المؤلفون: McKinley, N., McCain, S., Convie, L., Dempster, M., Clarke, M., Kirk, S., O’Kane, Rebecca, O’Brien, Anna, Martin, Tim, Waterfield, Thomas, Watson, Chris, Moore, Rebecca, Ferris, Kathryn, Tonry, Claire, Watt, Alison P, McGinn, Claire, Foster, Steven, Evans, Jennifer, Lyttle, Mark D, Ahmad, Shazaad, Ladhani, Shamez, Corr, Michael, McFetridge, Lisa, Mitchell, Hannah, Brown, Kevin, Amirthalingam, Gayatri, Maney, Julie-Ann, Christie, Sharon, McCorry, Eimear, Hogg, Meadhbh, Ferguson, Gemma, Dunwoody, Ian, Coulson, Rachael, Crompton, Rachael, Carville, Ruth, Slevin, Niamh, Cairns, Rebecca, Hickland, Patrick, Smyth, Jemma, McKeeve, Mark, McLaughlin, Diarmuid, McLoughlin, Peter, O’Brien, Scarlett, Stewart, Sarah, Harty, Megan, Gribbon, Catherine, Hayes, John, Tran, Christina, Graham, Michael, Hamilton, Heather, Hunter, Claire, McCarron, Eamon, Cody, Neil, Clements, Jamie, Leonard, Colin, Khan, Adeeb, Lazim, Mohamad, Lim, Su, Ansong, Sophia, Bradley, Beth, Roy, Dorina, Bojail-Alade, Rachel, Murphy, Tom, Clements, Jake, Aljanadi, Firas, Currie, Rachel, Martin, Serena, Shaw, Timothy, Craig, Sarah, Kelly, Niamh, Mullan, Ger, Tumelty, Maria, Faraz, Ahmed, Khan, Mohamad Noah, Mercer, Alex, Redenbaugh, Vyamka, McAnallen, Susan, Grimes, Karl, Donnelly, Sinead, Spence, Niamh, Mayne, Richard, Bamford, Jordan

المصدر: The Ulster Medical Journal

مصطلحات موضوعية: Abstracts, Oral Presentation

الوصف: Introduction: In 2014, the General Medical Council introduced the concept of resilience training to the medical school curriculum. Aims: This cross-sectional study assesses resilience, coping mechanisms and professional quality of life in medical students. Methods: Medical students at Queen’s University Belfast (HUB) were invited to participate in an anonymous online survey during 8 weeks (2019), comprising three validated psychological scales: Connor-Davidson Resilience Scale (CD-RISC), Professional quality of life scale (ProQOL V) and BRIEF COPE. Results: 324 HUB students (years 1-5) participated (response rate: 25%). Mean CD-RISC score was 68.5 (SD 11.5) (low for resilience). Mean burnout (BO) was 26.9 (6.0) (worse than population mean: 20), mean compassion satisfaction (CS) was 37.8 (5.8) (similar to population mean: 37) and mean secondary traumatic stress (STS) was 22.3 (5.9) (worse than population mean: 11). Pre-clinical students had higher compassion satisfaction than clinical students (p=0.01). More than a quarter (27.4%) of medical students had high burnout and 21 (8%) had high BO, high STS and low CS. Common coping mechanisms were planning and active coping. Discussion: The high levels of burnout in HUB medical students suggest that they may benefit from interventions to develop resilience and improve professional quality of life..
Problem: The on call weekend team is primarily in place to deal with emergencies, however a large amount of their time is spent performing routine jobs left over from weekdays. Strategy for change: To reduce the number of routine tasks left for weekend staff to complete by 25% by March 2020 Measurement of improvement: Initial discussions with foundation doctors revealed that the most common routine tasks were IV cannula, bloods to be taken and checked, insulin prescriptions. Baseline audit of number of tasks left for weekend staff to complete (4 weeks), then weekly audit, using ward jobs list as reference. We adapted and introduced the known F.R.I.D.A.Y.S. checklist. We used the PSDA model and implemented 3 cycles in order to achieve improvement. Effects of change: Baseline data revealed an average of 25 routine jobs left to be carried out. By end of PDSA cycle 3, there was an average of 10 jobs left. Discussion with juniors and nursing staff revealed that they were happier with less bleeps, nurses were able to complete tasks more timely and overall satisfaction had improved. Discussion: Overall F.R.I.D.A.Y. checklist was a successful tool for reducing weekend routine tasks. When implemented correctly, it reduced the number of routine jobs (40% reduction in our ward), improved communication between team and staff and improved patient safety.
Introduction: Studies based on molecular testing of oral/nasal swabs underestimate SARS-CoV-2 infection due to issues with test sensitivity and timing of testing. Aims: To report the presence of SARS-CoV-2 antibodies, consistent with previous infection, and to report the symptomatology of infection in children. Methods: This multicentre cohort study, conducted between 16th April - 3rd July 2020 at 5 UK sites, recruited children aged 2 to 15 years of age. Participants provided blood samples for SARS-CoV-2 antibody testing and data were gathered regarding unwell contacts and symptoms. Results: 992 participants were included in the final analysis. The median age was 10·1 years. There were 68 (6.9%) participants with positive SARS-CoV-2 antibody tests indicative of previous SARS-CoV-2 infection. Of these, 34/68 (50%) reported no symptoms. The presence of antibodies and the mean antibody titre was not influenced by age. Following multivariate analysis 4 independent variables were identified as significantly associated with SARS-CoV-2 infection. These were: known infected household contact; fatigue; gastrointestinal symptoms; and changes in sense of smell or taste. Discussion: The symptoms of SARS-CoV-2 infection in children were subtle but of those reported, fatigue, gastrointestinal symptoms and changes in sense of smell or taste were most strongly associated with antibody positivity.
Introduction: Prior to the pandemic there were already difficulties in delivering postgraduate medical education (PGME) with attempts to balance service delivery and training requirements. Social distancing guidelines imposed due to COVID added the final blow to traditional postgraduate teaching. Aims: We wanted to reintroduce a PGME programme that was: - safe - accessible to all - sustainable. Method: We opted to deliver teaching remotely. Numerous platforms were trialled with Zoom being preferred. Initially we focused on one weekly session and with initial positive engagement momentum built and we systematically increased the opportunities available. Results: There is now a comprehensive PGME programme within the Southern Trust with all activities available remotely. There have been up to 50 participants availing of multiple sessions per week across all sites and specialties. Feedback has been positive: - 100% liking remote teaching format - 100% viewing remote delivery as safer alternative. Discussion: For the majority of trainers and trainees this was a new concept requiring adaptability and overcoming barriers. However this innovative approach has been positively received. We recognise that this is a work in progress and seek feedback, evolve with alterations and addition of new elements.
