Reporting of health-related quality of life in emergency laparotomy trials: a systematic review and narrative synthesis.

PURPOSE: Emergency laparotomy is associated with high morbidity for the surgical patient. Understanding patients' health-related quality of life after their surgery is important to enhance the informed consent process, and to enable the evaluation and improvement of surgical care. This review aims to summarise the use of health-related quality of life tools in clinical trials involving patients undergoing emergency laparotomy. METHODS: A systematic review was undertaken of the scientific literature published in the MEDLINE® and PubMed databases between January 2011 and July 2021. A narrative synthesis approach was chosen to synthesise the diverse range of studies in a structured manner. All included papers were evaluated using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS: Eleven studies were selected for inclusion. Most of the studies had a low risk of bias. Two of the studies used health-related quality of life as the primary outcome measure. A variety of health-related quality of life measurement tools were used; the EQ-5D tool was the most popular questionnaire. Protocol adherence was dependent on the length of time which had elapsed after emergency surgery. CONCLUSION: There are many perceived challenges to collecting health-related quality of life data in the emergency surgery setting. Many of these can be offset with progressive trial designs. There is a need for further research in the systematic development of patient-reported outcomes for use in emergency surgery.

Clinical applications of contactless photoplethysmography for vital signs monitoring in pediatrics: A systematic review and meta-analysis.

Background: Contactless photoplethysmography (PPG) potentially affords the ability to obtain vital signs in pediatric populations without disturbing the child. Most validity studies have been conducted in laboratory settings or with healthy adult volunteers. This review aims to evaluate the current literature on contactless vital signs monitoring in pediatric populations and within a clinical setting. Methods: OVID, Webofscience, Cochrane library, and clinicaltrials.org were systematically searched by two authors for research studies which used contactless PPG to assess vital signs in children and within a clinical setting. Results: Fifteen studies were included with a total of 170 individuals. Ten studies were included in a meta-analysis for neonatal heart rate (HR), which demonstrated a pooled mean bias of -0.25 (95% limits of agreement (LOA), -1.83 to 1.32). Four studies assessed respiratory rate (RR) in neonates, and meta-analysis demonstrated a pooled mean bias of 0.65 (95% LOA, -3.08 to 4.37). All studies were small, and there were variations in the methods used and risk of bias. Conclusion: Contactless PPG is a promising tool for vital signs monitoring in children and accurately measures neonatal HR and RR. Further research is needed to assess children of different age groups, the effects of skin type variation, and the addition of other vital signs.

Impact of in-hospital postoperative complications on quality of life up to 12 months after major abdominal surgery.

BACKGROUND: Postoperative complications are common, but there are limited data regarding their implications on patients' quality of life. This study aimed to address this gap in the literature by analysing the impact of postoperative complications on patients' health-related quality of life. METHODS: Data from the Perioperative Quality Improvement Programme were analysed, and included patient-level data for 19 685 adults who underwent elective major abdominal procedures in England since 2016. Postoperative complications were graded using the Clavien-Dindo classification. Quality of life was assessed by responses to the EuroQol five-dimension five-levels-of-response (EQ-5D-5L™) questionnaire before surgery, and at 6 and 12 months after operation. Ordinal logistic regression was used to estimate the association between Clavien-Dindo grades and quality of life. Tobit and ordinary least squares regression analyses were used to estimate the quality-adjusted life-year (QALY) loss resulting from postoperative complications between admission and 12 months after surgery. RESULTS: At 6 and 12 months after surgery, increasingly severe postoperative complications were significantly associated with poorer health-related quality of life. The effect of postoperative complications on quality of life was sustained until at least 12 months after operation. Between admission and 12 months after surgery, 0.012, 0.026, 0.033, and 0.086 QALYs were lost for those experiencing a grade I, II, III, or IV postoperative complication respectively. CONCLUSION: Postoperative complications have a significant and sustained effect on patients' quality of life after surgery; this effect worsens as the severity of the complications increases.

Clinical applications of contactless photoplethysmography for monitoring in adults: A systematic review and meta-analysis.

