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Article ; Online: Dynamic assessment of the upper extremity: a review of available and emerging technologies.

Wolff, Aviva L / Kwasnicki, Richard M / Farnebo, Simon / Horwitz, Maxim D

The Journal of hand surgery, European volume

2023 Volume 48, Issue 5, Page(s) 404–411

Abstract: The purpose of this review article is to provide an update on the realm of emerging technology available for the assessment of dynamic functional movement of the hand and upper limb. A critical overview of the literature and a conceptual framework for ... ...

Abstract	The purpose of this review article is to provide an update on the realm of emerging technology available for the assessment of dynamic functional movement of the hand and upper limb. A critical overview of the literature and a conceptual framework for use of such technologies is proposed. The framework explores three broad purpose categories including customization of care, functional surveillance and interventions through biofeedback strategies. State-of-the-art technologies are described, from basic activity monitors to feedback-enabled robotic gloves, along with exemplar trials and clinical applications. The future of technologies innovation in hand pathology is proposed in the context of the current obstacles and opportunities for hand surgeons and therapists.
MeSH term(s)	Humans ; Movement ; Upper Extremity ; Hand
Language	English
Publishing date	2023-02-20
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	2272801-6
ISSN	2043-6289 ; 1753-1934
ISSN (online)	2043-6289
ISSN	1753-1934
DOI	10.1177/17531934231153559
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Article ; Online: Outcomes and outcome measures reported in clinical studies of therapeutic mammaplasty: a systematic review protocol.

Lee, Alice / Kwasnicki, Richard M / Leff, Daniel R

BMJ open

2021 Volume 11, Issue 6, Page(s) e046438

Abstract: Introduction: Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated oncological safety of TM, but poor and inconsistent ... ...

Abstract	Introduction: Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated oncological safety of TM, but poor and inconsistent reporting of quality-of-life, aesthetic and functional outcomes, often with non-validated measurement tools. Moreover, there is a paucity of patient-reported outcome measures. Standardisation of outcome reporting is required to enable study results to be compared and combined, for example, through core outcome set (COS) development. This systematic review aims to comprehensively describe the outcomes reported in clinical studies of TM, their respective outcome measures and the time points at which they were evaluated. The overall objective is to facilitate the development of a COS for TM. Methods and analysis: A systematic review of clinical studies evaluating outcomes following TM will be completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following electronic databases have been searched from inception to 5 August 2020: Ovid MEDLINE, Embase, CINAHL and Web of Science. Primary outcomes will include the number of reported outcomes of various types (clinical, aesthetic, functional, quality-of-life and cost-effectiveness), whether these are patient-reported or clinician-reported, how outcomes are defined and the outcome measurement tool(s) used. The time point(s) at which outcomes were measured will be a secondary outcome. No studies will be excluded on the basis of methodological quality in order to generate a comprehensive list of reported outcomes and outcome measures; hence, risk of bias assessment is not required. The data will be described narratively. This protocol has been reported in line with PRISMA-Protocols. Ethics and dissemination: This study does not involve human or animal participants, hence ethical approval is not required. The findings will be published in a peer-reviewed journal and presented at relevant conferences. Prospero registration number: CRD42020200365.
MeSH term(s)	Female ; Humans ; Mammaplasty ; Outcome Assessment, Health Care ; Quality of Life ; Research Design ; Systematic Reviews as Topic
Language	English
Publishing date	2021-06-16
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2020-046438
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Article: Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis.

Kwasnicki, Richard M / Noakes, Alex J / Banhidy, Norbert / Hettiaratchy, Shehan

Plastic and reconstructive surgery. Global open

2021 Volume 9, Issue 7, Page(s) e3663

Abstract: Background: Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly ... ...

Abstract	Background: Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. Methods: A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. Results: A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). Conclusions: This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.
Language	English
Publishing date	2021-07-12
Publishing country	United States
Document type	Journal Article
ZDB-ID	2851682-5
ISSN	2169-7574 ; 2169-7574
ISSN (online)	2169-7574
ISSN	2169-7574
DOI	10.1097/GOX.0000000000003663
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Article: Investigating Lower Limb Hemodynamics during Flap Training Regimens and Patient-led Isometric Contraction Protocols.

Geoghegan, Luke / Kwasnicki, Richard M / Henton, John M D / Hettiaratchy, Shehan / Jain, Abhilash

Plastic and reconstructive surgery. Global open

2020 Volume 8, Issue 3, Page(s) e2731

Abstract: The evidence for lower limb flap (LLF) training regimens is equivocal. The commonest cause of LLF failure is venous congestion. The aim of this study was to investigate whether venous congestion could be reduced by patient-led isometric calf contractions ...

