Abstract
BACKGROUND AND AIMS
There is incomplete information on the impact of a third dose of the SARS-CoV-2 vaccine in advance chronic kidney disease (CKD). The aim of the present analysis was to ...evaluate the kinetics of humoral response in the CKD spectrum (KT, HD, PD and ND-CKD) 6 months after completing the initial vaccine schedule. Some patients of each group received a third dose before 6 months, providing a pragmatic insight into real-world responses to different vaccine schedules in patients with advanced CKD not on dialysis, on dialysis or in KT recipients.
METHOD
The SENCOVAC study describes the humoral response and safety of different SARS-CoV-2 vaccines in a real-world setting in 3687 CKD patients: 787 kidney transplant (KT), 319 peritoneal dialysis (PD), 2297 haemodialysis (HD) and 284 non-dialysis-CKD (ND-CKD) patients. Anti-Spike antibodies were assessed in an efficacy analysis at 28 days (n = 1755), 3 months (n = 1386), and 6 months (n = 1018, of whom 628 had received a third vaccine dose). Adverse events (AEs) were registered during follow-up, including SARS-CoV-2 infections in the safety analysis.
RESULTS
Among the patients included in the efficacy analysis, KT recipients presented lower anti-Spike antibody titers than other CKD cohorts at 28 days and 3 months (P < .001 for all). A total of 943 patients 249 (26%) KT, 108 (11%) PD, 511 (54%) HD and 75 (8%) ND-CKD had negative baseline anti-Spike antibodies. Again, at 28 days or 3 months, KT recipients developed lower anti-Spike antibody titers than PD (P < .001), HD (P < .001) and ND-CKD (P< .001) patients. At 6 months, patients that had received a third vaccine dose had higher anti-Spike antibody titers than those without the third dose 1837 (507–9726) UI/mL versus 80 (19–409) ml/UI; P < .001 and this was evident in all CKD cohorts. Anti-Spike titers after the third dose were higher in patients boosted with mRNA-1273 than with BNT162b2 1710 (322–9615) versus 472 (34–2094); P < .001). At 6 months, in patients that had received a third dose, a positive humoral response (anti-Spike antibodies > 36 UI/mL) was achieved in 584 (93%): 94 (80%) of 118 KT recipients, 20 (100%) of 20 patients on PD, 436 (96%) of 455 patients on HD and 34 (97%) of 35 patients with ND-CKD (Fig. 1). Among patients without humoral response 3 months after completing the initial vaccination schedule, 72 (69%) seroconverted after the third dose (62% KT, 76% HD, 100% ND-CKD, all PD patients had a positive humoral response at 3 months). Independent predictors of a positive humoral response at 6 months were not-KT (HR for KT 0.26, P = .011), third dose (HR 22.9, P < .001), initial mRNA-1273 (HT 1.78, P = .017) and humoral response at 3 months (HR 26.2, P < .001). Breakthrough SARS-CoV-2 infections occurred in 1.1% of patients, and mortality was 14.6%, none after the third dose.
CONCLUSION
In the CKD spectrum, anti-Spike antibody titers continued to decrease from 3 to 6 months after complete vaccination, and KT recipients presented higher rates of negative humoral response at 6 months. A third dose of mRNA vaccine increased anti-Spike antibody titers but was still insufficient to spur a humoral immune response in at least 38% of KT recipients and 24% of patients on HD that lacked anti-SARS-CoV-2 antibodies 3 months post-initial vaccination. New strategies are urgently needed to protect CKD patients that remain negative for anti-SARS-CoV-2 antibodies, given the high mortality of breakthrough SARS-CoV-2 infections.
FIGURE 1:
Presence of anti-Spike antibodies during follow-up in the different CKD cohorts. Data expressed as % of patients with presence of anti-Spike antibodies (i.e. titer > 36 IU/mL).
GRAPHICAL ABSTRACT
Graphical Abstract
During 2006–2021, Canada had 55 laboratory-confirmed outbreaks of foodborne botulism, involving 67 cases. The mean annual incidence was 0.01 case/100,000 population. Foodborne botulism in Indigenous ...communities accounted for 46% of all cases, which is down from 85% of all cases during 1990–2005. Among all cases, 52% were caused by botulinum neurotoxin type E, but types A (24%), B (16%), F (3%), and AB (1%) also occurred; 3% were caused by undetermined serotypes. Four outbreaks resulted from commercial products, including a 2006 international outbreak caused by carrot juice. Hospital data indicated that 78% of patients were transferred to special care units and 70% required mechanical ventilation; 7 deaths were reported. Botulinum neurotoxin type A was associated with much longer hospital stays and more time spent in special care than types B or E. Foodborne botulism often is misdiagnosed. Increased clinician awareness can improve diagnosis, which can aid epidemiologic investigations and patient treatment.