Introduction: Faced with a pandemic, educational activities stopped with teaching and training a distant memory. However, we recognised that an appetite for learning persisted and that our commitment to lifelong learning must never stop. EDHEAD was born to put education back on the agenda. Aims: - Offer platform for paediatric healthcare professionals to access everyday clinical problems answered in evidence-based format using 5-minute peer reviewed, quality-assured videos.- Offer leadership and educational opportunities as part of lifelong commitment to learning.- Improve team moral by incorporating technology and humour within educational videos, with video element allowing for social distancing. Method: The EDHEAD team created a ‘wish-list’ of clinical questions. All members of the paediatric team were invited to prepare 5 minute videos based on guidance provided. These were submitted electronically and EDHEAD team peer reviewed, quality assured, edited and uploaded to shared platform. Results: We have had great engagement from multiple team members with the catalogue of videos steadily increasing. Feedback is collated to inform future clips. Discussion: We have created a pandemic-proof approach to education! We plan to share learning and evolve by collaborating with other departments.
Introduction: The Academic Foundation Programme (AFP) provides foundation doctors with protected time for the development of the skills and aptitudes required in academic medicine. The NI AFP programme was established in 2008 with 9 AFP posts each year. To date, there has been no analysis of this cohort. Aims: We sought to describe the academic and career outcomes of the Northern Ireland AFP cohort. Methods: Anonymised data regarding AF2 post-holders from 2008-2018 was obtained from HUB and NIMDTA. A structured questionnaire was distributed to this cohort of 99 AFP trainees. Results: 41 males (41.4%) and 58 (58.6%) females completed the AFP with the majority (59.6%) being HUB graduates. The response rate was 44.8%. Of the respondents, 76.9% have presented and 46.2% have published their AFP project with 61.5% applying for a higher degree or academic position. 86.6% agreed that completion of the AFP has enhanced application for future training programmes and 76.9% believe that the AFP has influenced their intended or actual career pathway. Discussion: Our survey shows that participation in the NI AFP programme leads to research outputs, enhanced career opportunities and a clear pathway to academia
Background: Continued medical education (CME) for postgraduate Obstetrics and Gynaecology trainees is normal delivered by the consultant body in a face-to-face capacity, on a bi-monthly basis. Due to COVID-19, these teaching sessions were not able to occur. With the current pandemic it is important that we explore other options for delivering CME to postgraduate trainees including virtual delivery. Aims: To assess the viability of the consultant body delivering a virtual CME programme for obstetrics and gynaecology trainees in Northern Ireland Methods: Survey monkey sent to consultants to find out about their experience with virtual teaching and whether they would be comfortable teaching on a virtual session. Results: 41 consultants completed the virtual teaching survey, 67% had never used video-conferencing to teach doctors. 40% were not confident in sharing presentations and 92.5% in managing break-out sessions. 34 consultants would consider delivering CME if this became the standard teaching platform, with 82% having no objections to the sessions being recorded for trainees unable to attend. Conclusions: Consultants are keen to provide this method of teaching but require further training to deliver. Having consultants teach via zoom improves access to a diverse and rich knowledge base for postgraduate trainees.
Background: Obstetrics and Gynaecology trainees in Northern Ireland attend bi-monthly postgraduate continued medical education (CME). COVID-19 restrictions meant these teaching sessions could not occur. Collaborating with senior trainees we developed a virtual postgraduate teaching series via ZOOM. Aims: To assess the viability of virtual CME for obstetrics and gynaecology trainees in Northern Ireland. Methods: Survey monkey sent to participants/non-participants exploring experiences and attitudes towards this teaching series. Results: 33 trainees completed the participant survey, with most attending 1-2 ZOOM teaching sessions. Over 50% had never attended teaching via video conferencing before. 66% of trainees were confident in using video conferencing for learning. 27 participants agreed that pre reading for each topic added to their learning. All participants agreed that CME should be mapped to the current RCOG curriculum. 87% of participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME. 15 trainees completed the non-participant survey, with 93% of trainees stating that work commitments meant that they were unable to attend the ZOOM sessions. Interestingly 2 trainees were unable to work ZOOM. 73% of non-participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME, with 80% stating that if sessions were recorded and they were unable to attend, that they would use the recording for learning. Conclusions: Virtual teaching is an appropriate method to provide the necessary volume and quality of postgraduate medical education.
Introduction/Aims: This study explored what is known about training for rare, time-critical procedures in Emergency Medicine. Methods: A scoping review of the published literature was performed, 40 papers were found which discussed aspects of training in rare, time-critical procedures, relating to Emergency Medicine. Results: Gaining experience in rare, time-critical procedures is challenging as trainees have limited exposure during their training. Skills gained decay quickly, so maintenance of skills is difficult. Simulation is widely practised; it is seen as an ethical imperative as skills can be gained and maintained without putting patients at risk of harm. Skills need to be practised frequently to combat skill decay; the optimum frequency of practice has not been established. New educational techniques may help maintain competency if incorporated into educational programmes. Discussion: There are many challenges to gaining and maintaining skills in performance of rare, time-critical procedures in Emergency Medicine. Frequent practice is required, and this should take the form of simulation in the absence of frequent clinical practice. Further research is needed into the best type of simulation for specific time-critical procedures and into what impact simulation training has on clinical outcomes.
Introduction: As junior doctors we remember the difficulties with starting out as an FY1. Although Trust induction is comprehensive, in our experience, there is minimal induction covering the intricacies of daily workings of the ward and what life is really like as an FY1. Aim: To provide a peer-to-peer induction programme that is Trust specific but also role specific. We wanted to share invaluable tips gained through experience and ease transition into working life. Method: Four sessions were offered to all incoming FY1s. Given the current climate these were facilitated remotely. Current FY1s were recruited to deliver the sessions. To determine content we asked current FY1s to reflect on what they wished they had known when starting as a doctor and incoming FY1s were surveyed about what they wanted included. Results: Of the incoming FY1s that availed of the sessions 100% found them to be enjoyable, useful and increased their confidence for starting their new roles as junior doctors. Discussion: This initiative highlights the necessity and usefulness of a peer-to-peer element of induction. To improve this for further years we are currently in the process of seeking additional feedback.