Abstract	The evidence for lower limb flap (LLF) training regimens is equivocal. The commonest cause of LLF failure is venous congestion. The aim of this study was to investigate whether venous congestion could be reduced by patient-led isometric calf contractions during flap training. A prospective clinical study was conducted using photospectroscopy and laser Doppler (Oxygen to See) to assess healthy limbs and LLF characteristics during flap training and isometric calf contractions. Tissue oxygen saturation, venous congestion, and blood flow were measured at rest, as well as during and after limb dangling and calf contraction exercises. In the acute postoperative period following LLF surgery, dependency markedly reduced superficial flow (-55.20% ± 19.17%), with a concurrent increase in venous congestion (33.80% ± 28.80%); supine isometric contractions improved superficial flow and reduced venous congestion from postoperative day 5. Contractions cause a significant increase in blood flow in the outpatient cohort (+84.40% ± 7.86%,
Language	English
Publishing date	2020-03-25
Publishing country	United States
Document type	Journal Article
ZDB-ID	2851682-5
ISSN	2169-7574 ; 2169-7574
ISSN (online)	2169-7574
ISSN	2169-7574
DOI	10.1097/GOX.0000000000002731
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Article ; Online: ASO Author Reflections: Objective Outcome Measure of Upper Limb Function Following Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy.

Che Bakri, Nur Amalina / Kwasnicki, Richard M / Giannas, Emmanuel / Tenang, Luqman / Khan, Naairah / Moenig, Catharina / Imam, Zoha / Dhillon, Kieran / Ashrafian, Hutan / Darzi, Ara / Leff, Daniel R

Annals of surgical oncology

2023 Volume 30, Issue 12, Page(s) 7133–7134

MeSH term(s)	Humans ; Female ; Sentinel Lymph Node Biopsy ; Lymph Node Excision ; Lymph Nodes/pathology ; Upper Extremity/surgery ; Outcome Assessment, Health Care ; Breast Neoplasms/surgery ; Breast Neoplasms/pathology ; Axilla/pathology ; Sentinel Lymph Node
Language	English
Publishing date	2023-07-23
Publishing country	United States
Document type	Journal Article
ZDB-ID	1200469-8
ISSN	1534-4681 ; 1068-9265
ISSN (online)	1534-4681
ISSN	1068-9265
DOI	10.1245/s10434-023-13984-5
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Article ; Online: The Use of Wearable Activity Monitors to Measure Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy.

Che Bakri, Nur Amalina / Kwasnicki, Richard M / Giannas, Emmanuel / Tenang, Luqman / Khan, Naairah / Moenig, Catharina / Imam, Zoha / Dhillon, Kieran / Ashrafian, Hutan / Darzi, Ara / Leff, Daniel R

Annals of surgical oncology

2023 Volume 30, Issue 12, Page(s) 7036–7045

Abstract: Background: We suspect that morbidity from both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has been inadequately evaluated to date. Current methodologies are subjective and susceptible to bias. Objective assessment using ...

Abstract	Background: We suspect that morbidity from both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has been inadequately evaluated to date. Current methodologies are subjective and susceptible to bias. Objective assessment using wearable activity monitors (WAMs) would allow quantitative analysis of recovery by measuring physical activity (PA) and could provide evidence for axillary de-escalation. Patients and methods: A prospective, single center, observational study was conducted from February 2020 to May 2022. Consecutive patients undergoing breast and/or reconstructive surgery and axillary surgeries were identified from the operating schedules. Patients wore WAMs for an average of 3 days prior to surgery and up to 2 weeks following surgery. In total, 56 patients with breast cancer were recruited, of whom 35 underwent SLNB and 21 ALND. Results: Patients who underwent ALND experienced significantly worse PA compared with those who underwent SLNB in week 2 (median 66.4% versus 72.7%, p = 0.015). Subgroup analysis revealed significantly lower PA in simple mastectomy (Mx)-ALND versus Mx-SLNB (median 90.3% versus 70.5%, p = 0.015) in week 2. The PA for SLNB did not return to baseline at 2 weeks after surgery. Conclusions: Compared with SLNB, ALND results in a lower PA level in week 2. The findings also indicate that SLNB has a protracted effect on PA levels, which extend to 2 weeks postoperatively. Monitoring recovery objectively following breast cancer surgery provides patients and surgeons with more information regarding the predicted outcomes of their surgery, which can drive the development of a personalized rehabilitation program.
MeSH term(s)	Humans ; Female ; Sentinel Lymph Node Biopsy/methods ; Breast Neoplasms/surgery ; Breast Neoplasms/pathology ; Prospective Studies ; Mastectomy ; Lymphatic Metastasis ; Lymph Node Excision/methods ; Axilla/pathology ; Wearable Electronic Devices ; Sentinel Lymph Node/pathology
Language	English
Publishing date	2023-07-28
Publishing country	United States
Document type	Observational Study ; Journal Article
ZDB-ID	1200469-8
ISSN	1534-4681 ; 1068-9265
ISSN (online)	1534-4681
ISSN	1068-9265
DOI	10.1245/s10434-023-13966-7
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Article ; Online: Identifying variation in the cost of abdominally based breast reconstruction in the UK.