Abstract
Aims
Our lab is interested in signals that trigger schwannoma tumour formation and we have previously shown that peripheral nerve injury triggers tumour formation in nerves with Schwann ...cell-specific loss of the Merlin (NF2) tumour suppressor. The Ras/Raf/MAPK/ERK pathway activity in myelinating Schwann cells is involved in nerve regeneration, causing demyelination and recruitment of inflammatory cells in areas of nerve damage, as well as dedifferentiation of myelinating Schwann cells into a repair-competent state. We have used a mouse model expressing a tamoxifen-inducible Raf-Kinase estrogen receptor fusion protein (Raf-TR) in myelinating Schwann cells of the PNS in either a control wild-type Merlin or Merlin-null background. This allows us to determine the effects of an injury-like signal in Schwann cells and its role in generating schwannoma tumour development. We present here a detailed analysis of the proliferation of Schwann cells within the nerve and morphological changes in PNS structure following Raf-TR activation.
Method
The P0-promotor driving the Raf-TR transgene is active in myelinating Schwann cells but inactive in the non-myelinating population, allowing specific targeting of the myelinating Schwann cell population. In addition to the Raf-TR gene, the mice exhibit a separate P0-promotor controlled Cre floxed NF2 gene which undergoes Cre-mediated recombinase at embryonic day 13.5 causing NF2 knockout in all developing Schwann cells. Mice aged between 4-6 weeks received intraperitoneal injections of either 2mg Tamoxifen or oil vehicle for 5 consecutive days and were then studied at either 10 or 21 days post-first injection. The peripheral nervous system of the mice was studied with fluorescent immuno-histochemistry staining, semithin sections and transmission electron microscopy (TEM) on sciatic nerves and dorsal root ganglia (DRG).
Results
Activation of the Ras/Raf/MAPK/ERK pathway in NF2 null Schwann cells led to higher rates of proliferation within sciatic nerves at 10d post-tamoxifen injections. At both 10d and 21d Raf-TR+ NF2-null mice sciatic nerve fascicles were visibly larger with significantly more cell bodies present than controls, however at 21d the rate of proliferation had reduced. In the DRG, proliferation was higher in Raf-TR+ NF2-null mice compared to controls, with proliferation remaining high at 21 days. Quantitative imaging of peripheral nerve semi-thins analysed to date showed no significant difference in the number of myelin rings present in the fascicles between different genotypes. Additionally, dual immuno-histochemistry staining with Myelin Basic Protein and EdU, markers for myelin and proliferation respectively, appeared to show proliferation in the non-myelinating Schwann cell population. Results from staining with other cell markers will also be presented, as well as a detailed analysis of nerve structure using TEM.
Conclusion
While developmental myelination of Merlin-null Schwann cells appears largely normal, the reaction of Merlin-null Schwann cells in the nerve to an injury signal (activation of the Raf-TR) is remarkably different from those of control nerves. The high levels of proliferation in Merlin-null Schwann cells may be indicative of a higher tumorigenesis potential. While the proliferation of Merlin-null cells does reduce over time in the sciatic nerve, further experiments are now testing whether there may be ongoing tumour growth at other locations in the nervous system that are associated with NF2 tumours in human patients.
Abstract
Aims
Meningioma is the most common primary intracranial tumour. Although ~80% are benign WHO grade I and show high rates of recurrence. Surgery is the main therapeutic approach, yet location ...can hamper complete resection and chemotherapies are ineffective. Moreover, accurate biomarkers for clinical management are lacking. Approximately 60% sporadic meningiomas harbour mutations in the NF2gene, while mutations in genes including TRAF7, KLF4, AKT1, SMO and PIK3CAhave been identified majority in the NF2-positive low grade-tumours. Moreover, mutations in TRAF7 mostly co-occur with a KLF4K409Q or with AKT1E17K mutation. The mutations and their molecular manifestations consequently affect the signalling pathways at the protein level. The molecular mechanisms behind meningioma tumourigenesis are still obscure and the identification of specific biomarker is necessary to enable their implementation in routine diagnostics and therapeutics. Therefore, we aim to identify novel biomarkers and therapeutic targets of genetically stratified low-grade meningioma by characterising the proteomic landscape.
