call itself (22.3%). Call reasons or presenting issues were classified into two groups according to urgency. Calls in the year 2020, from the younger patient, preferred place of death outside the home, and caller types other than patient or healthcare worker were significantly associated with urgent calls. CONCLUSION: Deeper characterisation of after-hours calls offers possibilities: service redesign for optimal resourcing and customised training for better care. Ultimately, planners, providers, and patients all stand to benefit.

Rates and Outcomes of Breast Lesions of Uncertain Malignant Potential (B3) benchmarked against the National Breast Screening Pathology Audit; Improving Performance in a High Volume Screening Unit.

INTRODUCTION: Our breast screening unit was identified as high outlier for B3 lesions with a low positive predictive value (PPV) compared to the England average. This prompted a detailed internal audit and review of B3 lesions and their outcomes to identify causes and address any variation in practice. PATIENTS AND METHODS: The B3 rate was calculated in 4168 breast core biopsies from 2019, using the subsequent excision to determine the PPV. Atypical intraductal epithelial proliferation (AIDEP) cases were subject to microscopic review to reassess the presence of atypia against published criteria. The B3 rate was re-audited in 2021, and the results compared. RESULTS: Screening cases had a high B3 rate of 12.4% (30% above the national average), and a PPV of 7.7% (9.7% with atypia). AIDEP was identified as a possible cause of this outlier status. On review and by consensus, AIDEP was confirmed in only 66% of cases reported as such, 17% were downgraded, and 16% did not reach consensus, the latter highlighting the difficulty and subjectivity in diagnosis of these lesions. Repeat audit of B3 rates after this extended review revealed a reduction from 12.4% to 9.11%, which is more in line with national standards. CONCLUSION: Benchmarking against national reporting standards is critical for service improvement. Through a supportive environment, team working, rigorous internal review and adherence to guidelines, interobserver variation and outlier status in breast pathology screening outliers can both be addressed. This study can serve as a model to other outlier units to identify and tackle underlying causes.

Welfare Genome Project: A Participatory Korean Personal Genome Project With Free Health Check-Up and Genetic Report Followed by Counseling.

The Welfare Genome Project (WGP) provided 1,000 healthy Korean volunteers with detailed genetic and health reports to test the social perception of integrating personal genetic and healthcare data at a large-scale. WGP was launched in 2016 in the Ulsan Metropolitan City as the first large-scale genome project with public participation in Korea. The project produced a set of genetic materials, genotype information, clinical data, and lifestyle survey answers from participants aged 20-96. As compensation, the participants received a free general health check-up on 110 clinical traits, accompanied by a genetic report of their genotypes followed by genetic counseling. In a follow-up survey, 91.0% of the participants indicated that their genetic reports motivated them to improve their health. Overall, WGP expanded not only the general awareness of genomics, DNA sequencing technologies, bioinformatics, and bioethics regulations among all the parties involved, but also the general public's understanding of how genome projects can indirectly benefit their health and lifestyle management. WGP established a data construction framework for not only scientific research but also the welfare of participants. In the future, the WGP framework can help lay the groundwork for a new personalized healthcare system that is seamlessly integrated with existing public medical infrastructure.

Asymmetric 6-Strand Flexor Tendon Repair - Biomechanical Analysis Using Barbed Suture.

Background: This study investigates the biomechanical performance of the Asymmetric flexor tendon repair technique using barbed suture. The Asymmetric repair technique using monofilament nylon suture was previously reported to have a higher tensile strength than the modified Lim-Tsai repair technique, but its repair stiffness and load to gap force were significantly lower. There is hence an unmet need to improve this technique and the substitution of nylon suture with barbed sutures may be the solution. Methods: Two groups consisting of 10 porcine tendons each were repaired with the six-strand Asymmetric repair technique using V-Loc® 3-0 and Supramid® 4-0 respectively. The repairs were subjected to a mechanical tester for static testing. The ultimate tensile strength, load to 2 mm gap force, repair stiffness, time taken to complete a repair and failure mechanism of the repairs were recorded and analyzed. Results: All the repairs using V-Loc® 3-0 sutures had significantly higher median values of ultimate tensile strength (64.1 N; 56.9 N), load to 2 mm gap force (39.2 N; 19.7 N), repair stiffness (6.4 N/mm; 4.7 N/mm) and time taken to complete a repair (9.4 mins; 7.7 mins). All the repairs using V-Loc® sutures failed by suture breakage while 80% of repairs using Supramid® sutures failed by suture pullout. Conclusions: The use of the barbed sutures in the Asymmetric repair technique, whilst more time consuming, has shown promising improvement to its biomechanical performance (i.e. better ultimate tensile strength, stiffness and resistance to gap formation).

Are Flexor Tendon Ruptures Ever Spontaneous? - A Literature Review on Closed Flexor Tendon Ruptures of the Little Finger.