Contactless photoplethysmography (cPPG) is a method of physiological monitoring. It differs from conventional monitoring methods (e.g., saturation probe) by ensuring no contact with the subject by use of a camera. The majority of research on cPPG is conducted in a laboratory setting or in healthy populations. This review aims to evaluate the current literature on monitoring using cPPG in adults within a clinical setting. Adhering to the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA, 2020) guidelines, OVID, Webofscience, Cochrane library, and clinicaltrials.org were systematically searched by two researchers. Research articles using cPPG for monitoring purposes in adults within a clinical setting were selected. Twelve studies with a total of 654 individuals were included. Heart rate (HR) was the most investigated vital sign (n = 8) followed by respiratory rate ((n = 2), Sp02 (n = 2), and HR variability (n = 2). Four studies were included in a meta-analysis of HR compared to ECG data which demonstrated a mean bias of -0.13 (95% CI, -1.22-0.96). This study demonstrates cPPG can be a useful tool in the remote monitoring of patients and has demonstrated accuracy for HR. However, further research is needed into the clinical applications of this method.

Management of levator ani avulsion: a systematic review and narrative synthesis.

PURPOSE: Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women. METHODS: MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427). RESULTS: Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients. CONCLUSIONS: Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

A review of levator ani avulsion after childbirth: Incidence, imaging and management.

Key Content • Levator ani muscle (LAM) avulsion injury occurs occultly during childbirth, most commonly during operative vaginal deliveries. • Injuries of levator ani have long term sequelae for pelvic floor health. As life expectancy increases the burden of disease upon urogynaecology services will need to be considered. • Diagnosis of this condition can be difficult as there is no agreed 'gold standard' imaging modality. • There is no consensus regarding surgical management of LAM avulsion. Learning objectives • Review anatomy and function of levator ani muscle • Identify the risk factors for levator ani avulsion injury • Role of imaging to appropriately identify LAM injury and current management options including appropriate follow up • Management of subsequent pregnancy following LAM avulsion Ethical issues • Is there value to the patient in diagnosing levator ani avulsion when there is no recommended treatment for these injuries?

Participants' Perspectives of Their Involvement in Medical Device Trials: A Focus Groups Study.

BACKGROUND: Medical technologies have the potential to improve quality and efficiency of healthcare. The design of clinical trials should consider participants' perspectives to optimise enrolment, engagement and satisfaction. This study aims to assess patients' perceptions of their involvement in medical device trials, to inform the designs of future medical technology implementation and evaluation. METHODS: Four focus groups were undertaken with a total of 16 participants who had participated in a study testing hospital inpatient remote monitoring devices. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis. RESULTS: Four main themes emerged: patients' motivations for participating in medical device research; patients' perceptions of technology in medicine; patients' understanding of trial methodology; and patients' perceptions of the benefits of involvement in medical device trials. The appeal of new technology is a contributing factor to the decision to consent, although concerns remain regarding risks associated with technology in healthcare settings. Perceived benefits of participating in device trials include extra care, social benefits and comradery with other participants seen using the devices, although there is a perceived lack of confidence in using technology amongst older patients. CONCLUSION: Future device trials should prioritise information sharing with participants both before and after the trial. Verbal and written information alongside practical demonstrations can help to combat a lack of confidence with technology. Randomised trials and those with placebo- or sham-controlled arms should not be considered as barriers to participation. Study results should be disseminated to participants in lay format as soon as possible, subject to participant permission.

Nursing staff perspectives of continuous remote vital signs monitoring on surgical wards: Theory elicitation for a realist evaluation.