Method
Frozen tumour samples have already been analysed for NF2-/- by next generation sequencing and genotyped for common mutational hotspots in non-NF2 meningioma such as TRAF7, KLF4 and AKT1 and grouped in to three different mutational groups: AKT1E17K/TRAF7, KLF4K409Q/TRAF7and NF2-/- and all these mutations will be compared to normal healthy meninges. For global proteomics, proteins were separated by SDS-PAGE followed by in-gel tryptic digestion and sample preparation for LC-MS/MS analysis. Raw mass spectrometry data files were processed by MaxQuant (1.6.2.10) and Perseus software (1.6.1.3). Quantitative phospho-proteomics was performed using TMT 10plex labelling approach followed by motif analysis using motif-X algorithm. GO enrichment analyses were performed using (DAVID) v6.8 against all human proteins. Potential candidates from expression data analysis will be validated via Western Blot and immunohistochemistry.
Results
We have quantified 4162 proteins across all mutational meningioma subgroups and normal meninges (n=31). Hierarchical clustering analysis showed distinct proteomic profiles of mutational subgroups revealing clusters of differentially expressed proteins. Comparative analysis showed 10 proteins were commonly significantly upregulated (log2 fold-change≥1; p<0.05) among all mutational subtypes vs. normal meninges, indicating proteomic landscapes of mutational subtypes to be highly variable. In contrast, 257 proteins were commonly significantly downregulated (log2 fold-change≤-1; p<0.05) and enriched with molecular functions including aldehyde dehydrogenase and oxido-reductase. Mutational subtype-specific analysis identified 162 proteins significantly upregulated in AKT1E17K/TRAF7 vs. remaining sample groups to be enriched in the oxidative phosphorylation pathway. However, only 14 and 7 proteins were commonly significantly upregulated in KLF4K409Q/TRAF7 and NF2-/- mutant meningioma subtypes respectively. Several of these up-regulated proteins including ANNEXIN-3, CRABP2, CLIC3 and Endoglin were already verified via WB. Lastly, analyses of 6600 phospho-sites (n=8) predicted regulatory kinases including CHEK1, CHEK2 and LCK.
Conclusion
Global proteomic and phos-phoproteomics analysis has led to the identification of proteins differentially expressed in mutant subtypes. Results of this study to date suggest that a proteomic approach is an effective tool to identify distinct patterns in genetically distinct meningioma subgroups. Further validation and functional verification (with inhibitory or knockdown approaches) of potential candidates will allow us to identify potential drug targets/biomarkers for meningiomas.
Abstract
Aims
Magnetic resonance imaging (MRI) is a valuable tool for non-invasive diagnosis of paediatric brain tumours. The rarity of the disease dictates multi-centre studies and imaging ...biomarkers that are robust to protocol variability. We investigated diffusion tensor MRI (DT-MRI), combined with machine learning, as an aid to diagnosis and evaluated the robustness of the imaging metrics.
Method
A multi-centre cohort of 52 clinical DT-MRI scans (20 medulloblastomas (MB), 21 pilocytic astrocytomas (PA), 11 ependymomas (EP)) were analysed retrospectively. Histograms for regions of solid tumour for fractional anisotropy (FA), mean diffusivity (MD), pure anisotropic diffusion (q) and pure isotropic diffusion (p) were compared to assess diagnostic capability. Linear discriminate analysis (LDA) was used for classification and validated using leave-one-out-cross-validation (LOOCV).
Results
Histogram medians for FA, MD, q and p were all different between tumor groups (P<.0001, Kruskal Wallis test). Median MD, p and q values were highest in PA, then EP and lowest in MB (P<.0001, Pairwise Wilcox test). FA median was higher for EP than PA (P=.004) with no significant difference between EP and MB (P=.591). ROC analysis showed that median MD, q and p perform best as a diagnostic marker (AUC= 0.92 to 0.99). LOOCV showed an overall accuracy of the LDA classification, ranging between 67% - 87%. FA values were highly dependent on protocol parameters, whereas pure anisotropic diffusion, q, was not.