Introduction: The outbreak of a novel coronavirus in 2020 required significant and rapid changes to standard operating procedures within the psychiatric inpatient unit, in order to protect patients as well as staff. Aims: To develop standard operating procedures (SOPs) for managing Covid-19 positive patients, and to refine these and train staff using simulation based education. Methods: Phase 1 of the simulation exercise involved “run-throughs” of the SOPs with the MDT on a closed ward to identify latent safety threats and issues with equipment and supplies etc. SOPs were refined based on the issues identified and these were used in Phase 2 which focused more on training redeployed staff and managing anxiety. Results: Feedback was obtained using a staff survey. 85% felt that the SOPs had improved after their involvement in the Sim, 87% felt more confident about managing Covid positive patients, and 81% felt less anxious after attending the Sim. Discussion: Simulations are a useful way to test new care pathways and can identify latent safety threats, engage staff in improvement, and provide a forum for raising concerns and managing anxiety.
Introduction: There are over 1.2 million chronically lonely people in the UK. Admission to hospital increases the prevalence of loneliness. Loneliness can significantly increase morbidity and mortality. Aims: The aim of this project was to reduce loneliness by an increasing awareness, befriending scheme, posters and a loneliness protocol. Methods: Use of patient surveys with qualitatitive and quantitive data. Open and closed questions used with implementation of a UCLA loneliness scale. Results: Each intervention decreased the median UCla scale, the befriending scheme had the greatest effect on Ucla reduction. Discussion: Due to social distancing policy, there has been a reduction in number and duration of visitors. Patients described loneliness as loss of purpose, days being very long and not feeling close to others. Many felt a shame associated with loneliness. Patients were reluctant to tell hcps about loneliness due to fear of offending staff. Loneliness was seen by many patients as a natural part of growing old. Patients felt face masks reduced ability to engage with Hcps.
Problem: Foundation doctors are contacted regularly out of hours to complete routine prescribing tasks that should be completed in normal working hours. Strategy for Change: The “KIWI Checklist” is a communication tool designed to be used at ward level to ensure completion of 4 routine prescribing tasks within normal working hours. These include: rewriting of Kardexes; Insulin Prescribing; Warfarin prescriptions and IV fluid plans. Measure of Improvement: The primary outcome measure for this project was the percentage of bleeps out of hours received by FY1 doctors that were for routine prescribing tasks. Effects of Change: Data was collected over 10 weeks from October 2019- December 2019. The KIWI Checklist was introduced to 2 wards in BCH after week 5. Ward 7N had a reduction in the percentage of bleeps out of hours that were for routine prescribing tasks from 40% to 0% and Ward 9N had a reduction from 70% to 20%. Discussion: A simple checklist at ward level reduces the burden of prescribing out of hours, improving patient safety. Senior medical and nursing leads within have approved the checklist for rollout across a number of divisions in BHSCT.
Problem: The need to reduce the number of general surgical inpatients to create capacity in preparation for the COVID-19 pandemic. Strategy for change: Restructuring of our emergency general surgery (EGS) service, including establishing an enhanced ambulatory service, and non-operative management of selected conditions. Measurement of Improvement: Patients referred by the emergency department were prospectively identified over four weeks from the date of reconfiguration (COVID) and compared to patients retrospectively identified from the equivalent period the previous year (Pre-COVID), followed up for 30 days. Data was extracted from handover documents and electronic care records. Effects of Change: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Rates of admission decreased (78.1% to 41.7%) whilst there were increased rates of ambulation (7.1% to 17.3%) and discharge (6% to 22.6%). Duration of admission decreased (6.9 to 4.8 days), and there were fewer operative and endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39), telephone reviews (0 to 39), and use of early CT to facilitate discharge (5% to 34.7%). There were no differences in 30-day readmission or mortality in any group. Discussion: Restructuring of our EGS service in response to COVID-19 facilitated a 62.7% reduction in inpatient bed days (1519 to 567) whilst maintaining patient safety.
Problem: Sleep, both in the recommended duration and quality, is a controversial area. However, it is acknowledged that sleep plays an important role in recovery from illness. Hospital wards are loud, busy and bright – an environment not conducive to sleep. Strategy for change: We sought to tackle two issues negatively impacting patient sleep – noise and light. We offered ear plugs (PDSA cycle 1) and ear plugs with an eye mask ( PDSA cycle 2) aiming to improve the amount of sleep on the respiratory ward in BCH by 25% in a 4 month period. Measurement of improvement: We distributed qualitative and quantitative patient surveys prior to our intervention and after. We compared the data from these surveys. Effects of change: PDSA cycle one (ear plugs) showed evidence of a significant improvement in patient sleep – achieving our aim. PDSA cycle two did not show that the use of both ear plugs and eyes masks had a significant impact than ear plugs alone. Discussion: These were simple changes which could reduce consequences of sleep deprivation such as delirium and hasten patient recovery.
Problem: No collection of data on morbidity for discussion occurring in the EMSU Strategy for change: Implementation of morbidity function on the excel handover template already in use, before discharging any patient from the handover a prompt would appear for consideration of morbidity discussion. Teaching to all junior staff about the morbidity function on the excel handover was then provided. At the beginning of the placement a core trainee was designated as the responsible person for collection of morbidity data. Measurement of Improvement: From April to June 0 morbidity cases were discussed prior to change, from July to September 49 cases were discussed. The change was sustained with 45 cases discussed from October to December. Discussion: The problem with morbidity collection was compounded by constant rotation of senior staff. Giving the responsibility of improving the morbidity collection and discussion to a core trainee, who was permanently based in the EMSU, empowered them to organise the rest of the team and make a sustained change, provided permanent point of contact for the team on site. The prompt on the excel handover sheet ensured that patients were not removed from the handover without consideration of morbidity status.
Problem: Poor handover process in place for postnatal ward; Handover was handwritten via a ward diary. Often due to lack of space, unclear handwriting or no verbal handover taking place – there were a number of antibiotic doses not given for suspected neonatal sepsis, missed clinical reviews of infants amongst other concerns. Strategy for change: Introduced a new typed & printed handover template and face-face handover to occur between each change of shift. Senior member of staff (Registrar/Consultant) met with post-natal ward SHO mid-morning to address any issues. Measurement of Improvement: Staff questionnaires (initial, re-audit x2 over 6 months) to nursing and medical teams and the recording of any incident report forms completed. Effects of Change: No incidents of missed antibiotics/clinical reviews/concerns were recorded after the introduction of the typed, formal face-face handover. Improved staff morale overall amongst staff – clear, face-face handovers were now expected and became the norm. Staff felt more supported as a result of a formal meeting with registrar/consultant midmorning to trouble-shoot any issues. Discussion: As a result of our QI project, babies were better cared for and were placed at less risk. The project has demonstrated that clear communication at all times has the ability to enhance patient care and staff wellbeing.
