Centralising specialist cancer surgery services in England: survey of factors that matter to patients and carers and health professionals.

BACKGROUND: The centralisation of specialist cancer surgical services across London Cancer and Greater Manchester Cancer, England, may significantly change how patients experience care. These centres are changing specialist surgical pathways for several cancers including prostate, bladder, kidney, and oesophago-gastric cancers, increasing the specialisation of centres and providing surgery in fewer hospitals. While there are potential benefits related to centralising services, changes of this kind are often controversial. The aim of this study was to identify factors related to the centralisation of specialist surgical services that are important to patients, carers and health care professionals. METHODS: This was a questionnaire-based study involving a convenience sample of patient and public involvement (PPI) and cancer health care professional (HCP) sub-groups in London and Greater Manchester (n = 186). Participants were asked to identify which of a list of factors potentially influenced by the centralisation of specialist cancer surgery were important to them and to rank these in order of importance. We ranked and shortlisted the most important factors. RESULTS: We obtained 52 responses (28% response rate). The factors across both groups rated most important were: highly trained staff; likelihood and severity of complications; waiting time for cancer surgery; and access to staff members from various disciplines with specialised skills in cancer. These factors were also ranked as being important separately by the PPI and HCP sub-groups. There was considerable heterogeneity in the relative ordering of factors within sub-groups and overall. CONCLUSIONS: This study examines and ranks factors important to patients and carers, and health care professionals in order to inform the implementation of centralisation of specialist cancer surgical services. The most important factors were similar in the two stakeholder sub-groups. Planners should consider the impact of reorganising services on these factors, and disseminate this information to patients, the public and health care professionals when deciding whether or not and how to centralise specialist cancer surgical services.

Gastric endoscopic submucosal dissection as a treatment for early neoplasia and for accurate staging of early cancers in a United Kingdom Caucasian population.

AIM: To investigate the efficacy of endoscopic submucosal dissection (ESD) at diagnosing and treating superficial neoplastic lesions of the stomach in a United Kingdom Caucasian population. METHODS: Data of patients treated with or considered for ESD at a tertiary referral center in the United Kingdom were retrieved for a period of 2 years (May 2015 to June 2017) from the electronic patient records of the hospital. Only Caucasian patients were included. Primary outcomes were curative resection (CR) and were defined as ESD resections with clear horizontal and vertical margin and an absence of lympho-vascular invasion, poor differentiation and submucosal involvement on histological evaluation of the resected specimen. Secondary end-points were reversal of dysplasia at 12 mo endoscopic follow-up and/or at the latest follow up. Change in histological diagnosis pre and post ESD was also analysed. RESULTS: Twenty-four patients were initially identified with intention to treat. 19 patients were eligible after mapping gastroscopy and ESD was attempted on a total of 25 ESD lesions, 4 of which failed and had to be aborted mid-procedure. Out of 21 ESD performed, en-bloc resection was achieved in 71.4% of cases. Resection was considered complete on endoscopy in 90.5% of cases compared to only 38.1% on histology. A total of 6 resections were considered curative (28%), 5 non-curative (24%) and 10 indefinite for CR or non-CR (24%). ESD changed the histological diagnosis in 66.6% of cases post ESD. Endoscopic follow-up in the "indefinite" group and CR group showed that 50% and 80% of patients were clear of dysplasia at the latest follow-up respectively; 2 cases of recurrence were observed in the "indefinite"group. Survival rate for the entire cohort was 91.7%. CONCLUSION: This study provides early evidence for the efficacy of ESD as a therapeutic and diagnostic intervention in Caucasian populations and supports its application in the United Kingdom.

Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21).