Conclusion
DT-MRI metrics from multi-centre acquisitions can classify paediatric brain tumours. FA is the least robust metric to protocol variability and q provides the most robust quantification of anisotropic behaviour.
Abstract
Aims
Glioblastoma Multiforme (GBM) is one of the most aggressive primary brain tumors with poor prognosis (median survival 18 months) and no cure. Management strategies often involve maximum ...safe resection followed by chemoradiotherapy. There has been a move from managing such patients electively rather than the traditional model of treating them as an emergency. While this may have advantages, this can delay the time from presentation to operation. This delay has recently been further compounded by the current COVID-19 pandemic.
There is no data available as to whether the surgical delays that are currently occurring have an impact on patient care, and may outweigh the benefits of elective management on health services.
We aimed to conduct a single centre observational study to assess how long patients should be waiting prior to surgery. We hypothesised that the longer the wait, the higher the pre-operative complication rate and worse the outcomes.
Method
698 patients in a GBM database over a 5-year period (29/10/14- 8/11/19) were studied. All patient data was accessed via electronic patient records
Surgical delay was defined as the interval between date of being put on the waiting list (the date seen in the neuro-oncology clinic) to date of surgery.
Primary outcome measure was preoperative complications, which was categorised into transient neurological decline, stroke, seizures, diabetes/erratic blood sugars, emergency admission, others (e.g., cardiovascular compromise, steroid complications, blood disorders)
Inclusion criteria included: First presentation supratentorial WHO Grade 4 GBM confirmed on histology (this included histological variants such as Gliosarcoma and Epithelioid Glioblastoma), and all patients who had been seen in the neuro-oncology clinic prior to surgery.
Exclusion criteria included all patients who were not thought to have a GBM or high-grade glioma on initial imaging, those admitted as an emergency without being seen in a neuro-oncology clinic, recurrent or secondary GBMs.
Results
460 patients met the inclusion criteria in this study. There was a pre-operative complication rate of 14.6% (67/460). 55% of complications were due to a transient neurological decline (37/67) with 16.4 % (11/67) of patients presenting with seizures. For those with surgical delays ≤7 days pre-operative complication rates were 2.2 % vs 15.9% in those with delays >7 days, p value 0.012, Odds ratio 8.53 (95% CI 1.48- 88.09). Results were statistically significant in those with delays greater than 10 and 14 days (p values 0.0026 and 0.0004 respectively)
ROC Curve analysis revealed an AUC of 0.66 with sensitivities of 99%, 90% and 76% at surgical delays of 7,10 and 14 days respectively.
The median length of hospital admission in both groups of patients was 5 days (p= 0.2065)
All statistical analysis was carried out using Prism 9 and SPSS
Conclusion
In spite of unchanged length of hospital stay, we note a significant increase in pre-operative complication rates as a result of surgical delays greater than 7,10 and 14 days, which introduces an interesting debate in the merit of delaying operations for further assessment in clinic. Our objectives would be to minimize complication rate, therefore a high sensitivity i.e. true positive rate would be most desirable. The 99% levels achieved at 7 days In the ROC analysis lends weight to introducing policy to fast-track admissions for primary GBM patients.
Further directions could include assessing the impact reduced surgical services and redeployment might have had on complications rates and length of hospital stay on patients admitted over the COVID 19 pandemic.
Abstract
Aims
Molecular profiling is increasingly used in the diagnosis of CNS and non-CNS neoplasms. More than a quarter of all soft tissue tumours are characterized by specific recurrent ...chromosomal translocations which can be used as molecular signatures. With increasing frequency, EWSR1 rearrangements are found on both mesenchymal tumours and primary glial/neuronal tumours.
Here we present a case of intracranial myxoid mesenchymal tumour (IMMT), a rare tumour which is becoming more recognised in recent years, affecting mainly children and young adults, and rarely older adults. It can be found in intraaxial and extraaxial location, with frequent dural connection. The tumour is defined by the genetic hallmark of EWSR1-CREB family gene fusion. Including our case, 16 intracranial tumours with this gene fusion have been reported to date.
Our goal is to contribute further to the characterisation of the morphological spectrum, fusion partners and biological behaviour of rare EWSR1-CREB (non-ETS)-rearranged tumours of the CNS.
