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IntroductionConventional methods for axillary sentinel lymph node biopsy (SLNB) are fraught with complications such as allergic reactions, skin tattooing, radiation, and limitations on infrastructure. A novel technique has been developed for lymphatic mapping utilizing fluorescence imaging. This meta-analysis aims to compare the gold standard blue dye and radioisotope (BD-RI) technique with fluorescence-guided SLNB using indocyanine green (ICG).MethodsThis study was registered with PROSPERO (CRD42019129224). The MEDLINE, EMBASE, Scopus, and Web of Science databases were searched using the Medical Subject Heading (MESH) terms ‘Surgery’ AND ‘Lymph node’ AND ‘Near infrared fluorescence’ AND ‘Indocyanine green’. Studies containing raw data on the sentinel node identification rate in breast cancer surgery were included. A heterogeneity test (using Cochran’s Q) determined the use of fixed- or random-effects models for pooled odds ratios (OR).ResultsOverall, 1748 studies were screened, of which 10 met the inclusion criteria for meta-analysis. ICG was equivalent to radioisotope (RI) at sentinel node identification (OR 2.58, 95% confidence interval [CI] 0.35–19.08, p < 0.05) but superior to blue dye (BD) (OR 9.07, 95% CI 6.73–12.23, p < 0.05). Furthermore, ICG was superior to the gold standard BD-RI technique (OR 4.22, 95% CI 2.17–8.20, p < 0.001).ConclusionFluorescence imaging for axillary sentinel node identification with ICG is equivalent to the single technique using RI, and superior to the dual technique (RI-BD) and single technique with BD. Hospitals using RI and/or BD could consider changing their practice to ICG given the comparable efficacy and improved safety profile, as well as the lesser burden on hospital infrastructure.

Background Re-operation for positive resection margins following breast-conserving surgery occurs frequently (average = 20–25%), is cost-inefficient, and leads to physical and psychological morbidity. Current margin assessment techniques are slow and labour intensive. Rapid evaporative ionisation mass spectrometry (REIMS) rapidly identifies dissected tissues by determination of tissue structural lipid profiles through on-line chemical analysis of electrosurgical aerosol toward real-time margin assessment. Methods Electrosurgical aerosol produced from ex-vivo and in-vivo breast samples was aspirated into a mass spectrometer (MS) using a monopolar hand-piece. Tissue identification results obtained by multivariate statistical analysis of MS data were validated by histopathology. Ex-vivo classification models were constructed from a mass spectral database of normal and tumour breast samples. Univariate and tandem MS analysis of significant peaks was conducted to identify biochemical differences between normal and cancerous tissues. An ex-vivo classification model was used in combination with bespoke recognition software, as an intelligent knife (iKnife), to predict the diagnosis for an ex-vivo validation set. Intraoperative REIMS data were acquired during breast surgery and time-synchronized to operative videos. Results A classification model using histologically validated spectral data acquired from 932 sampling points in normal tissue and 226 in tumour tissue provided 93.4% sensitivity and 94.9% specificity. Tandem MS identified 63 phospholipids and 6 triglyceride species responsible for 24 spectral differences between tissue types. iKnife recognition accuracy with 260 newly acquired fresh and frozen breast tissue specimens (normal n  = 161, tumour n  = 99) provided sensitivity of 90.9% and specificity of 98.8%. The ex-vivo and intra-operative method produced visually comparable high intensity spectra. iKnife interpretation of intra-operative electrosurgical vapours, including data acquisition and analysis was possible within a mean of 1.80 seconds (SD ±0.40). Conclusions The REIMS method has been optimised for real-time iKnife analysis of heterogeneous breast tissues based on subtle changes in lipid metabolism, and the results suggest spectral analysis is both accurate and rapid. Proof-of-concept data demonstrate the iKnife method is capable of online intraoperative data collection and analysis. Further validation studies are required to determine the accuracy of intra-operative REIMS for oncological margin assessment.

Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy. We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3–4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42·72 Gy in 16 fractions (over 3·2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2–6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment. Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12·1%, 95% CI 3·4–28·2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths. Preoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life. Cancer Research UK, National Institute for Health Research.

This systematic review analyses advancements in cognitive state recognition from 2010 to early 2024, evaluating 405 relevant articles from an initial pool of 2398 records identified through five databases: Scopus, Engineering Village, Web of Science, IEEE Xplore, and PubMed. Studies were included if they assessed cognitive states using physiological signals and applied machine learning (ML) or deep learning (DL) techniques in practical task settings. The review highlights a pivotal shift from shallow ML to DL approaches for analysing physiological signals, driven by DL’s ability to autonomously learn complex patterns in large datasets. By 2023, DL has become the dominant methodology, though traditional ML techniques remain relevant. Additionally, there has been a move from neuroimaging to multimodal physiological modalities, with the decrease in neuroimaging use reflecting a trend towards integrating various physiological signals for more comprehensive insights. Cognitive state recognition is applied across diverse domains such as the automotive, aviation, maritime, and healthcare industries, enhancing performance and safety in high-stakes environments. Electrocardiogram (ECG) is the most utilised modality, with convolutional neural networks (CNNs) being the primary DL approach. The trend in cognitive state recognition research is moving towards integrating ECG signals with CNNs and adopting privacy-preserving methodologies like differential privacy and federated learning, highlighting the potential of cognitive state recognition to enhance performance, safety, and innovation across various real-world applications.

ObjectivesTo evaluate whether commercially available ‘off-the-shelf’ wearable technology can improve patient rehabilitation outcomes, and to categorise all wearables currently being used to augment rehabilitation, including the disciplines and conditions under investigation.DesignSystematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement checklist, and using the Grading of Recommendations, Assessment, Development and Evaluation approach.Data sourcesEmbase, MEDLINE, Web of Science and the Cochrane Library were searched up to and including July 2023.Eligibility criteriaWe included trials and observational studies evaluating the use of consumer-grade wearables, in real patient cohorts, to aid physical therapy or rehabilitation. Only studies investigating rehabilitation of acute events with defined recovery affecting adult patients were included.Data extraction and synthesisTwo independent reviewers used a standardised protocol to search, screen and extract data from the included studies. Risk of bias was assessed using the Cochrane Methods Risk of Bias in Randomised Trials V.2 and Risk of Bias in Non-Randomised Studies of Interventions tools for randomised controlled trials (RCTs) and observational studies, respectively.ResultsEighteen studies encompassing 1754 patients met eligibility criteria, including six RCTs, six quasi-experimental studies and six observational studies. Eight studies used wearables in Orthopaedics, seven in Stroke Medicine, two in Oncology and one in General Surgery. All six RCTs demonstrated that wearable-driven feedback increases physical activity. Step count was the most common measure of physical activity. Two RCTs in orthopaedics demonstrated non-inferiority of wearable self-directed rehabilitation compared with traditional physiotherapy, highlighting the potential of wearables as alternatives to traditional physiotherapy. All 12 non-randomised studies demonstrated the feasibility and acceptability of wearable-driven self-directed rehabilitation.ConclusionThis review demonstrates that consumer-grade wearables can be used as adjuncts to traditional physiotherapy, and potentially as alternatives for self-directed rehabilitation of non-chronic conditions. Better designed studies, and larger RCTs, with a focus on economic evaluations are needed before a case can be made for their widespread adoption in healthcare settings.PROSPERO registration IDCRD42023459567

