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Good morning everyone. Thank you for um, for joining us for the SR S session. Just some introductions. Uh My name is Alex. I'm a plastic surgery registrar and the um, SR S representative on Asset Council. Uh My name is Roberta, I'm the new Asset President and I'm also a phd fellow in Edinburgh. My name is Michael. I'm one of the SOS council members and I'm an academic foundation trainer in London. So we're delighted to welcome you for the SRS session. For those of you who don't know the SRS as the surgical Research society, one of the oldest research societies in the world runs in the United Kingdom. They've recently had their conference in Cambridge. They have a partnership with assets where they run a prize session. These can be from any topic and we've got a few sort of submissions that we've got in, in this session. They're all excellent. Unfortunately, not everybody is here. So we currently have two who we know are present and correct. If Georgios Gero is around, could you please identify yourself and give your slides to the AV team and you can do that during the session. But for the time being, we would like to start by inviting our first speaker that will be Fiona Crotty who is presenting research priorities for esophageal cancer results from a prior setting partnership. Thank you. Hi, everyone. Uh Can you all hear me? Yes. Uh So I'm Fiona, I'm a surgical trainee in KSS, but I've been out of program for the last three years in Ireland at Trinity in Saint James's. Uh And this uh that I'm presenting was my patient in public involvement project, which was part of my research there. Um And just while I have my list of coauthors here, I just wanna point out that of them, four of them are actually patients uh which is part of patient and public involvement. And so I want, I want to point it out while I have the chance. So uh just very brief background, esophageal cancer is one of the uh it's the seventh most common cancer worldwide and it's the sixth leading cause of cancer related deaths despite advances in treatment in the last 10 to 20 years, particularly around neoadjuvant treatment and immunotherapies. More recently, it still has quite a high morbidity and mortality burden. Um And when you think, try to think about that in the positive, it means that research still has great scope to improve patient care and outcomes. These two pictures here are of Saint James's Hospital at the top which is in Dublin. Um And then the Trinity translational medicine institute. And the reason I show that is because they're on the same campus. And it means that traditionally, there's been a lot of back and forth between clinicians and scientists uh which um which facilitates research. Um And they actually have a biobank going back 20 years worth of both um archive patient samples but also clinical information to go with it. But while you have that nice balance between the scientists and the clinicians, you miss out on all of the patients and the other stakeholders in esophageal cancer. Um And so patients in public involvement projects are aimed at sort of bridging that gap. So what I did was something called a priority setting partnership, which is a very clearly defined PPI project uh which was brought about by the James Lind Alliance, which aims to bring together different uh groups, different stakeholders, patients carers funding bodies to identify key uh unanswered questions in a topic. And the reason that that's important is because you can often get patients involved at later stages down the line and ask them well, you know, is this information uh appropriate for patient dissemination? Are we doing this well enough? But this is bringing it right back to the beginning. So when you ask your research questions, are these things that patients and carers care about? Um And ultimately, the goal is to direct funding and, and attention to what matters most to patients and what can make the most difference for their care. Uh And in some uh part, in some topics like cystic fibrosis, it's helped to direct millions of pounds worth of funding to questions that particularly mattered to people who matter most most. Um The nice thing about the James Lind Alliance is it's a very clearly defined methodology. They have advisors on board to help you at every stage. They have an online guidebook that teach you that teaches you takes you through each step. Um And so the first step is an initial survey. So we disseminated this to all of our own patient groups to our patient lists. We used the Esophageal Cancer Fund and the breakthrough cancer research to reach their groups of patients. And from that, we had 230 responses. And ultimately, what we just ask is for everyone to list all of the questions that they have about esophageal cancer. And from there, we review all of those uncertainties that were submitted, we remove the duplicates and we remove the already answered questions. And that in itself was an interesting um projects for us because we realized that there was actually a lot of information, a lot of questions that patients had that we weren't answering. And so we were able to change the patient leaflet books and talk to them earlier on about, you know, answering their questions so that they weren't missing out on information that they wanted. Uh from there, we had 63 remaining uncertainties which went, went through a second interim ranking again, an online survey because this was uh towards the end of COVID in Ireland had quite a very strict lockdown. Um And we had 25 that were ultimately shortlisted. You both of these surveys went out to patients and carers, but also all of the clinicians, so, surgeons and oncologists, dieticians, specialist