Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: single-center evaluation of 6-month treatment safety and functional outcomes of intensified treatment parameters.

OBJECTIVES: To evaluate the effect of intensified treatment parameters on safety, functional outcomes, and PSA after MR-Guided Transurethral Ultrasound Ablation (TULSA) of prostatic tissue. PATIENTS AND METHODS: Baseline and 6-month follow-up data were collected for a single-center cohort of the multicenter Phase I (n = 14/30 at 3 sites) and Pivotal (n = 15/115 at 13 sites) trials of TULSA in men with localized prostate cancer. The Pivotal study used intensified treatment parameters (increased temperature and spatial extent of ablation coverage). The reporting site recruited the most patients to both trials, minimizing the influence of physician experience on this comparison of adverse events, urinary symptoms, continence, and erectile function between subgroups of both studies. RESULTS: For Phase I and TACT patients, median age was 71.0 and 67.0 years, prostate volume 41.0 and 44.5 ml, and PSA 6.7 and 6.7 ng/ml, respectively. All 14 Phase I patients had low-risk prostate cancer, whereas 7 of 15 TACT patients had intermediate-risk disease. Baseline IIEF, IPSS, quality of life, and pad use were similar between groups. Pad use at 1 month and quality of life at 3 months favored Phase I patients. At 6 months, there were no significant differences in functional outcomes or adverse events. CONCLUSION: TULSA demonstrated acceptable clinical safety in Phase I trial. Intensified treatment parameters in the TACT Pivotal trial increased ablation coverage from 90 to 98% of the prostate without affecting 6-month adverse events or functional outcomes. Long-term follow-up and 12-month biopsies are needed to evaluate oncological safety.

Twelve-month prostate volume reduction after MRI-guided transurethral ultrasound ablation of the prostate.

PURPOSE: To quantitatively assess 12-month prostate volume (PV) reduction based on T2-weighted MRI and immediate post-treatment contrast-enhanced MRI non-perfused volume (NPV), and to compare measurements with predictions of acute and delayed ablation volumes based on MR-thermometry (MR-t), in a central radiology review of the Phase I clinical trial of MRI-guided transurethral ultrasound ablation (TULSA) in patients with localized prostate cancer. MATERIALS AND METHODS: Treatment day MRI and 12-month follow-up MRI and biopsy were available for central radiology review in 29 of 30 patients from the published institutional review board-approved, prospective, multi-centre, single-arm Phase I clinical trial of TULSA. Viable PV at 12 months was measured as the remaining PV on T2-weighted MRI, less 12-month NPV, scaled by the fraction of fibrosis in 12-month biopsy cores. Reduction of viable PV was compared to predictions based on the fraction of the prostate covered by the MR-t derived acute thermal ablation volume (ATAV, 55°C isotherm), delayed thermal ablation volume (DTAV, 240 cumulative equivalent minutes at 43°C thermal dose isocontour) and treatment-day NPV. We also report linear and volumetric comparisons between metrics. RESULTS: After TULSA, the median 12-month reduction in viable PV was 88%. DTAV predicted a reduction of 90%. Treatment day NPV predicted only 53% volume reduction, and underestimated ATAV and DTAV by 36% and 51%. CONCLUSION: Quantitative volumetry of the TULSA phase I MR and biopsy data identifies DTAV (240 CEM43 thermal dose boundary) as a useful predictor of viable prostate tissue reduction at 12 months. Immediate post-treatment NPV underestimates tissue ablation. KEY POINTS: • MRI-guided transurethral ultrasound ablation (TULSA) achieved an 88% reduction of viable prostate tissue volume at 12 months, in excellent agreement with expectation from thermal dose calculations. • Non-perfused volume on immediate post-treatment contrast-enhanced MRI represents only 64% of the acute thermal ablation volume (ATAV), and reports only 60% (53% instead of 88% achieved) of the reduction in viable prostate tissue volume at 12 months. • MR-thermometry-based predictions of 12-month prostate volume reduction based on 240 cumulative equivalent minute thermal dose volume are in excellent agreement with reduction in viable prostate tissue volume measured on pre- and 12-month post-treatment T2w-MRI.

Delivery of UK military upper limb prosthetics: current concepts and future directions.

Upper limb prosthetics have a challenging task. A natural upper limb combines strength, coordination and dexterity to accomplish daily activities such as eating, writing, working and social interaction. Artificially replicating these functions requires a prosthetic with composite, synchronous motor function while maintaining sensory feedback and skeletal stability. Achieving these functions requires interfaces between biology and machine across nerve, muscle, bone and skin. This leads to issues related to infection, foreign material encapsulation and implant stability, and electrical signal transduction and interpretation. Over the last 20 years the advent of technologies such as osseointegration, targeted muscle reinnervation, implantable myoelectric sensors, peripheral nerve interfaces and pattern recognition technology has sought to address these problems.Due to many advances in prehospital care, truncated timelines to damage control surgery and improved combat personal protective equipment, the numbers of amputees have increased with more patients surviving injury. From October 2001 to March 2019 there were 333 amputees from Afghanistan and Iraq compared with 457 fatalities over a similar period. Over a third of these were significant multiple amputees. With a functional, robust upper limb prosthetic which mirrors or exceeds normal function, injured service personnel could be returned to an active combat role. This has benefits for their physical and mental health, improves employability prospects and allows Defence to retain some of its most highly motivated and skilled people who represent significant financial investment.

Why is priority setting important for global burn care research?