BACKGROUND: There are longstanding recommendations to centralise specialist healthcare services, citing the potential to reduce variations in care and improve patient outcomes. Current activity to centralise specialist cancer surgical services in two areas of England provides an opportunity to study the planning, implementation and outcomes of such changes. London Cancer and Manchester Cancer are centralising specialist surgical pathways for prostate, bladder, renal, and oesophago-gastric cancers, so that these services are provided in fewer hospitals. The centralisations in London were implemented between November 2015 and April 2016, while implementation in Manchester is anticipated in 2017. METHODS/DESIGN: This mixed methods evaluation will analyse stakeholder preferences for centralisations; it will use qualitative methods to analyse planning, implementation and sustainability of the centralisations ('how and why?'); and it will use a controlled before and after design to study the impact of centralisation on clinical processes, clinical outcomes, cost-effectiveness and patient experience ('what works and at what cost?'). The study will use a framework developed in previous research on major system change in acute stroke services. A discrete choice experiment will examine patient, public and professional preferences for centralisations of this kind. Qualitative methods will include documentary analysis, stakeholder interviews and non-participant observations of meetings. Quantitative methods will include analysis of local and national data on clinical processes, outcomes, costs and National Cancer Patient Experience Survey data. Finally, we will hold a workshop for those involved in centralisations of specialist services in other settings to discuss how these lessons might apply more widely. DISCUSSION: This multi-site study will address gaps in the evidence on stakeholder preferences for centralisations of specialist cancer surgery and the processes, impact and cost-effectiveness of changes of this kind. With increasing drives to centralise specialist services, lessons from this study will be of value to those who commission, organise and manage cancer services, as well as services for other conditions and in other settings. The study will face challenges in terms of recruitment, the retrospective analysis of some of the changes, the distinction between primary and secondary outcome measures, and obtaining information on the resources spent on the reconfiguration.

A plastic total internal reflection photoluminescence device for enzymatic biosensing.

A total internal reflection photoluminescence (TIRPh) device employing an easily fabricated PMMA/PDMS waveguide system provides a detection limit comparable to the best reported results but without using an excitation filter. The optical mechanism is similar to total-internal-reflection-fluorescence (TIRF) but uses a ruthenium-based phosphorescent dye (Ru(dpp)3) deposited on the PMMA core, motivating the generalized term of photoluminescence to include both fluorescence and phosphorescence. An enzymatic hydrogen peroxide (H2O2) biosensor incorporating catalase was fabricated on the TIRPh platform without photolithography or etching. The O2-sensitive phosphorescence of Ru(dpp)3 was used as a transduction mechanism and catalase was used as a biocomponent for sensing. The H2O2 sensor exhibits a phosphorescence to scattered excitation light ratio of 76 ± 10 without filtering. The unfiltered device demonstrates a detection limit of (2.2 ± 0.6) µM with a linear range of 0.1 mM to 20 mM. The device is the first total internal reflection photoluminescence based enzymatic biosensor platform, and is promising for cost-effective, low excitation interference, field-portable sensing.

Thermoset polyester as an alternative material for microchip electrophoresis/electrochemistry.

Microchip CE coupled with electrochemical detection (MCE-EC) is a good method for the direct detection of many small molecule analytes because the technique is sensitive and readily miniaturized. Polymer materials are being increasingly used with MCE due to their affordability and ease of fabrication. While PDMS has become arguably the most widely used material in MCE-EC due to the simplicity of microelectrode incorporation, it suffers from a lack of separation efficiency, lower surface stability, and a tendency for analyte sorption. Other polymers, such as poly(methylmethacrylate) (PMMA) and poly(carbonate) (PC), have higher separation efficiencies but require more difficult fabrication techniques for electrode incorporation. In this report, thermoset polyester (TPE) was characterized as an alternative material for MCE-EC. TPE microchips were characterized in their native and plasma oxidized forms and after coating with polyelectrolyte multilayers (PEMs). TPE provides higher separation efficiencies when compared to PDMS microchips, while still using simple fabrication protocols. In this work, separation efficiencies as high as 295,000 N/m were seen when using TPE MCE-EC devices. Furthermore, the EOF was higher and more consistent as a function of pH for both native and plasma-treated TPE than PDMS. Finally, TPE is amenable to modification using simple PEM coatings as another way to control surface chemistry and surface charge.