RATIONALE, AIMS AND OBJECTIVES: Continuous remote monitoring (CRM) provides a novel solution to the challenges of monitoring patients' vital signs in hospital, but the results of quantitative studies have been mixed. Acceptance by staff is a crucial determinant of the success of healthcare technologies and may explain these discrepancies. Drawing on the approach of realist evaluation, this paper aims to identify theories about how, why and in what conditions nursing staff perceptions vary regarding the CRM of patients' vital signs. METHODS: Multiple methods were used to elicit theories about factors likely to facilitate or impede the successful implementation of continuous remote vital signs monitoring. This included a literature review, consultation with patients and observational work conducted during a randomized controlled trial (RCT) of CRM. In addition, a priori theories developed through informal interactions with patients and ward staff during the day-to-day set-up of the trial were included. RESULTS: The findings suggest that the perceptions of nursing staff regarding remote monitoring can be influenced by the type of patients under their care and their previous experience of telemetry. Factors which may undermine the engagement of staff are perceived staff burden, which can be dependent on contextual factors such as staffing levels, time of day and senior staff attitudes. Staff attitudes are also likely to be influenced by patient perspectives and the utility of the devices associated with remote monitoring. The successful implementation of CRM may be dependent on staff training, research staff input and hospital culture. CONCLUSIONS: Theories regarding nursing staff engagement with remote monitoring are numerous, varied and contradictory. The theories elicited in this initial phase will be refined during interviews with the nursing staff involved with the RCT.

Failure to Rescue Deteriorating Patients: A Systematic Review of Root Causes and Improvement Strategies.

OBJECTIVES: "Failure to rescue" (FTR) is the failure to prevent a death resulting from a complication of medical care or from a complication of underlying illness or surgery. There is a growing body of evidence that identifies causes and interventions that may improve institutional FTR rates. Why do patients "fail to rescue" after complications in hospital? What clinically relevant interventions have been shown to improve organizational fail to rescue rates? Can successful rescue methods be classified into a simple strategy? METHODS: A systematic review was performed and the following electronic databases searched between January 1, 2006, to February 12, 2018: MEDLINE, PsycINFO, Cochrane Library, CINAHL, and BNI databases. All studies that explored an intervention to improve failure to rescue in the adult population were considered. RESULTS: The search returned 1486 articles. Eight hundred forty-two abstracts were reviewed leaving 52 articles for full assessment. Articles were classified into 3 strategic arms (recognize, relay, and react) incorporating 6 areas of intervention with specific recommendations. CONCLUSIONS: Complications occur consistently within healthcare organizations. They represent a huge burden on patients, clinicians, and healthcare systems. Organizations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context. We propose "The 3 Rs of Failure to Rescue" of recognize, relay, and react and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this proposed framework into institutional quality improvement.

Cost utility analysis of continuous and intermittent versus intermittent vital signs monitoring in patients admitted to surgical wards.

Background: Complications after surgical procedures are common and can lead to a prolonged hospital stay, increased rates of postoperative hospital readmission, and increased mortality. Monitoring vital signs is an effective way to identify patients who are experiencing a deterioration in health. SensiumVitals is wireless system that includes a lightweight, digital patch that monitors vital signs at two minute intervals, and has shown promise in the early identification of patients at high risk of deterioration.Objective: To evaluate the cost-utility of continuous monitoring of vital signs with SensiumVitals in addition to intermittent monitoring compared to the usual care of patients admitted to surgical wards.Methods: A de novo decision analytic model, based on current treatment pathways, was developed to estimate the costs and outcomes. Results from randomised clinical trials and national standard sources were used to inform the model. Costs were estimated from the NHS and PSS perspective. Deterministic and probabilistic sensitivity analyses (PSA) were conducted to explore uncertainty surrounding input parameters.Results: Over a 30-day time horizon, intermittent monitoring in addition to continuous monitoring of vital signs with SensiumVitals was less costly than intermittent vital signs monitoring alone. The total cost per patient was £6,329 versus £5,863 for the comparator and intervention groups respectively and the total effectiveness per patient was 0.057 QALYs in each group. Results from the PSA showed that use of SensiumVitals in addition to intermittent monitoring has 73% probability of being cost-effective at a £20,000 willingness-to-pay threshold and 73% probability of being cost-saving compared to the comparator. Cost savings were driven by reduced costs of hospital readmissions and length of stays in hospital.Conclusions: Use of SensiumVitals as a postoperative intervention for patients on surgical wards is a cost-saving and cost-effective strategy, yielding improvements in recovery with decreased health resource use.Key Points for Decision MakersSensiumVitals has the potential to reduce the length of postoperative hospital stay, readmission rates, and associated costs in postoperative patients.In this study, SensiumVitals has been found to be a cost-saving (dominant) and cost-effective (dominant) intervention for monitoring the vital signs of surgical patients postoperatively.