Background: When closed ruptures of flexor tendons of fingers occur, there is often an identifiable pathology, which should be addressed in the same surgical setting as the tendon repair. The concept of "spontaneous" tendon rupture, occurring in the absence of identified pathology, however, has also been reported in a significant number of papers. This controversy has prompted us to do a review of the existing literature. Methods: We did a review of cases of closed ruptures of the flexor digitorum profundus (FDP) of the little finger in existing literature. Fifty-three publications were retrieved by searching "FDP tendon rupture" and "little finger" using PubMed database. We analyzed data such as the zone of rupture noted intra-operatively; and any precipitating factors, pathology or trauma. We also conducted a review on papers which discussed the concept of "spontaneous rupture". Results: Fifty-three publications were retrieved. There were 8 cases of ruptures in Zone I; 2 in Zone II; 30 in Zone III; 59 in Zone IV and 5 in Zone V. Majority of cases were associated with an element of trauma of varying severity, or pathology. A precipitating cause was not documented in 12 cases. Amongst all 36 cases of ruptures labelled as "spontaneous", only 1 case was truly "spontaneous" without any associated trauma or pathology. Conclusions: Most reports labeled as spontaneous rupture occurred in Zone III, where tendon ruptures are rare. There are documented pathological causes or evidence of trauma to most of these cases. We conclude these ruptures may have been mislabeled as spontaneous ruptures. Bearing in mind the propensity for tendon excursion, we suspect the lack of documentation of exploration in proximal zones contributed to this mislabeling. Understanding this concept of non-spontaneity to most tendon ruptures and the common sites of rupture or pathology is crucial for a surgeon to make strategic incisions and minimize future recurrence.

IPET study: an FLT-PET window study to assess the activity of the steroid sulfatase inhibitor irosustat in early breast cancer.

BACKGROUND: Steroid sulfatase (STS) is involved in oestrogen biosynthesis and irosustat is a first generation, irreversible steroid sulfatase inhibitor. A pre-surgical window-of-opportunity study with irosustat was undertaken in estrogen receptor-positive (ER+) breast cancer to assess the effect of irosustat on tumour cell proliferation as measured by 3'-deoxy-3'-[18F] fluorothymidine uptake measured by PET scanning (FLT-PET) and Ki67. METHODS: Postmenopausal women with untreated ER+ early breast cancer were recruited, and imaged with FLT-PET at baseline and after at least 2 weeks treatment with irosustat, 40 mg once daily orally. The primary endpoint was changed in FLT uptake; secondary endpoints included safety and tolerability of irosustat, changes in tumoral Ki67 and steroidogenic enzymes expression and circulating steroid hormone levels. RESULTS: Thirteen women were recruited, and ten started irosustat for 2 weeks, followed by repeat FLT-PET scans in eight. Defining response as decreases of ≥20% in standardized uptake value (SUV) or ≥30% in Ki, 1 (12.5% (95% CI 2-47%, p = 0.001)) and 3 (43% (95% CI 16-75%, p = <0.001) patients, respectively, responded. 6 out of 7 patients had a Ki67 reduction (range = -19.3 to 76.4%), and median percentage difference in Ki67 was 52.3% (p = 0.028). In one patient with a low baseline STS expression, a 19.7% increase in Ki67 was recorded. STS decreases were seen in tumours with high basal STS expression, significant decreases were also noted in aromatase, and 17ß-hydroxysteroid dehydrogenase type 1 and 2. Irosustat was generally well tolerated with all adverse event CTCAE Grade ≤2. CONCLUSIONS: Irosustat resulted in a significant reduction in FLT uptake and Ki67, and is well tolerated. These data are the first demonstrating clinical activity of irosustat in early breast cancer. Baseline expression of STS may be a biomarker of sensitivity to irosustat.

Evaluation of the optimal provision of formalin-fixed, paraffin-embedded material for reverse transcription-PCR in soft-tissue tumour diagnosis.

AIMS: Molecular genetic analysis is now a routine ancillary diagnostic modality to the histopathological diagnosis of soft-tissue neoplasms, many of which harbour characteristic gene fusions detectable by reverse transcription-PCR (RT-PCR). As the final diagnosis often depends on the molecular result, it is important to obtain the optimal yield of patient RNA. METHODS: We assessed the most reliable method of providing formalin-fixed, paraffin-embedded material for optimal RNA yield by comparing three consecutive periods in which different preparations (5×10 µm scrolls, 5×5 µm sections and 1×10 µm sections) were used for RNA extraction for RT-PCR, with its technical success rate. RESULTS: For '2011', '2012' and '2013', RT-PCR technical failure rates were 13.4%, 4.4% and 7.9%, respectively. The percentage of failed referral cases was 71.4%, 85.7% and 31.3%, and the proportion of core biopsy to excision specimens was 3:15, 2:5 and 13:3. CONCLUSIONS: This study shows that the effectiveness of RNA extraction and purification is dependent on both specimen type and the tissue sectioning strategy. The failure rate has improved over recent years, particularly for large specimens as large numbers of thick 10 µm scrolls can saturate RNA extraction columns. In contrast, recent technical fails are more frequent in core biopsies, where 1×10 µm sections are insufficient for adequate RNA extraction. While previous technical fails occurred mostly in referred cases, this appears no longer the case due to the better fixation and processing of specimens in external surgical pathology departments because of the widespread recognition of the importance of molecular diagnostics as an important part of the patient pathway.