Problem: Central Venous Access devices (CVADs) are common on medical and surgical wards. Complications including blockage and infection are relatively common. These need addressed appropriately to prevent loss of IV access, days without TPN or line sepsis. There is limited training in hospitals, therefore junior doctors can be unsure in dealing with issues that arise. Strategy for Change: To improve junior doctor aptitude and confidence in managing CVADs, a survey was prepared which consisted of two sections. Firstly one which junior doctors’ rated their confidence on a 1-10 scale and a further section which tested technical knowledge of CVADs and their associated guidelines. An education session was then set up with information provided by the Infusional Services team. Measurement of Improvement: The survey was re-taken after the education session to assess areas which improved and areas which still required attention. Effects of Change: Junior Doctor confidence increased 36% overall for all 3 types of CVAD. There was a 57% improvement in the technical knowledge of CVADs and management of complications. Discussion: Both junior doctor confidence rating and technical knowledge greatly improved after the education session. To ensure retention of knowledge we plan to re-audit. Further measures for implementation include easy access to CVAD protocols on the trust intranet.
Problem: During the COVID-19 pandemic, surgical service and practice has been adjusted in order to reduce acute surgical admissions. Acute appendicitis accounts for a significant proportion surgical admissions in the UK. Strategy for Change: Intercollegiate general surgery guidance during the COVID-19 pandemic advised appendicitis should be managed conservatively, or with an open appendicectomy if indicated. Our aim was to determine the efficacy and safety of our ambulation service in the conservative management of acute uncomplicated appendicitis. Measurement of Improvement: Data was collected prospectively from 30th March 2020 – 16th August 2020 on all patients presenting with suspected appendicitis. Stable patients with clinically suspected or CT-proven appendicitis were discharged with oral antibiotics as per trust guidance. Readmissions for ambulated patients were recorded. Effects of Change: 190 patients presented with suspected appendicitis (range 5-71years). 49.4% patients were deemed suitable for ambulation on initial assessment, 22% of which had a CT confirmed diagnosis on discharge. 65% of the ambulated patients underwent a telephone review within a 72 hour window. 13.8% of patients represented within a 30 day period, 7.4% of which proceeded to appendicectomy. Discussion: Patients with uncomplicated appendicitis can be safely managed with antibiotics out of hospital, with low representation rates.
Reasons for criterion chosen: Belfast’s Rheumatology Department facilitates infusions of biologics on a daily basis. Usual protocol was that patients had routine bloods taken on arrival. We evaluated guidance on drug monitoring, according to British Society of Rheumatology and Summary of Product Characteristics, finding that frequency of blood monitoring was surplus to requirement. We recorded bloods taken and were struck by the unnecessary frequency of blood monitoring. We constructed a proforma of correct frequency of drug monitoring according to the British Society of Rheumatology and Summary of Product Characteristics. A one page poster of guidance. Data Collection: Frequency of blood monitoring checked in a two week period went from 80% to 10% with use of our guidance poster. Conclusion: Difference in cost of blood tests sent, in a two week period, after implementation of monitoring guidance was £1681.29. It is important to continually assess whether current practise is correct or could be updated. This project has demonstrated how reviewing guidance can lead to significant saving. This project will save at least £43,713.54, in one Rheumatology Unit, per year.
Problem: No allocated time for morning handover at Lagan Valley Hospital contributes to anxiety among F1 doctors. It can result in the night-F1 staying beyond their shift to handover to each ward individually; leads to unfamiliarity of sick patients and outstanding tasks; and has the potential to compromise patient safety. Strategy for change: We propose designating time each morning at 9am for handover between F1 doctors. It will follow a standardised format including: Sick patients Outstanding investigations Deaths overnight Any other outstanding issues/concerns This qualitative project aims reducing anxiety among F1 doctors; familiarise the day-F1 with patients on their ward and improve patient safety by minimising errors associated with poor handover. Measurement of improvement: Qualitative pre- and postintervention questionnaires were completed by F1 doctors in relation to job satisfaction, confidence and the perceived impact on patient safety. Effects of change: All respondents felt that the proposed F1 handover improved confidence among F1 doctors and minimised disruptions in patient care. Discussion: Shift patterns and lack of a formal handover between doctors can disrupt continuity of patient care compromising patient safety. Formal handover ensures safe transfer of patients between doctors and reduces anxiety among F1 doctors.
Problem: Given the COVID-19 pandemic, reduce face-to-face consultations to only complex burns or those necessitating hospital admission to Northern Ireland’s Regional Burns Unit. Strategy for Change: Establish a virtual burns service, using a combination of telephone calls, emails, photography and Microsoft Teams software. Our initial adoption of the system was audited during April and May 2020. Through Plan-Do-Study-Act (PDSA) methodology an electronic tertiary-referral proforma was subsequently created prior to closure of the audit cycle in July 2020. Measurement of Improvement: 1. Reduction in face-to-face consultations 2. Completeness of burns referral data (including: demographic, clinical and initial management) both pre- (April & May 2020) and postintroduction (July 2020) of e-Referral pathway. Effects of Change: From the start of lockdown a significant reduction in face-to-face consultations was observed. Given the increasing use of virtual telephone consultation only 19.5% of the unit’s total referrals (April, May and July) were either reviewed face-to-face in dressing clinic or admitted. Following implementation of the e-Referral pathway an improvement in both the detail and completeness (95%) of patient referral information was achieved. Discussion: Our experience demonstrates that virtual burns care can be safely and rapidly adapted in response to evolving need. The potential role of virtual care post-COVID, in selected patients, is an exciting one.
Problem: Hospitalisation is associated with a deterioration in patient oral health. The pharmacy team can advise on management of common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Survey data revealed the King’s College Hospital (KCH) pharmacy team had low confidence in these areas and were unaware of where to access appropriate guidance. Strategy for change: Two teaching sessions on management of oral conditions were planned and delivered to the pharmacy teams at two KCH sites. Health Education England’s (HEE) Dental Factsheets for the Pharmacy Team were distributed to all team members, with reference copies kept in each department. Measurement of Improvement: An online questionnaire was circulated to measure confidence in managing common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Effects of change: Confidence in managing all the oral conditions covered showed significant improvement. 75% of participants would consider using HEE’s Dental Factsheets for the Pharmacy Team for further guidance. Discussion: This project enabled and empowered the pharmacy team to take a more active role in improving patient oral health. Future work lies in evaluating the patient impact of these measures.