The use of polymeric meshes for pelvic organ prolapse: Current concepts, challenges, and future perspectives.

Pelvic organ prolapse (POP) is one of the most common chronic disorders in women, impacting the quality of life of millions of them worldwide. More than 100 surgical procedures have been developed over the decades to treat POP. However, the failure of conservative strategies and the number of patients with recurrence risk have increased the need for further adjuvant treatments. Since their introduction, surgical synthetic meshes have dramatically transformed POP repair showing superior anatomic outcomes in comparison to traditional approaches. Although significant progress has been attained, among the meshes in clinical use, there is no single mesh appropriate for every surgery. Furthermore, due to the risk of complications including acute and chronic infection, mesh shrinkage, and erosion of the tissue, the benefits of the use of meshes have recently been questioned. The aim of this work is to review the evolution of POP surgery, analyzing the current challenges, and detailing the key factors pertinent to the design of new mesh systems. Starting with a description of the pelvic floor anatomy, the article then presents the traditional treatments used in pelvic organ disorders. Next, the development of synthetic meshes is described with an insight into how their function is dependent on both mesh design variables (i.e., material, structure, and functional treatment) and surgical applications. These are then linked to common mesh-related complications, and an indication of current research aiming to address these issues.

The role of ABCG2 in modulating responses to anti-cancer photodynamic therapy.

The ATP-binding cassette (ABC) superfamily G member 2 (ABCG2) transmembrane protein transporter is known for conferring resistance to treatment in cancers. Photodynamic therapy (PDT) is a promising anti-cancer method involving the use of light-activated photosensitisers to precisely induce oxidative stress and cell death in cancers. ABCG2 can efflux photosensitisers from out of cells, reducing the capacity of PDT and limiting the efficacy of treatment. Many studies have attempted to elucidate the relationship between the expression of ABCG2 in cancers, its effect on the cellular retention of photosensitisers and its impact on PDT. This review looks at the studies which investigate the effect of ABCG2 on a range of different photosensitisers in different pre-clinical models of cancer. This work also evaluates the approaches that are being investigated to address the role of ABCG2 in PDT with an outlook on potential clinical validation.

Reliability of a wearable wireless patch for continuous remote monitoring of vital signs in patients recovering from major surgery: a clinical validation study from the TRaCINg trial.

OBJECTIVE: To validate whether a wearable remote vital signs monitor could accurately measure heart rate (HR), respiratory rate (RR) and temperature in a postsurgical patient population at high risk of complications. DESIGN: Manually recorded vital signs data were paired with vital signs data derived from the remote monitor set in patients participating in the Trial of Remote versus Continuous INtermittent monitoring (TRaCINg) study: a trial of continuous remote vital signs monitoring. SETTING: St James's University Hospital, UK. PARTICIPANTS: 51 patients who had undergone major elective general surgery. INTERVENTIONS: The intervention was the SensiumVitals monitoring system. This is a wireless patch worn on the patient's chest that measures HR, RR and temperature continuously. The reference standard was nurse-measured manually recorded vital signs. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the 95% limits of agreement between manually recorded and wearable patch vital sign recordings of HR, RR and temperature. The secondary outcomes were the percentage completeness of vital sign patch data for each vital sign. RESULTS: 1135 nurse observations were available for analysis. There was no clinically meaningful bias in HR (1.85 bpm), but precision was poor (95% limits of agreement -23.92 to 20.22 bpm). Agreement was poor for RR (bias 2.93 breaths per minute, 95% limits of agreement -8.19 to 14.05 breaths per minute) and temperature (bias 0.82°C, 95% limits of agreement -1.13°C to 2.78°C). Vital sign patch data completeness was 72.8% for temperature, 59.2% for HR and 34.1% for RR. Distributions of RR in manually recorded measurements were clinically implausible. CONCLUSIONS: The continuous monitoring system did not reliably provide HR consistent with nurse measurements. The accuracy of RR and temperature was outside of acceptable limits. Limitations of the system could potentially be overcome through better signal processing. While acknowledging the time pressures placed on nursing staff, inaccuracies in the manually recorded data present an opportunity to increase awareness about the importance of manual observations, particularly with regard to methods of manual HR and RR measurements.