The use of robust evidence is a key component of providing high quality care to patients. Synthesised evidence to support clinical decision-making is lacking for many aspects of clinical burn care. Identifying the most important areas of care that lack high quality evidence and requires research is necessary, as funding for primary research is limited. Priority setting research studies are a joint endeavour between patients, carers and clinicians to identify and rank topics for research in a healthcare area in order to reduce research waste. Such an exercise has yet to be undertaken in burns. The aim of this paper is to outline the importance of research prioritisation in burn care, to discuss how it facilitates the maximum benefit from limited research funding and to explain the methodologies used.

A report on the state of bullying & harassment within plastic surgery in the United Kingdom.

Many surgical and medical groups in the UK and around the world have investigated the existing cultures within their own workplaces. The Australian college of surgeons, in 2015, conducted a survey that identified that bullying, harassment, sexual harassment and discrimination were endemic. Unsurprisingly this culture persists, and not only produces a workforce which underperforms but leads to continuous poor behaviour and substandard clinical outcomes for patients. PLASTA, in collaboration with BAPRAS, adopted the Royal College of Australian Surgeons survey (RACS) to sample our own plastic surgery community, at all grades. We present the results here and our suggestions for addressing these issues in the following editorial.

A correlation analysis of metacarpal & phalangeal injury pattern from improvised explosive devices amongst armed force personnel.

Injuries to the hand during military combat operations, particularly from improvised explosive devices (IEDs) have a significant impact on form, function, mental health and future employment but remain underreported amidst the life and limb-threatening emergencies that garner more attention. An understanding the patterns of hand injuries encountered from IEDs is crucial to optimizing reconstruction and rehabilitation. The aim of this study was to re-evaluate hand injury sustained from IED in order to understand the clinical burden for reconstruction and direct the focus for future hand protection. We identified 484 hand injuries in 380 patients sustained as a result of IEDs among military personnel service in Afghanistan between 2006 and 2013. 53% of all surviving military personnel injured by IEDs sustain injuries to the hand. Analysis of the 103 patients who sustained injury to the metacarpal, phalanges or digital amputation revealed that the middle and ring fingers are most commonly injured. Amputation to the ring finger is strongly associated with injury to the adjacent fingers and amputations to the middle, ring and little fingers concurrently is a commonly observed pattern. The proximal phalanges of the middle and ring fingers had a strong correlation for fracture together. These findings disprove the conventional belief in an ulnar focus of injury and support the quest for a development of combat hand protection that addresses the injury pattern seen.

Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision.

INTRODUCTION: Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit. METHOD: Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed. RESULTS: The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%. CONCLUSION: After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Comparing the surgical timelines of military and civilians traumatic lower limb amputations.

The care and challenges of injured service have been well documented in the literature from a variety of specialities. The aim of this study was to analyse the surgical timelines of military and civilian traumatic amputees and compare the surgical and resuscitative interventions. A retrospective review of patient notes was undertaken. Military patients were identified from the Joint Theatre Trauma Registry (JTTR) in 2009. Civilian patients were identified using the hospital informatics database. Patient demographics, treatment timelines as well as surgical and critical care interventions were reviewed. In total 71 military patients sustained traumatic amputations within this time period. This represented 11% of the total injury demographic in 2009. Excluding upper limb amputees 46 patients sustained lower extremity amputations. These were investigated further. In total 21 civilian patients were identified in a 7-year period. Analysis revealed there was a statistically significant difference between patient age, ITU length of stay, blood products used and number of surgical procedures between military and civilian traumatic amputees. This study identified that military patients were treated for longer in critical care and required more surgical interventions for their amputations. Despite this, their time to stump closure and length of stay were not statistically different compared to civilian patients. Such observations reflect the importance of an Orthoplastic approach, as well as daily surgical theatre co-ordination and weekly multi-disciplinary meetings in providing optimal care for these complex patients. This study reports the epidemiological observed differences between two lower limb trauma groups.

The targeting accuracy of a preclinical MRI-guided focused ultrasound system.

PURPOSE: Assess the accuracy, precision, and sources of error using a preclinical MR-guided focused ultrasound system. METHODS: A preclinical focused ultrasound system, described previously [Chopra et al., Med. Phys. 36(5), 1867-1874 (2009)], was tested on a benchtop and with 3T GE, 3T Philips, and 7 T Bruker MR scanners for spatial targeting accuracy and precision. Randomly distributed water-filled holes drilled into a polystyrene plate were imaged using MRI and targeted using treatment planning software. The ultrasound focus of a 72 mm, f-number 0.8, 1.16 MHz transducer was aimed at the target locations, and 1-2 s continuous-wave sonications were performed on clear polystyrene plates to create localized spots of melted plastic. The distance between target and observed locations was measured and analyzed. Retrospective analysis of targeting accuracy was performed on preclinical data obtained from other experiments at their institution using the same system. RESULTS: The results suggest that the sources of targeting error under MR guidance can be roughly separated into three components--normally distributed random error; constant shift from inaccuracy in detection of the initial ultrasound focus; and angular misalignment between MR and focused ultrasound (FUS) coordinates. The lower bound on the targeting error was estimated to be 0.25 ± 0.13 mm, while the maximum observed targeting error did not exceed 2 mm. Measures required to reduce errors and improve targeting were developed to reduce the registration and misalignment errors such that maximum error was reduced to 0.36 ± 0.14 mm. Retrospective in vivo analysis indicated that the error was 1.02 ± 0.43 mm, including error extrinsic to the system. CONCLUSIONS: The FUS system, as described, is capable of precise and accurate sonications. The largest source of error--misregistration of the coordinate systems of the scanner and ultrasound system--was addressed which reduced the error to 0.36 ± 0.14 mm, sufficient for many preclinical applications.