Problem: During the Covid pandemic information for pregnant patients was updated regularly and printed leaflets were often out of date. Strategy for change: Dynamic QR codes were introduced to antenatal clinics across Northern Ireland. Dynamic codes allow for the destination of a code to be changed without changing the printed code. This allows patients to scan the codes on their phones, providing up to date patient information on their device. Measurement of Improvement: The exact number of codes scanned was recorded digitally. A regional staff and patient survey was undertaken. Effects of change: Both staff (82%) and patients (81%) were keen to provide and receive information leaflets via QR codes. Intervention 1 = printed laminated codes used in clinics – 10 scans per day over 4 weeks Intervention 2 = targeted education sessions at clinics – 17.7 scans per day over 3 weeks Intervention 3 = codes included in patient notes – 26.6 scans per day over 3 weeks. Discussion: This 3 cycle QI project was devised due to the challenges created by the Covid pandemic. QR code use has increased with each intervention saving resources and providing patients with up to date information.
Problem: Coronavirus Lockdown meant all non-emergency essential services were reduced. Face-to-face epilepsy clinics had to be cancelled. Strategy for change: Instead of cancellations, all scheduled epilepsy clinic reviews were conducted by pre-arranged telephone call. Measurement of Improvement: DNA rates during the virtual clinic review period were compared with face-to-face review clinics during the same 6 month period last year. We found a 37% reduction in non-attendances when using telephone reviews. Qualitative feedback from parents favoured the approach in terms of convenience and stress reduction, but highlighted reservations regarding variable signal quality, and wanting reassurance of a doctor physically seeing their child. Effects of change: Ongoing use of telephone reviews for this stable patient population. Discussion: Successful improvement in attendance rates and positive feedback from patients indicates telephone clinics are an effective form of review. A combination of face-to-face and telephone reviews is likely to be implemented. This raises questions; who is eligible for this review format and how to we decide? Are any other clinics amenable to this pattern? What are the benefits for the clinician and the financial benefits for the NHS?
Introduction: What appears on the skin can be a manifestation of systemic disease; an infectious, autoimmune or malignant process. Not all new inpatient rashes are drug-related. Description of case: We report a 53 year old female inpatient, being treated for decompensated alcoholic liver disease, who developed a widespread, polymorphic rash, with crops of sterile vesicles. Rifaximin had been newly commenced. Drug eruption was a differential. However, histological findings from a skin biopsy were in keeping with herpes virus infection, with background erythema multiforme changes. Subsequent viral PCR confirmed varicella zoster. Dermatology review confirmed a diagnosis of disseminated herpes infection. Aciclovir, potent topical steroid, emollients and anti-histamines were recommended. Discussion: Confirmation of an alternative diagnosis to a drug reaction enabled the patient to continue on necessary medication. Dual pathology may be present. Her confusion and fluctuating cognitive state was proven to be due to encephalopathy on EEG, thought to be explained by hepatic encephalopathy. Herpes encephalitis may have contributed. Immunosuppression puts patients at risk of VZV. This patient had a prolonged ICU admission, and background of chronic alcoholism and poor nutrition. Allow initial presumptive diagnoses to be challenged, with emerging clinical details.
Introduction: Spinning is a popular high-intensity training (HIT) exercise which is increasingly reported as a cause of rhabdomyolysis. Rarely, rhabdomyolysis can lead to limb-threatening acute compartment syndrome (ACS) requiring urgent fasciotomy. Description: We describe spinning-induced rhabdomyolysis in three young women, two of whom required emergency bilateral fasciotomies for ACS. None had neurovascular compromise at the time, and all three had a good outcome. Discussion: Patients with exercise-induced rhabdomyolysis present with severe pain, swelling, and weakness of affected muscle groups accompanied with a rise in serum creatinine kinase (CK). Inadequate physical conditioning and increased duration and intensity of exercise are all associated with a higher risk of rhabdomyolysis. Although in itself it is a recognised phenomenon, diagnostic consideration should be given to occult metabolic myopathies in a young patient population. Learning points: Early involvement of senior / experienced surgeons leads to early diagnosis and rapid intervention. Compartment syndrome can occur without neurovascular compromise. The public and exercise instructors should be aware of the risks to new spin-class attendees, and how to mitigate these risks.
Introduction: COVID-19 infection can result in a severe viral pneumonia clinically indistinguishable from acute respiratory distress syndrome (ARDS). Mortality rates of mechanically ventilated patients are high and it is suggested that heterogeneity of disease pathophysiology means established therapeutic approaches to ARDS are not applicable in its management. Aim: This case series aims to describe the physiological and outcome data of patients with Covid-19 who were admitted to Intensive Care (ICU) and treated with standardised evidence based guidelines for ARDS. Method: Retrospective case review of all patients admitted to Intensive Care within the Belfast trust with Covid-19 between March and June 2020. Results: 45 patients were included, 37 (82.2%) were male with a mean age of 55. 42 patient (93.3%) fulfilled ARDS criteria at time of admission. Clinical management was highly compliant with institution evidence-based ARDS guidelines. Median length of ICU stay was 14 days and ICU mortality was 8.9%. Discussion: COVID-19 fits within the spectrum of ARDS and results in similar respiratory physiology. Adherence to established evidence based therapies for ARDS in ICU patients with COVID-19 pneumonia is associated with a low mortality in this cohort.
Introduction: We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity. Description: A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft. Discussion: Neonatal limb ischaemia is a rare disease entity with devastating morbidity-including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity.
Introduction: Sotos syndrome a genetic disorder characterised by delayed neurodevelopment, learning disability, excessive childhood growth and craniofacial abnormalities occurs as a result of a mutation in the NSD1 gene. We present a case series of 5 children with Sotos Syndrome who have been treated for cholesteatoma and review the literature. Case Series: Retrospective case note review of patients cholesteatoma (n = 5 (1 Bilateral)) and Sotos Syndrome between 2012 and 2019. Median age at first surgery was 8 years old (3.5 years – 10.9 years). All children presented with otorrhoea. 4 children (5 ears) had abnormal hearing thresholds (>30dB HL) pre and post operatively. Median follow up is 32 months with 50% risk of recurrence and 25% risk of residual disease at 24 months. PubMed search of the MEDLINE database returned no articles reporting cholesteatoma in children with Sotos Syndrome. Discussion: Cholesteatoma has not previously been reported in Sotos Syndrome. Otolaryngologists should be vigilant for cholesteatoma in children with Sotos Syndrome.