Kwasnicki, Richard M / Irukulla, Meghna / Che Bakri, Nur Amalina / Whiteman, Elena / Gardiner, Matthew / Dunne, Jonathan / Henry, Francis P / Gokani, Vimal / Hunter, Judith E / Williams, Georgina / Wood, Simon H

Journal of plastic, reconstructive & aesthetic surgery : JPRAS

2023 Volume 88, Page(s) 466–472

Abstract: Aims: To understand variation in the cost of autologous breast reconstruction in the UK, including identifying key areas of cost variability, differences between and within units and the impact of enhanced recovery protocols (ERAS).: Methods: A micro- ...

Abstract	Aims: To understand variation in the cost of autologous breast reconstruction in the UK, including identifying key areas of cost variability, differences between and within units and the impact of enhanced recovery protocols (ERAS). Methods: A micro-costing study was designed based on the responses to a national survey of clinical preferences completed by the majority of plastic surgeons and anaesthetists involved in the UK. Detailed costs were estimated from macro elements such as ward and theatre running costs, down to that of surgical meshes, anaesthetic drugs and flap monitoring devices. Results: The largest variation in cost arose from postoperative location and length of stay, preoperative imaging and flap monitoring strategies. Plastic surgeon costs varied from £1282 to £3141, whereas anaesthetic costs were between £32 and £151 (not including salary). Estimated cost variation within units was up to £893 per case. Units with ERAS had significantly lower total costs than those without (p < 0.05). Conclusion: This study reveals significant cost variation in breast reconstruction in the UK based on clinician preferences. Many areas of practice driving this variation lack strong evidence of any clinical advantage. The total cost of a deep inferior epigastric perforator in the majority, if not all units, likely surpasses the national tariff for reimbursement, particularly when considering additional resource demand for immediate and bilateral breast reconstruction, as well as future symmetrisation procedures. Whilst units should look to streamline costs through ERAS, there should also be a realistic tariff that promotes excellent care.
MeSH term(s)	Humans ; Female ; Mammaplasty/methods ; Surgical Flaps/surgery ; United Kingdom ; Perforator Flap/surgery ; Breast Neoplasms/surgery ; Epigastric Arteries/surgery ; Retrospective Studies
Language	English
Publishing date	2023-11-22
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	2217750-4
ISSN	1878-0539 ; 1748-6815 ; 0007-1226
ISSN (online)	1878-0539
ISSN	1748-6815 ; 0007-1226
DOI	10.1016/j.bjps.2023.11.025
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Article ; Online: Outcome reporting in therapeutic mammaplasty: a systematic review.

Lee, Alice / Kwasnicki, Richard M / Khan, Hasaan / Grant, Yasmin / Chan, Abigail / Fanshawe, Angela E E / Leff, Daniel R

BJS open

2021 Volume 5, Issue 6

Abstract: Background: Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically ... ...

Abstract	Background: Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set. Methods: Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools. Results: Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent). Conclusion: Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.
MeSH term(s)	Adult ; Breast Neoplasms/surgery ; Esthetics ; Female ; Humans ; Mammaplasty ; Mastectomy ; Quality of Life
Language	English
Publishing date	2021-12-10
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Systematic Review
ISSN	2474-9842
ISSN (online)	2474-9842
DOI	10.1093/bjsopen/zrab126
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Article ; Online: Objective Assessment of Postoperative Morbidity After Breast Cancer Treatments with Wearable Activity Monitors: The "BRACELET" Study.

Che Bakri, Nur Amalina / Kwasnicki, Richard M / Dhillon, Kieran / Khan, Naairah / Ghandour, Omar / Cairns, Alexander / Darzi, Ara / Leff, Daniel R

Annals of surgical oncology

2021 Volume 28, Issue 10, Page(s) 5597–5609

Abstract: Background: Current 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 ... ...

Abstract	Background: Current 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). Methods: A 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. Results: The 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). Conclusion: This 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.
MeSH term(s)	Adult ; Aged ; Breast Neoplasms/surgery ; Female ; Humans ; Mastectomy ; Middle Aged ; Morbidity ; Prospective Studies ; Quality of Life ; Surveys and Questionnaires ; Wearable Electronic Devices
Language	English
Publishing date	2021-07-26
Publishing country	United States
Document type	Journal Article ; Observational Study
ZDB-ID	1200469-8
ISSN	1534-4681 ; 1068-9265
ISSN (online)	1534-4681
ISSN	1068-9265
DOI	10.1245/s10434-021-10458-4
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Article ; Online: ASO Author Reflections: Improving Management of Upper Limb Complications after Breast Cancer Treatments.

Che Bakri, Nur Amalina / Kwasnicki, Richard M / Dhillon, Kieran / Khan, Naairah / Ghandour, Omar / Cairns, Alexander / Darzi, Ara / Leff, Daniel R

Annals of surgical oncology

2021 Volume 29, Issue Suppl 3, Page(s) 566–567

MeSH term(s)	Humans ; Female ; Breast Neoplasms/therapy ; Breast ; Upper Extremity
Language	English
Publishing date	2021-08-24
Publishing country	United States
Document type	Journal Article ; Comment
ZDB-ID	1200469-8
ISSN	1534-4681 ; 1068-9265
ISSN (online)	1534-4681
ISSN	1068-9265
DOI	10.1245/s10434-021-10603-z
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