Method
Case: The patient is a 27 year old woman with a frontal lobe lesion, radiologically described as a tumour with dural attachment. She underwent surgical debulking, and tumour tissue was histologically examined with conventional immunohistochemistry. Additional genetic testing included targeted mutation screening, FISH, EPIC (Illumina BeadChip) methylation array and next generation sequencing. Histology showed a mitotically active neoplasm with relatively uniform cells, round nuclei and oligodendroglioma-like clear cell change, but no myxoid change. Glomeruloid microvascular proliferation and large areas of tumour necrosis were present. Immunohistochemistry was focally positive for GFAP, and negative or normal for synaptophysin, IDH1 R132H mutation, ATRX and p53. The ki-67 index reached ~20%. Sequencing of IDH1 and IDH2 did not reveal rare IDH mutations, and FISH did not show 1p19q codeletion. Testing for BRAF V600 mutation was negative.
Results
Although the histology initially suggested a diagnosis of oligodendroglioma, the integrated diagnosis was compatible with glioblastoma, IDH wildtype. Methylation array analysis by EPIC array did not result in classification of currently known entities, neither confirming glioblastoma, nor providing a new diagnosis, when analysed on both brain tumour and sarcoma classifier. This suggested a novel tumour entity not yet represented in the classifier algorithm. Additional testing including next generation sequencing revealed EWSR1 gene rearrangement with fusion partner ATF1 (EWSR1-ATF1 fusion). Based on this, the diagnosis was revised to the emerging new entity of ‘intracranial myxoid mesenchymal tumor’ (IMMT) characterised by EWSR1 fusion with members of the cAMP response element binding protein (CREB) family (ATF1, CREB1 and CREM). Subsequent immunohistochemistry demonstrated positive staining for CD99 and EMA but not desmin. The patient underwent various oncological treatments and is recurrence-free 3 years after initial diagnosis.
Conclusion
Histologically, IMMT demonstrates a spectrum of features that overlaps with other tumours, but often displays circumscribed growth, uniform cellularity, cytoplasmic clearing and variable myxoid change. The clinical behaviour of these tumours is not fully understood, however provisionally considered intermediate grade.
EWSR1-CREB family fusion is not specific but shared with a diverse group of extracranial tumours including soft tissue, salivary gland, odontogenic and myoepithelial tumours. Therefore, clinico-radiologico-pathological correlation is essential to achieve the final diagnosis, and ensure the absence of a primary tumour elsewhere.
Familiarisation with IMMT, its characteristic genetic profile and its as yet underreported natural course is crucial, as it can clinically mimic other intracranial tumours such as malignant meningioma or glioma but appears to behave less aggressively than high grade glioma.
It is also important to further our understanding of its optimal treatment through review of larger case series and global comparison of patient management.
Abstract
Aims
The development of melanoma brain metastasis (MBM) occurs in ~50% of metastatic melanoma cases, and significantly worsens prognosis to a median survival of 12.8 months. Melanoma is ...often reported as an arginine auxotroph due to transcriptional silencing of argininosuccinate synthase 1 (ASS1). Arginine deiminase (ADI) is a non-mammalian enzyme which depletes blood arginine by converting it to citrulline and ammonia, and in its pegylated form ADI shows clinical efficacy in the treatment of a number of cancers via exploiting tumour arginine auxotrophy, resulting in targeted arginine deprivation of tumour cells. While cutaneous melanoma is the prototype cancer for this therapy, studies to date have excluded central nervous system metastasis.
We have demonstrated that patient derived primary MBM models are sensitive to arginine deprivation in vitro, confirmed suitable clinical biomarkers of sensitivity, and established the mechanism of tumour cell specific cytotoxicity.
Method
Patient derived primary cultures of MBM were established and subject to treatment with arginine deprivation. Gene expression and methylation analysis was examined by RT-qPCR, western blot, Illumina mRNA sequencing and Illumina methylated DNA immunoprecipitation-sequencing (MeDIP-seq) on ADI treated and untreated samples. Cell death, cytotoxicity induction and caspase-3 and-7 recruitment was analysed using an Incucyte S3 live-cell imager, by fluorescently labelling cells with Incucyte Cytolight Red Rapid dye, Cytotox Green dye and Caspase-3/7 Green dye, and imaging cells every 2 hours over the course of 2 weeks. 3D spheroid growth and invasion was measured by culturing cells as tumour spheroids before treating with ADI, and imaging spheroids every 2 hours for 2 weeks using an Incucyte S3 live-cell imager. Nuclear leakage and mitochondrial morphology was observed by fluorescently staining treated and untreated cells with DAPI and MitoTracker Red, and imaging on a Leica DMi8 confocal microscope.