Continuous Versus Intermittent Vital Signs Monitoring Using a Wearable, Wireless Patch in Patients Admitted to Surgical Wards: Pilot Cluster Randomized Controlled Trial.

BACKGROUND: Vital signs monitoring is a universal tool for the detection of postoperative complications; however, unwell patients can be missed between traditional observation rounds. New remote monitoring technologies promise to convey the benefits of continuous monitoring to patients in general wards. OBJECTIVE: The aim of this pilot study was to evaluate whether continuous remote vital signs monitoring is a practical and acceptable way of monitoring surgical patients and to optimize the delivery of a definitive trial. METHODS: We performed a prospective, cluster-randomized, parallel-group, unblinded, controlled pilot study. Patients admitted to 2 surgical wards at a large tertiary hospital received either continuous and intermittent vital signs monitoring or intermittent monitoring alone using an early warning score system. Continuous monitoring was provided by a wireless patch, worn on the patient's chest, with data transmitted wirelessly every 2 minutes to a central monitoring station or a mobile device carried by the patient's nurse. The primary outcome measure was time to administration of antibiotics in sepsis. The secondary outcome measures included the length of hospital stay, 30-day readmission rate, mortality, and patient acceptability. RESULTS: Overall, 226 patients were randomized between January and June 2017. Of 226 patients, 140 were randomized to continuous remote monitoring and 86 to intermittent monitoring alone. On average, patients receiving continuous monitoring were administered antibiotics faster after evidence of sepsis (626 minutes, n=22, 95% CI 431.7-820.3 minutes vs 1012.8 minutes, n=12, 95% CI 425.0-1600.6 minutes), had a shorter average length of hospital stay (13.3 days, 95% CI 11.3-15.3 days vs 14.6 days, 95% CI 11.5-17.7 days), and were less likely to require readmission within 30 days of discharge (11.4%, 95% CI 6.16-16.7 vs 20.9%, 95% CI 12.3-29.5). Wide CIs suggest these differences are not statistically significant. Patients found the monitoring device to be acceptable in terms of comfort and perceived an enhanced sense of safety, despite 24% discontinuing the intervention early. CONCLUSIONS: Remote continuous vital signs monitoring on surgical wards is practical and acceptable to patients. Large, well-controlled studies in high-risk populations are required to determine whether the observed trends translate into a significant benefit for continuous over intermittent monitoring. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN60999823; http://www.isrctn.com /ISRCTN60999823 (Archived by WebCite at http://www.webcitation.org/73ikP6OQz).

Dementia and osteoporosis in a geriatric population: Is there a common link?

AIM: To determine the existence of a common pathological link between dementia and osteoporosis through reviewing the current evidence base. METHODS: This paper reviews the current literature on osteoporosis and dementia in order to ascertain evidence of a common predisposing aetiology. A literature search of Ovid MED-LINE (1950 to June 2016) was conducted. The keywords "osteoporosis", "osteoporotic fracture", "dementia" and "Alzheimer's disease" (AD) were used to determine the theoretical links with the most significant evidence base behind them. The key links were found to be vitamins D and K, calcium, thyroid disease, statins, alcohol and sex steroids. These subjects were then searched in combination with the previous terms and the resulting papers manually examined. Theoretical, in vitro and in vivo research were all used to inform this review which focuses on the most well developed theoretical common causes for dementia (predominantly Alzheimer's type) and osteoporosis. RESULTS: Dementia and osteoporosis are multifaceted disease processes with similar epidemiology and a marked increase in prevalence in elderly populations. The existence of a common link between the two has been suggested despite a lack of clear pathological overlap in our current understanding. Research to date has tended to be fragmented and relatively weak in nature with multiple confounding factors reflecting the difficulties of in vivo experimentation in the population of interest. Despite exploration of various possible mechanisms in search for a link between the two pathologies, this paper found that it is possible that these associations are coincidental due to the nature of the evidence available. One finding in this review is that prior investigation into common aetiologies has found raised amyloid beta peptide levels in osteoporotic bone tissue, with a hypothesis that amyloid beta disorders are systemic disorders resulting in differing tissue manifestations. However, our findings were that the most compelling evidence of a common yet independent aetiology lies in the APOE4 allele, which is a well-established risk for AD but also carries an independent association with fracture risk. The mechanism behind this is thought to be the reduced plasma vitamin K levels in individuals exhibiting the APOE4 allele which may be amplified by the nutritional deficiencies associated with dementia, which are known to include vitamins K and D. The vitamin theory postulates that malnutrition and reduced exposure to sunlight in patients with AD leads to vitamin deficiencies. CONCLUSION: Robust evidence remains to be produced regarding potential links and regarding the exact aetiology of these diseases and remains relevant given the burden of dementia and osteoporosis in our ageing population. Future research into amyloid beta, APOE4 and vitamins K and D as the most promising aetiological links should be welcomed.