Introduction: Bartholin’s glands provide lubrication to the vagina and are a common site for infection. Lifetime incidence is 2-7%. 1,3,4,6 Bartholin’s abscesses cause pain, dyspareunia, incontinence and obstructive voiding symptoms. 1,5 Scarcely reported in literature are simultaneous presentations of Bartholin’s and peri-urethral abscesses. Peri-urethral abscesses typically follow trauma caused by childbirth or surgical interventions. 2,7 Case Study: A 23 year old was admitted in the spinal unit with acute urinary retention, saddle paraesthesia, back pain and a reduction in lower limb power and unusually high inflammatory markers. MRI spine ruled out cauda equina. On vaginal examination a right sided Bartholin’s abscess was detected. Following a Gynaecology review CT abdomen and pelvis demonstrated a peri-urethral abscess deviating the urethra to the left side. Treatment: The abscess was incised and drained at the bedside. She was discharged with an indwelling catheter and oral antibiotics to return in one week for trial removal of catheter which was successful. Outcome and Follow Up: She was clinically well, discharged and no follow up arranged. Discussion: A common gynaecological pathology presented in an atypical way. Although good clinical history and examination findings are key, imaging modalities can be a vital adjunct for patient care.
Introduction: Collisions tumours are a rare but well documented phenomenon. They comprise of two histologically distinct tumour types occurring in the same site. The mechanism of which this comes about can be; 1) Two tumours arising with the same organ in close vicinity, 2) One tumour metastasizes into another tumour (tumour to tumour metastasis), 3) Two different tumours metastasize to a different organ, commonly a lymph node. Collision metastasis of two different primary tumours within the same lymph node is extremely rare. Description of Case: The authors report a case of a 74 year old woman found to have collision metastasizes of lobular breast carcinoma and adenocarcinoma of the caecum metastasizing to the same mesenteric lymph node. Discussion: The case is, to the best of the author’s knowledge, the first to describe the metastatic spread of two tumours to a single lymph node involving breast carcinoma and adenocarcinoma of the colon.
Introduction: The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern. Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries. Description: We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings. Discussion: Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full skin thickness burns warranting operative intervention.
Introduction: Endometrial ablation is an established treatment option for the management of women with Heavy Menstrual Bleeding. Following this procedure, women may still conceive and therefore effective contraceptive methods are recommended. We report 3 cases of unplanned pregnancies following endometrial ablation. Our series demonstrate the spectrum of possible complications and outcomes. Cases: Case 1 is a 43-year-old woman who had an unplanned pregnancy following hydrothermal balloon ablation. Her pregnancy was complicated by Fetal Growth Restriction and Morbidly Adherent Placenta at delivery. Case 2 is a 40-year-old presenting with a missed miscarriage after previous Bilateral Tubal Ligation at C-Section and subsequent Novasure endometrial ablation. She underwent management by Total Abdominal Hysterectomy. Case 3 is a 41-year-old woman who had an unplanned pregnancy after Novasure endometrial ablation but went on to have relatively uncomplicated pregnancy and delivery. Discussion: Pregnancy after endometrial ablation has the potential to increase patient morbidity significantly. According to Bauer et al. there is a 20-fold increased risk of morbidly adherent placenta. The overall risk of termination, ectopic pregnancy or miscarriage was quoted to be about 85% in another study. Consequently, it is important that appropriate contraceptive methods are discussed with patients post-ablation. The risk of failure of contraceptive methods should also be included in the discussion and an appropriate plan made if this occurs.
Introduction: This case demonstrates the complexity of diagnosing and treating a tooth associated with a mandibular fracture and fixation. Description of Case: This 19-year-old male patient attended with a history of severe spontaneous pain lower RHS. On examination the LR7 was acutely TTP, heavily restored and associated swelling painful on palpation. Pre-operative radiographs revealed periapical radiolucency associated with apical third LR7 and a radiopaque mini-plate with an associated tracking sinus. The patient was diagnosed with chronic apical periodontitis with an associated draining sinus. Treatment options; - Endodontic treatment at GDP - Specialist endodontic referral - Extraction Treatment was carried out under LA and a recall for review set at 6 months. Discussion: The challenge was the difficulty of diagnosis. It demonstrates how mini-plates can interfere with accurate diagnosing. It is likely that damage was a result of the trauma or surgery (2 years previously). It highlights the potential that all modern endodontics could routinely use 3D imagery, CBCT. Conclusion: It is important to recognise teeth with an associated history of trauma or elective surgery involving mini-plate/screw placement. Thorough radiographic and assessment with monitoring is required to ensure an accurate diagnosis.
Introduction: Radial artery pseudoaneurysm is a rare complication of a common procedure such as trans-radial arterial catheterisation. There are multiple risk factors increasing the likelihood of developing pseudoaneurysms, including traumatic insertion of the radial catheter or concomitant infection. Few cases are reported, and no established cause is described in literature. We describe a case of a young patient who developed an iatrogenic pseudoaneurysm post arterial line cannulation. Description of Case: A 36 years old male was admitted with subarachnoid haemorrhage (SAH) due to a ruptured intra-cranial aneurysm. He underwent invasive monitoring with radial arterial line catheter during coil embolization treatment. He underwent the procedure uneventfully but was complicated later by the development of a pseudoaneurysm. Discussion: In our case, the patient had borderline levels of inflammatory markers on blood examinations and no overt signs of local infection. There was a history of multiple attempts at arterial cannulation, and he was also commenced on antiplatelet therapy post coil embolization of the aneurysm. Concurrent use of anticoagulation agents is associated with an increased risk of formation of pseudoaneurysms. Arterial line monitoring is an invaluable aid in assessing the critically ill patient, however pseudoaneurysms is a potential complication with high morbidity even in younger age groups. Atraumatic insertion and careful removal are strongly recommended for its prevention.
Introduction: Squamous cell carcinoma arising in a dermoid usually affects elderly persons and usually found in 1% of mature teratomas. It usually has a poor prognosis and quite rare in the middle aged women. Dr Tom Murphy Description of Case: The case report presented is a 49year old lady referred from the GP with a large right ovarian mass with radiology suspecting to be an ovarian teratoma. Underwent a laparoscopic BSO with histology coming back as Stage 2b, CT afterwards showed no metastatic disease, she underwent Laparotomy, TAH, recto sigmoid colectomy, end colostomy, appendectomy, anterior caecal resection, SB resection, omental biopsy, re implantation of urethra, urethral resection, stent Right ureter. Histology post op coming back as Stage 3b. She deteriorated quite rapidly despite measures to improve outcomes, knowing that prognosis is usually poor when disease has spread beyond the ovary. Conclusion: A high index of suspicion should be indicated for women in that age group with a pelvic mass. The length of time from diagnosis to death was 7months and begs the question if any of the surgical interventions were of benefit.