Results
Primary MBMs differentially express ASS1 at substantially lower levels than non-cancerous melanocytes, however some models are capable of upregulating ASS1 following confrontation with arginine deprivation. Despite this, long-term sensitivity of primary MBMs to arginine deprivation was observed in both 2D and 3D models. In addition, arginine deprivation was seen to inhibit MBM invasion in a 3D model – an important feature in MBM pathogenesis. Initially, autophagy was induced in arginine deprived MBM, however in all models the induction of cytotoxicity correlated with recruitment of caspase-3 and -7, and intrinsic apoptotic cell death confirmed. Nuclear leakage, and eventually complete nuclear destruction was observed, in addition to mitochondrial fragmentation.
Conclusion
Arginine deprivation is highly effective in reducing 2D and 3D MBM growth, as well as limiting invasion. While apoptotic cell death was observed in all models, the initial induction of autophagy could pose threat of resistance development in a clinical setting, and so combinational therapies with autophagic inhibitors and/or additional apoptotic inducers should be investigated. It is unclear whether nuclear leakage and mitochondrial degradation are the cause or product of apoptosis. Considering the strong clinical evidence for the use of arginine deprivation in non-CNS metastatic melanoma and the results of this study, arginine deprivation is a highly suitable treatment for pre-surgical MBM to limit invasion and increase resection, and for post-surgical continuation.
Abstract
Aims
It is common to have adjuvant chemo-radiotherapy after primary brain tumour resection. It is a known side effect that enhancing lesion could be seen in radiation territory after ...treatment, termed as pseudoprogression.
It has been a difficult task to distinguish brain between tumour recurrence from pseudoprogression after radiotherapy. Timing of occurrence of these can overlap. It is important to distinguish the two as management is completely different. Early intervention in recurrence could improve survival time while pseudoprogression could be self-limiting. Surgical resection of pseudoprogression could be counter-productive.
The radiological approach has been relying on multimodality investigation and close follow up. It has come to our institution notice that there is a new technique which could distinguish the two conditions efficiently. That's static permeability assessment method, also known as treatment response assessment maps (TRAMs). Our experience with it so far has been beneficial.
Method
This is a retrospective case series review of primary brain tumour treatment in our neurosurgical institution in 2020.
Two high resolution 3D T1-weighted brain MRI images were acquired after a standard dose of gadolinium based contrast agent was injected. The first acquisition began five minutes after injection, and the second began 60 – 105 minutes post contrast injection. The TRAMs technique is based on image subtraction that is post processed after acquisition.
The resultant subtracted image set was mapped to grey scale values, where voxels showing contrast clearance were light grey/white, and those showing contrast accumulation were dark grey/black. The zero value (i.e. no clearance or accumulation) was therefore mid-grey. Those with contrast clearance is associated with tumour recurrence.
TRAMs images were compared to serial follow up imaging and histopathology results to determine the diagnostic accuracy of the technique.
Results
We have identified 21 patients in this period who had concern of either of pseudoprogression or tumour recurrence/progression. There were 6 females and 15 males, mean age 51. There were 14 glioblastoma multiforme (GBM), 5 astrocytoma, 1 oligodendroglioma and 1 post radiotherapy arteriovenous malformation.
17 cases were found to have clear cut recurrence, pseudoprogression or mixture of both in TRAMS. These findings are backed up by histology or repeated follow up scan. 4 cases were considered as equivocal. In retrospect, these cases have challenging interpretation due to poor case selection. TRAMs could distinguish high grade transformation as well as detecting recurrence. In some difficult cases, it is found that both pseudoprogression and recurrence could happen together.
Conclusion
TRAMs is a useful adjunct to the multimodalities of diagnostic techniques in tricky situation. This has provided an efficient and easy to use tool for radiologists to come up with the answer. We are the first independent centre to report on this technique. This is still early days and fine-tuning of its use is still undergoing. It is clear this has saved precious resources and has given patients more suitable care. We think it would be beneficial for us to share our experience with others and hope to get future collaboration with other centres.
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