nurses, everyone else involved in the care team. Um And when we did our shortlisting, we included both the rankings in terms of uh clinicians and separately patients and carers. So we knew which ones were important to which groups. And then finally, you have a final workshop of, I think we had 1212 to be 12 to finish with which was a mix of, as I said, patients, carers, nurses, dieticians, clinicians, and we had one tumor immunologist from the lab as well. And from there you agree on the top 10. Um And ultimately, these are our top 10. I won't read them all out. They're not surprising questions, they make sense. But what was more interesting was to see what mattered more to patients and carers compared to clinicians. So a lot of the clinical team were interested in survivors, survivorship questions, uh things about nutrition and weight loss and things like that, whereas the patients were much more interested about. Ok. Well, what could I have done to reduce my risk? What can my family do? Are there things diagno diagnostic tests that can be used to identify cancer earlier. Uh And so that was, that was more a more interesting and sort of unexpected result that we found. Um So that's it. Thank you very much Fiona intriguing study. Um So we'll, we'll open up for questions now. I'd like to kick off if that's OK. Um So just going back to your methodology in terms of the questions that you got from the initial question screening, um if I understand correctly, you asked the patients what questions they had and then you excluded duplicates, but you also removed things that you felt were already answered. Is there perhaps something to be said about those questions already have been answered, but the patients not thinking that they had been answered and perhaps that needing to be more clearly communicated and, and that was, and that was why we went back and we reviewed our patient information booklets and looked at the information that we were giving patients early on in their treatment. And so we, we completely changed how we did that. We introduced some people earlier. So for example, dieticians got involved a lot earlier about answering questions and things like that. Um And so it, it really, it, it changed the way that like all of our pre op work was done, which was interesting. Oh Perfect. So that did did translate to a change in. Yes, perfect. Yeah. Uh uh Anyone else questions? I have a question from the audience. OK. Can you hear me? I'm a breast cancer surgeon. It's really, really fabulous research. Thank you. And I think it's really hard to realize how important this is and how unusual it is that we're actually getting proper patient involvement. I think it's really interesting that you've got two almost completely different sets of questions. And I wondered after that, have you put the two groups in a room together? So, in our final workshop, we get all of the groups together. And so that's where we had, we had four patients, we had a family member, we had a dietician, a specialist nurse, the tumor immunologists, two surgeons and an oncologist. And so that's where we got everyone together. And so our ultimate sort of 10 questions, we, we came up with 10 because that's what we needed to. But we decided we weren't ranking them in order of most important to least important because nobody could, could agree. The answer was all of these questions need to be answered. Uh And part of what we're looking at is uh highlighting which ones were the important ones to patients. So it was interesting because even things like reflux sitting in the room, the patients were telling us yes, I had lots of reflux. I don't really care. Uh And so that was, that was an interesting question or an interesting experiment in getting everyone together. Um But it was nice to have sort of the whole, the whole team team there. I did have one more question if that's OK. So two more questions then. So um would you like to go first, please? Just, I was um it really, really interesting, very different from the research. I do. Um just looking at what was your methodology exactly for a short list to 25 questions? And how did you make sure there was no bias from kind of clinicians in choosing those questions? The James Ly guidebook, online guidebook has all of the different ways that you can do it. We had 63. So what we did in our interim ranking was we had everyone rank them from 1 to 10. And then we gave them a weighted value based on what rank they had from 1 to 10. And we did it in two for groups. So we did clinicians in one group and we did patients and carers in another group and we included scientists and the clinicians because we thought that they would have particularly the scientists who responded to this, as I say, work very closely with the clinical team. So we included them with the clinicians and then you rank them separately and then you look at the overall ranking in patients group versus clinicians group and see which ones have the highest overall ranking. And do you have of a big difference between the two groups at that stage? There were some um ultimately, when you, so at the interim ranking stage, you're bringing it down from 63 to 25. And actually there were a lot of questions that then weren't, that weren't as a whole people weren't interested in. But it meant that in the in the clinicians group, things that ranked 1 to 2 were potentially ranked sort of around 20 in the patients groups and vice versa. Thank you. And just finally, um looking at the slide again, with the top 10 priorities, it was quite striking to me that there's a significant amount that that is concerning prevention and knowledge and public health, which from my understanding obviously falls far earlier in