Introduction: The aim of this case report aims to discuss the surgical management of deep facial lacerations, specifically for dental trainees transitioning to a position in Maxillofacial Surgery. It covers the important anatomical structures that need assessed and repaired. Description: Assessment of a patient with a full thickness facial laceration with a chainsaw, extending into the oral cavity. On examination the patient had some loss of function to the buccal branch of their facial nerve. Intra-orally the parotid duct was located and checked for patency, ensuring that it was not severed and it did not require stenting. The wound was closed in layers, aiming to reattach severed muscle bellies to maximise post-operative function. Postoperative wound care management was carried out as well as post-operative instruction. Discussion: Dentists entering Dental Core Training typically may find the transition to a maxillofacial surgery post daunting as it is extremely out of their comfort zone. This article aims to highlight some stages which are key to address when assessing facial soft tissue trauma as well as ways in which to manage these.
Introduction: Colorectal villous adenomas are common. A rare but important complication of rectal villous adenoma is the electrolyte and water “depletion syndrome” which can be elusive as a diagnosis. If recognised and managed expediently, severe metabolic and renal sequelae can be prevented through appropriate replacement therapy and timely surgery. Case Description: We present a case of an elderly female who gave a 2-year history of progressive chronic watery diarrhoea, necessitating multiple attendances to her GP and several hospital admissions where she had been treated successfully with fluid and electrolyte replacement and a diagnosis of autonomic neuropathy was made. It was only after a thorough examination of the patient including a rectal examination that a large mass was detected and biopsies revealed a giant villous adenoma. She ultimately came to surgical resection with complete resolution of her symptoms Discussion: Villous adenomata have a propensity for secreting large volumes of mucus rich in potassium and sodium and the losses can be so great as to result in cardiovascular, neurological and renal sequelae. Where rare, this case highlights the values in carrying out a thorough clinical assessment.
Introduction: Upper ministernotomy(UMS) for Aortic valve surgery is a well-established approach.It has been proven to be a competitive alternative to full sternotomy with improved aesthetic appearance and non-inferior safety. Aims: We present our single centre experience showing short and medium term surgical outcomes of UMS approach for aortic surgery. Methods: Retrospective analysis of patients who undergone UMS Aortic valve procedures over the last five years. Analysis of patients’ demographics, intra-op findings and evaluation of early/medium term outcomes. Data presented as median (interquartile range) or percentages. Results: 231 patients had UMS Aortic valve surgery at our Hospital over 5 years (Sep2014-Sep2019). Mean age: 67 (37-86) years, BMI >30 in 120 (52%). Majority were done in J shape hemi-sternotomy (87%) and through Right fourth ICS (94.4%). Central cannulation was the most favoured approach (99.2%). The aortic valve was replaced in 230 patients, mechanical valve: 37 (16%) and bio-prosthetic valve:193 (84%). Combined aortic surgery was performed in 7 patients(3%),cross clamp time: 60 (33-170) min, CPB time: 108 (51-190) min. 30-day Mortality: 1 (0.4%), conversion to full sternotomy: 11 (4.7%), reoperation for bleeding: 8 (3.4%), ICU stay: 1 (1-20) day, hospital stay: 8 (3-32) days, new onset AF: 8 (3.4%), CVA/TIA in 0.86%, 30-day readmission: 7 (3%). Early follow up echo mean gradient: 9. 7 (3-34) mmhg. Follow up: 2.8±2 years. Discussion: Aortic valve, aortic root and ascending aorta surgery is amenable by mini sternotomy incision with good outcomes taking into consideration careful patient selection. It is essential to respect the learning curve and accepting low threshold for conversion to conventional full sternotomy when required
Introduction: The incidence of cutaneous malignant melanoma (cMM) is increasing; Vitamin D deficiency at presentation is associated with increased tumour thickness and poorer outcomes. Aims: To examine the epidemiological and histopathological characteristics of cMM in Northern Ireland (NI), and to correlate with socioeconomic status (SES) and Vitamin D levels. Methods: A retrospective review was performed from August 2015 - March 2020. Patients were identified from electronic theatre records and a prospectively-collected database; further information was gained from paper and electronic clinical records. SES was determined by the NI Multiple Deprivation Measure 2017. Results: 440 patients presented with cMM; there are some differences in tumour site between the devolved nations. Vitamin D levels were assessed in 27%, of whom 44% had deficient levels. Higher SES correlated with increased incidence of cMM (Correlation coefficient (CC) 0.922). This did not correlate with thicker tumours (CC -0.020). There was only a very weak negative correlation between Vitamin D deficiency and tumour thickness (CC -0.14). Discussion: Despite being included in the NICE guidelines since 2015, almost three-quarters of patients had not had Vitamin D levels assessed. Interestingly, higher SES was related to higher incidence of cMM but with presentation at earlier stage of disease.
Introduction: Many developed countries have reported a recent rise in non-tuberculous mycobacterial (NTM) infections but the trend in Northern Ireland (NI) is unknown. This study aimed to characterise the epidemiological profile of mycobacterial species isolated from NI patients between 2007-2019. Methods: All positive mycobacterial culture results reported by the NI Mycobacterial Reference Laboratory between 2007-2019 were analysed by species and specimen site. Annual population data was obtained from the NI Statistics and Research Agency. Results: 2193 mycobacterial isolates were captured in the study period. Mycobacterium tuberculosis (M.tb) isolates remained stable at ~3 per 100,000 population whereas NTM isolates increased from 3.2 to 8.1 per 100,000 between 20072019. Eighteen different species of NTM were identified, five of which accounted for ~75% of isolates. Mycobacterium avium complex (MAC) species accounted for the greatest rise in NTM (1.8 to 4.6 per 100,000), of which over 90% were isolated from pulmonary specimens. Discussion: NTM isolates now outnumber M.tb in NI, with a substantial rise in pulmonary MAC specimens. Clinicians in all specialties will increasingly encounter these poorly understood and drug-resistant organisms. More research into NTM disease is required to tackle this emerging problem.