Generation of hydrophilic poly(dimethylsiloxane) for high-performance microchip electrophoresis.

Poly(dimethylsiloxane) (PDMS) has become one of the most widely used materials for microchip capillary electrophoresis and microfluidics. The popularity of this material is the result of its low cost, simple fabrication, and rugged elastomeric properties. The hydrophobic nature of PDMS, however, limits its applicability for microchip CE, microfluidic patterning, and other nonelectrophoresis applications. The surface of PDMS can be made hydrophilic using a simple air plasma treatment; however, this property is quickly lost through hydrophobic recovery caused by diffusion of unreacted oligomer to the surface. Here, a simple approach for the generation of hydrophilic PDMS with long-term stability in air is presented. PDMS is rendered hydrophilic through a simple two-step extraction/oxidation process. First, PDMS is extracted in a series of solvents designed to remove unreacted oligomers from the bulk phase. Second, the oligomer-free PDMS is oxidized in a simple air plasma, generating a stable layer of hydrophilic SiO2. The conversion of surface-bound siloxane to SiO2 was followed with X-ray photoelectron spectroscopy. SiO2 on extracted-oxidized PDMS was stable for 7 days in air as compared to less than 3 h for native PDMS. Furthermore, the contact angle for modified PDMS was reduced to <40 degrees and remained low throughout the experiments. As a result of the decreased contact angle, capillary channels self-wet through capillary action, making the microchannels much easier to fill. Finally, the modification significantly improved the performance of the devices for microchip electrophoresis. The electroosmotic flow increased from 4.1 x 10(-4) to 6.8 x 10(-4) cm(2)/V.s for native compared to oxidized PDMS. Separation efficiencies for electrochemical detection also increased from 50 000 to 400 000 N/m for a 1.1-nL injection volume. The result of this modification is a significant improvement in the performance of PDMS for microchip electrophoresis and microfluidic applications.

Simplified current decoupler for microchip capillary electrophoresis with electrochemical and pulsed amperometric detection.

There is a need to develop broadly applicable, highly sensitive detection methods for microchip CE that do not require analyte derivatization. LIF is highly sensitive but typically requires analyte derivatization. Electrochemistry provides an alternative method for direct analyte detection; however, in its most common form, direct current (DC) amperometry, it is limited to a small number of easily oxidizable or reducible analytes. Pulsed amperometric detection (PAD) is an alternative waveform that can increase the number of electrochemically detectable analytes. Increasing sensitivity for electrochemical detection (EC) and PAD requires the isolation of detection current (nA) from the separation current (muA) in a process generally referred to as current decoupling. Here, we present the development of a simple integrated decoupler to improve sensitivity and its coupling with PAD. A Pd microwire is used as the cathode for decoupling and a second Au or Pt wire is used as the working electrode for either EC or PAD. The electrode system is easy to make, requiring no clean-room facilities or specialized metallization systems. Sensitive detection of a wide range of analytes is shown to be possible using this system. Using this system we were able to achieve detection limits as low as 5 nM for dopamine, 74 nM for glutathione, and 100 nM for glucose.

Simple and sensitive electrode design for microchip electrophoresis/electrochemistry.

A simple and sensitive electrode design for microchip capillary electrophoresis/electrochemistry (CE-EC) is presented. The system employs metal microwires as the working electrodes for electrochemical detection. Two general approaches for integration of electrodes in microchip CE-EC are commonly used, end-channel and microfabrication. The end-channel approach allows electrode cleaning and the use of chemically modified electrodes; however, the designs generally lack portability and the ability to incorporate multiple electrodes. Microfabrication allows the incorporation of multiple electrodes on-chip and is easily made portable; however, it requires the use of expensive metallization and clean room facilities, and integration of more than one electrode material is challenging. The reported approach aligns a solid metal microwire through the separation channel allowing integration of multiple electrodes and the use of different electrode materials without sacrificing the portability. A detection limit of 100 nM for dopamine was achieved without the use of a decoupler as a result of a higher collection efficiency with the new design.