Systematic Review of Retraction Devices for Laparoscopic Surgery.

BACKGROUND: Retraction plays a vital role in optimizing the field of vision in minimal-access surgery. As such, a number of devices have been marketed to aid the surgeon in laparoscopic retraction. This systematic review explores the advantages and disadvantages of the different instruments in order to aid surgeons and their institutions in selecting the appropriate device. Primary outcome measures include operation time, length of stay, use of staff, patient morbidity, ease of use, conversion rates to open surgery, and cost. METHODS: Systematic literature searches were performed in MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials, and ClinicalTrials.gov. The search strategy focused on studies testing a retraction device. The selection process was based on a predefined set of inclusion and exclusion criteria. Data were then extracted and analyzed. RESULTS: Out of 1360 papers initially retrieved, 12 articles were selected for data extraction and analysis. A total of 10 instruments or techniques were tested. Devices included the Nathanson's liver retractor, liver suspension tape, the V-List technique, a silicone disk with or without a snake retractor, the Endoloop, the Endograb, a magnetic retractor, the VaroLift, a laparoscope holder, and a retraction sponge. None of the instruments reported were associated with increased morbidity. No studies found increased rates of conversion to open surgery. All articles reported that the tested instruments might spare the use of an assistant during the procedure. It was not possible to determine the impact on length of stay or operation time. CONCLUSIONS: Each analyzed device facilitates retraction, providing a good field of view while allowing reduced staff numbers and minimal patient morbidity. Due to economic and environmental advantages, reusable devices may be preferable to disposable instruments, although the choice must be primarily based on clinical judgement.

Prognostic significance of tumour stroma ratio in inflammatory breast cancer.

Tumour stroma ratio (TSR) is emerging as an important prognostic indicator in cancer. We have previously shown TSR to be prognostic in oestrogen receptor positive breast cancer. Its role in inflammatory breast cancer, a rare but aggressive form of breast cancer, has not been identified. Here we aimed to determine the prognostic significance of TSR in a cohort of patients with inflammatory breast carcinoma. TSR was measured by point counting virtual H&E stained tissue sections in 45 inflammatory breast cancer cases. The whole tumour area was sampled. Optimum cut-offs to distinguish high and low TSR was determined by log-rank test. The relationship of TSR to overall survival and disease-free survival (DFS) was analysed alongside multivariate analysis. The optimal cut-offs between high and low TSR were determined to be 31% for OS and 46% for DFS. There was no significant difference in OS (p = 0.53) nor DFS (p = 0.66) between high and low TSR groups. Multivariate analysis did not demonstrate any new trends, within the limits of a small data sample. A significant correlation was found between pathological response to neoadjuvant chemotherapy and survival (p = 0.008). There is no evidence that TSR has prognostic significance in inflammatory breast cancer. When compared with published data in non-inflammatory breast carcinoma, this supports the view that differences in stromal biology exist between tumour types and highlights the importance of considering this when interpreting the prognostic value of TSR. However, these findings must be interpreted in the light of the small sample size.