the pathway, maybe not something that you would have a direct input in. So what are your next steps in terms of action that and making sure that translates to tangible change? So the other nice thing about this is because from even within the steering group committee, you get uh funding bodies and research bodies involved. So, breakthrough cancer Research and the Esophageal Cancer Fund, um they were both, we had representatives from both on our steering committee. Um Part of what we're doing is feeding back to them and they have a lot more, they're even more, they've got even more PPI projects involved. And so for example, breakthrough do a um a whole thing about nutrition around cancer. And so feeding that in and they, and obviously there are things like uh lollipop day and all of the other funding activities that they do. And so they're much better at disseminating uh things on social media and throughout their own chains. And so that's really how we're, we're feeding it back through them. Perfect. Thank you very much. So, our next, just quickly to ask and to echo again, if Georgios Gero is around and can identify themselves and give their slides, will slot you in at the end. But otherwise our final talk of this session will be from Diar who will be presenting a study entitled Morphometric Study of human aortic valve along with a case of bicuspid aortic valve in a cadaver. Can I start? Good morning everyone. So, uh I am presenting today a KAIC study and the topic of the study is Morphometric study of the human aortic valve along with a case of bicuspid aortic valve in Kava. This study was carried out in the anatomy department of all India Institute of Medical Science, New Delhi India. So when we talk about the aortic valve, all of you know that this valve is separating the left ventricle from the aorta. Normally, it is in most of the cases, most of the population, it is a dry foliate uh semi nerve. However, in 1% of the population, it can be by and it very rarely, it can be unicuspid quadric and PTA also. And the shape of diotic root aids in the valve closure. This is the normal uh schematic diagram showing the normal human aortic valve which shows the right left and the posterior aortic cals and the two right and the left cast leading to the right and the left coronary arteries. Figure B shows the valves in open state and figure C shows the valves in close state where the line and the nodules meet in the center. The aortic root is a continuation of the left ventricular outflow tract which extends from the aortic annulus to the sinotubular junction which is short in length, measuring approximately 2 to 3 centimeter. These are the components of the aortic root which includes sinotubular junction, the sinuses of valsalva, aortic annulus, the aortic segment and the leaflets. And here we can see the central position of the human aortic uh valve, which is a uh related anteriorly to the pulmonary valve and posteriorly to the mitral valve and the tricuspid valve. And it is also intimately related to the fibro skeleton of the heart. This picture shows the sinotubular junction which is actually located at the tips of the leaflets, which is actually a uh rich transverse reach of collagen and elastic fibers. And it is to be noted here that the green line and the brown line, the green line represents the aortic annulus and the sinotubular junction represents uh the uh brown line indicates the sinotubular junction, the sinotubular junction in young, it's smaller in diameter with respect to the aortic uh annulus. But where in adults uh in elderly, this becomes dilated, it becomes more in diameter with respect to diotic annul. And it is to be appreciated here here. If you look at the red line, the atic ANAs, which we are speaking, it is not actually a circle, it is actually crown like it is, the attachment site is like a crown, so it is not exactly circular. Then a quick note about the bicuspid valve, the bicuspid valve, it's uh prevalent in approximately 1% of the population. And it is one of the most common congenital cardiac defect with a male preponderance approximately 2 to 3 times in more. And these are different diseases, aortic stenosis, aortic regurgitation, aortic dilation, dissection, et cetera, et cetera, which are commonly seen associated with bicuspid aortic valve. And these are the types of the broad classification of the types of the by valves, by severs, classification, type zero without any repair. Only two C, type 11 and type 22. For our study, what we did with 34 million fixed cadaveric hearts were included and these were uh taken from undifferentiated genders. The details of the patients were available but genders were undifferentiated dissection was performed according to the standard methods and guidelines. And we noted the number of casts, number of uh cast height, number and depth of diotic sinuses and number of coronary osteo. And we measured all the measurements with V and we took the average measurements of three independent observers measurements. This is how we took the measurement with a minimal veneer calipers and coming to the results. The mean is in our uh study for the 30 uh individual's uh heart where 62.5 years, the circumference of mean circumference of diotic canola 68 plus minus 4.24. And in the results, what we can see our results corresponds it corroborated. Well, with all the existing studies, except in case of uh uh dryly flat valves. The distance of the opening of the coronary ostia from the sinotubular junction was la on the right side, which is pretty normal. But the single case which we obtained that is a bicuspid aortic valve. So we can clearly see it is a type zero type. According to SRS classification here, the opening of the