The spatial architecture of the lymphoid tissue in follicular lymphoma (FL) presents unique challenges to studying its immune microenvironment. We investigated the spatial interplay of T cells, macrophages, myeloid cells and natural killer T cells using multispectral immunofluorescence images of diagnostic biopsies of 32 patients. A deep learning-based image analysis pipeline was tailored to the needs of follicular lymphoma spatial histology research, enabling the identification of different immune cells within and outside neoplastic follicles. We analyzed the density and spatial colocalization of immune cells in the inter-follicular and intra-follicular regions of follicular lymphoma. Low inter-follicular density of CD8+FOXP3+ cells and colocalization of CD8+FOXP3+ with CD4+CD8+ cells were significantly associated with relapse (p = 0.0057 and p = 0.0019, respectively) and shorter time to progression after first-line treatment (Logrank p = 0.0097 and log-rank p = 0.0093, respectively). A low inter-follicular density of CD8+FOXP3+ cells is associated with Yeman B. Hagos and Ayse U. Akarca contributed equally to this study.

Many junior doctors have reported a lack of confidence in managing emergency conditions. However, there is insufficient literature summarising the current knowledge about the non-technical skills needed by junior doctors to tackle medical emergencies. This paper aims to identify the non-technical skills necessary for the management of medical emergencies by junior doctors. Three databases were systematically searched to identify relevant articles published between January 2000 and March 2020. In total, 8707 unique articles were identified and independently screened by at least two authors, using predetermined inclusion and exclusion criteria. A coding framework was applied to extract relevant data and for thematic analysis of the included studies. These methods have been performed following the PRISMA-ScR Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. There were a total of 13 articles included in the thematic analysis. The result of this review was the identification of several key non-technical skills: teamwork, communication, asking for help, challenging seniority, task prioritisation, decision-making, leadership and handling stress. In conclusion, lack of non-technical skills in junior doctors has a negative impact on patient care in a medical emergency. The training of junior doctors can be re-evaluated and designed to reflect the importance of these non-technical skills.

Over the past 50 years the capability of technology to improve surgical care has been realised and while surgical trainees and trainers strive to deliver care and train; the technological ‘solutions’ market continues to expand. However, there remains no coordinated process to assess these technologies. The FOS:TEST Report aimed to (1) define the current, unmet needs in surgical training, (2) assess the current evidence-base of technologies that may be beneficial to training and map these onto both the patient and trainee pathway and (3) make recommendations on the development, assessment, and adoption of novel surgical technologies. The FOS:TEST Commission was formed by the Association of Surgeons in Training (ASiT), The Royal College of Surgeons of England (RCS England) Robotics and Digital Surgery Group and representatives from all trainee specialty associations. Two national datasets provided by Health Education England were used to identify unmet surgical training needs through qualitative analysis against pre-defined coding frameworks. These unmet needs were prioritised at two virtual consensus hackathons and mapped to the patient and trainee pathway and the capabilities in practice (CiPs) framework. The commission received more than 120 evidence submissions from surgeons in training, consultant surgeons and training leaders. Following peer review, 32 were selected that covered a range of innovations. Contributors also highlighted several important key considerations, including the changing pedagogy of surgical training, the ethics and challenges of big data and machine learning, sustainability, and health economics. This summates to 7 Key Recommendations and 51 concluding statements. The FOS:TEST Commission was borne out of what is a pivotal point in the digital transformation of surgical training. Academic expertise and collaboration will be required to evaluate efficacy of any novel training solution. However, this must be coupled with pragmatic assessments of feasibility and cost to ensure that any intervention is scalable for national implementation. Currently, there is no replacement for hands-on operating. However, for future UK and ROI surgeons to stay relevant in a global market, our training methods must adapt. The Future of Surgery: Technology Enhanced Surgical Training Report provides a blueprint for how this can be achieved.

Purpose Axillary staging is an important prognostic factor in breast cancer. Sentinel lymph node biopsy (SNB) is currently used to stage patients who are clinically and radiologically node-negative. Since the establishment that axillary node clearance (ANC) does not improve overall survival in breast-conserving surgery for patients with low-risk biological cancers, axillary management has become increasingly conservative. This study aims to identify and assess the clinical predictive value of variables that could play a role in the quantification of axillary burden, including the accuracy of quantifying abnormal axillary nodes on ultrasound. Methods A retrospective analysis was conducted of hospital data for female breast cancer patients receiving an ANC at our centre between January 2018 and January 2020. The reference standard for axillary burden was surgical histology following SNB and ANC, allowing categorisation of the patients under ‘low axillary burden’ (2 or fewer pathological macrometastases) or ‘high axillary burden’ (> 2). After exploratory univariate analysis, multivariate logistic regression was conducted to determine relationships between the outcome category and candidate predictor variables: patient age at diagnosis, tumour focality, tumour size on ultrasound and number of abnormal lymph nodes on axillary ultrasound. Results One hundred and thirty-five patients were included in the analysis. Logistic regression showed that the number of abnormal lymph nodes on axillary ultrasound was the strongest predictor of axillary burden and statistically significant (P = 0.044), with a sensitivity of 66.7% and specificity of 86.8% (P = 0.011). Conclusion Identifying the number of abnormal lymph nodes on preoperative ultrasound can help to quantify axillary nodal burden and identify patients with high axillary burden, and should be documented as standard in axillary ultrasound reports of patients with breast cancer.