Re-operation due to disease being inadvertently close to the resection margin is a major challenge in breast conserving surgery (BCS). Indocyanine green (ICG) fluorescence imaging could be used to visualize the tumor boundaries and help surgeons resect disease more efficiently. In this work, ICG fluorescence and color images were acquired with a custom-built camera system from 40 patients treated with BCS. Images were acquired from the tumor in-sit u, surgical cavity post-excision, freshly excised tumor and histopathology tumour grossing. Fluorescence image intensity and texture were used as individual or combined predictors in both logistic regression (LR) and support vector machine models to predict the tumor extent. ICG fluorescence spectra in formalin-fixed histopathology grossing tumor were acquired and analyzed. Our results showed that ICG remains in the tissue after formalin fixation. Therefore, tissue imaging could be validated in freshly excised and in formalin-fixed grossing tumor. The trained LR model with combined fluorescence intensity (pixel values) and texture (slope of power spectral density curve) identified the tumor’s extent in the grossing images with pixel-level resolution and sensitivity, specificity of 0.75 ± 0.3, 0.89 ± 0.2.This model was applied on tumor in-situ and surgical cavity (post-excision) images to predict tumor presence.

Inadequate exposure to real-life operating can impede timely acquisition of technical competence among surgical residents, and is a major challenge faced in the current training climate. Mental rehearsal (MR)-the cognitive rehearsal of a motor task without overt physical movement-has been shown to accelerate surgical skills learning. However, the neuroplastic effect of MR of a complex bimanual surgical task is unknown. The aim of this study is to use functional near-infrared spectroscopy (fNIRS) to assess the impact of MR on prefrontal and motor cortical activation during a laparoscopic knot tying task. Twelve surgical residents performed a laparoscopic knot tying task before and after either mental rehearsal (MR, intervention group) or textbook reading (TR, control group). In both groups, fNIRS was used to measure changes in oxygenated hemoglobin concentration (HbO2) in the prefrontal (24 channels) and motor cortices (22 channels). Technical performance was measured using leak volume, objective performance score and task progression score. MR led to a decrease in HbO (reduced activation) in the bilateral prefrontal cortex (PFC), and an increase in HbO (increased activation) in the left middle frontal gyrus, left precentral gyrus, and left postcentral gyrus. No discernible changes in activation were observed after TR in either the PFC or motor cortex. Moreover, smaller ΔHbO2 responses in the right PFC and greater ΔHbO responses in the left motor cortex were observed in the MR group compared with the TR group. Leak volume was significantly less following MR (  = 0.019), but not after TR (  = 0.347). Mean objective performance score was significantly higher following MR compared with TR (  = 0.043). Mental rehearsal may enhance surgical skill acquisition and technical proficiency by reducing utilization of attentional resources in the prefrontal cortex and improving neural efficiency in motor areas during a laparoscopic surgical task.

BackgroundCurrent validated tools to measure upper limb dysfunction after breast cancer treatment, such as questionnaires, are prone to recall bias and do not enable comparisons between patients. This study aimed to test the feasibility of wearable activity monitors (WAMs) for achieving a continuous, objective assessment of functional recovery by measuring peri-operative physical activity (PA).MethodsA prospective, single-center, non-randomized, observational study was conducted. Patients undergoing breast and axillary surgery were invited to wear WAMs on both wrists in the peri-operative period and then complete upper limb function (DASH) and quality-of-life (EQ-5D-5L) questionnaires. Statistical analyses were performed to determine the construct validity and concurrent validity of WAMs.ResultsThe analysis included 39 patients with a mean age of 55 ± 13.2 years. Regain of function on the surgically treated side was observed to be an increase of arm activity as a percentage of preoperative levels, with the greatest increase observed between the postoperative days 1 and 2. The PA was significantly greater on the side not treated by surgery than on the surgically treated side after week 1 (mean PA, 75.8% vs. 62.3%; p < 0.0005) and week 2 (mean PA, 91.6% vs. 77.4%; p < 0.005). Subgroup analyses showed differences in recovery trends between different surgical procedures. Concurrent validity was demonstrated by a significant negative moderate correlation between the PA and DASH questionnaires (R = −0.506; p < 0.05).ConclusionThis study demonstrated the feasibility and validity of WAMs to objectively measure postoperative recovery of upper limb function after breast surgery, providing a starting point for personalized rehabilitation through early detection of upper limb physical morbidity.