aortic ostia was more than the sinotubular junction. And coming to the discussion, there are very few studies with regard to the morphometry XL Morphometry in cadavers with respect to the human aortic valve or the human aortic valve complex. These are the few studies which are available in the literature and our results correspond and corroborated well with uh with respect to the height with and the circumference with fa as at all the last study in the slide. And regarding the circumference, it corresponds with the Pravin Kumar et all. And these are the only few 5 to 6 studies which are available in the literature. And we noted that there are high variability which are noted between individuals. And we also noted that all the coronary were located well within the sinus. Then, uh to conclude from this small study, what we can uh Deif is that there is high variability of morphometric parameters uh of the human aortic valve, which can be due to racial age or gender differences. And this should be actually taken into account and while considering a prosthetic valve replacement, and moreover, as we have encountered with a bicuspid valve, that was in a 68 year old individual, which was pretty normal. And his uh medical records when we reviewed the day cause update was not related to the by valve. So whenever we screen a patient, the sons encounter of about uh sos encounter for a congenital bicuspid aortic valve should also be born in mind. So, thank you. And these are the references and these are my coauthors and the mentors who were involved in the study. Thank you so much. Thank you very much. Do we have any questions from the floor? Uh I'll, I'll kick off then. Um So with regards to um thank you, first of all, for an excellent study. It's very interesting to, to see, see that whole process and also the clinical relevance um downstream with the 30 participants cadaveric samples that you included in this study. Morphometrically, there would be a difference if there's a presence of, say, for example, heart failure did you control for those? Because I saw in your demographics you included age, I'm presuming they're all in Indian population. So you presumably controlled for ethnicity. But in terms of other potential confounding factors to affect your results, have you controlled for those? Oh, actually, when you see about, first of all, getting a cade is a difficult task, then 30 cade to get it somewhat difficult. But we normally we take out 10 calibers per year for the entire batch of the students. And this is this 30 calibers accumulated over three years. And uh the problem, the problem and the consideration which is to be taken here is whenever we fix the hard informal. So there is some sort of shrinkage so that may not actually corroborate well with what we can see by echocardiographic measurements. So that point is uh that point we understand. But whenever we correlated with the echocardiographic measurements, so it is somewhat, it is somewhat corroborating with uh 20% standard to 20% range, 20% range of the echocardiographic data. But as morphometry data was first in the literature, so we considered that we should do this and we should present so that further study can be carried out with a bigger number of samples, of course. And there's a very handy slide that you've put talking about where it sits within the existing literature base. Just to follow on from, from the last question, how did those other studies measure the morphometric properties of the cadaveric valves. Did they also use Averia caliper like like you did or did they use some different way? Uh in uh yeah. Uh most of the time uh we use the for all measurements, caliber is good enough, preferably a digital one. Wherever digital is not available, then we can use a manual one for circumference, cardiac seizure is available in the other studies that you've quoted talking about where your measurements sit. And I think they, they fairly accurately sit within the existing data set. Did they use any different ways to measure that distance or did they use the same as you? No, all all, all these Os they use calibers except one which was Pravin Kumar OL, they used cardiac cer cardiac CCIS is a uh it's, it's a kind of uh different ring like structure which will be placed into the lumen of the aortic valve from within that will give you an approximate, but that is also approximate that is not accurate via caliper. What gives the measurement is accurate but preferably with a digital one which we did not have at that time. Do we have any other questions? I think we've got a couple s start with Michael uh just to follow on from, from Alex. So I think towards the end, you, you've sort of pointed towards the clinical significance of that. Uh So what are your future plans to use this data? And, and do you have plans for any studies that, that correlate the cadaveric findings you have with uh sort of pre op or pre prosthetic valve measurements with echocardiogram. As you mentioned, our future plan, we have recently procured a ultrasound machine and with the ultrasound machine, we are planning that before dissection only, we will collect the data with the help of ultrasound Doppler. And we'll try to figure out we'll try to figure out and correlate the ultrasonographic data with the uh cadaveric data, which will be available after day section. But getting an echo in a cadaver is a difficult thing. And we are also planning to collaborate with our card uh CTS people. So cardiothoracic vascular surgeon, they will also assist here, but that study actually is uh awaiting ethical approval. Thank you. Perfect. Thank you very much. Thank you final call for GEOS. If he's around, er if not, then thank you all for your kind attention.