Introduction: The global pandemic has resulted in mass cancellation of elective operations; impacting cancer procedures, waiting times and training opportunities. In the Southern Trust, Craigavon Area Hospital is the designated “COVID site” and Daisy Hill the “Non-COVID site”. Aim: To assess if systems introduced resulted in low postoperative COVID cases in a COVID site compared to a non-COVID site. Method: A prospective audit of elective surgeries performed on COVID site from May-July and non-COVID site AprilJune 2020. Data collected using standardized audit proforma with 30 day follow up. Measures introduced included PPE, a separate ‘clean ward’, routine staff and patient testing, 7 day patient self-isolation prior to surgery and a no visiting policy. Results: 44 elective operations performed in COVID site and 21 in non-COVID site. 2.3 %( 1/44) developed clinical COVID 6 days post-op on COVID site - did not require ICU and alive at 30 days. Zero COVID cases in non-COVID site and zero staff cases across both sites. Discussion: Precautionary methods introduced may have contributed to low numbers of COVID and were enough to enable elective operations to continue on a COVID site. In light of recent rising community COVID cases, a re-audit will be conducted.
Introduction: UK guidelines recommend sentinel lymph node biopsy (SLNB) for patients with malignant melanoma >1mm Breslow thickness; those found to have micrometastatic disease are considered for adjuvant therapy. Aims: Service evaluation of the new NI SLNB service, which began in December 2018. Methods: Consecutive patients were identified from a prospectively-collected database. Results: 166 patients were referred to the service. A total of 115 nodal basins were investigated with SLNB. Seventy-three patients were male, 95 were female; mean age at presentation was 58 (range 20 - 87). Commonest primary tumour site in men was trunk/back (47%), and lower limb in women (41%). Eighteen nodal basins were positive for micrometastases, 91 nodal basins were negative, and SLN localisation failed in 6 nodal basins. Average waiting time from referral to outpatient appointment is 2.6 weeks, less than 3-week target; however, the mean time from diagnosis to surgery is breaching the 12-week target. Almost 10% of patients were not suitable for SLNB surgery, either due to co-morbidities or previous surgery. Discussion: Surgical outcomes will be compared to international data, and considerations in starting a new service will be discussed, along with methods to reduce proportion of unsuitable referrals.
Introduction: Evidence from emerging studies suggests that oral bacteria and poor oral health may contribute to COPD exacerbations. Interventions to improve oral health such as periodontal therapy may improve lung function, decrease the frequency of COPD exacerbations, hospitalisations and improve quality of life. Aims: The aim of this systematic review was to analyse the association between poor oral health and frequency of COPD exacerbations. Methods: The databases, Pubmed; Embase; Web of Science; CINAHL and Medline were searched up to May 2020, with no language restriction. Eight articles met the inclusion criteria and were included in qualitive synthesis, five articles were included in quantitative analysis. Results: The data from randomised controlled clinical trials showed a significant reduction in frequency of exacerbations following periodontal treatment (RR 0.28; 95% CI 0.090.83, p=0.02). Based on random-effects meta-analysis amongst case control studies, plaque index (OR=1.63, 95% CI 1.15 to 2.31, p=0.01), probing pocket depth (OR=2.03, 95% CI 1.46 to 2.82, p
Introduction: The inflammasome is a protein complex that initiates immune responses to danger signals by releasing cytokines interleukin-1β (IL-1β) and IL-18. Inflammasomes are thought to be involved in multiple sclerosis. Studies have shown that inflammasome activity can promote CNS repair. Aims: To determine if inflammasomes can be stimulated in CNS cells, and whether inflammasome activity promotes oligodendrocyte progenitor cell (OPC) proliferation and/or differentiation. Methods: Mixed glial cultures were generated from wildtype and Il1r1-/- mouse brains. Cells were stimulated with IL-1β to test glial response to inflammasome activity, or with inflammasome triggers to test endogenous inflammasome response in glial cells. Cells were then stained for oligodendrocyte and inflammasome markers. Results: Glial cells mounted an inflammasome response upon danger signal sensing. The formation of putative ASC specks denoted inflammasome activation. IL-1β increased oligodendrocyte lineage cell numbers, promoted OPC differentiation and increased myelin production in vitro, mediated via IL-1 receptor 1.
Introduction: Orofacial granulomatosis (OFG) is a chronic granulomatous oral inflammatory disease and can precede gut Crohn’s Disease (CD). Not all OFG patients have, or ever develop, CD. Therefore, whether OFG and oral CD are one and the same disease is a matter of debate. Aim: To use proximity extension assay (PEA) to interrogate phenotypic differences between health and oral inflammatory conditions. Methods: PEA analysis was performed using ProSeek Inflammation and Immune Response panel. Olink Proteomics (Uppsala, Sweden). Saliva samples from 32 patients with OFG were processed and analysed. Controls included saliva samples from 30 healthy volunteers and 28 patients with Oral Lichen Planus (OLP). Results: No significant difference between the proteome of health vs OFG / OLP vs OFG. Significant differences in the levels of 8 proteins between OLP vs OFG (TWEAK, PRDX1, CDSN, LY75, MCP.1, FGF.23, CLEC4G, CX3CL1). Within the OFG group there were two distinct subtypes that correlate with idiopathic OFG and gut CD. Discussion: Analysis of the oral proteome may offer a means of differentiating between different oral inflammatory diseases. More importantly it may help predict those cases of OFG that will progress to gut CD.
Introduction: De Quervain tenosynovitis is a disorder of the tendons of first dorsal compartment of wrist that causes pain and functional disability managed by platelet-rich plasma (PRP). Objective: To determine efficacy of intralesional injection of platelet rich plasma in patients of De Quervain’s tenosynovitis Material & Methods: This is a descriptive Case series conducted over 6 months, 100 patients were included. Platelet rich plasma was obtained after centrifugation, received intralesional injection plus oral non-steroidal anti-inflammatory drug. Results: 57 males and 43 females with mean age of 41.26±11.26 years, 53(53%) were diabetic. Efficacy of treatment was seen among 85(85%) patients, whereas Intralesional platelet rich plasma had. No significant association was noticed between gender of patients and efficacy of Intralesional injection of platelet rich plasma (p-value=0.756). Efficacy of Intralesional injection of platelet rich plasma was not dependent on the diabetic status of the patients (p-value=0.556).Efficacy of Intralesional injection of platelet rich plasma was not dependent on duration of start of symptoms of patients. i.e. (p-value=0.978). Conclusion: We conclude that Intralesional injection of platelet rich plasma can be effectively used for de Quervain’s tenosynovitis.
Introduction: COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. Aim: We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Methods: Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (
Introduction: Studies estimate that 21% of patients with XLA (X Linked Agamaglobulinemia) have had at least one episode of infectious conjunctivitis. In contrast, conjunctivitis is not a commonly described problem in patients with CVID (Common Variable Immunodeficiency). Aims: We aimed to determine whether the association of XLA and eye infections is unique amongst primary antibody deficiencies. Methods: A retrospective observational study was carried out. Age-matched CVID patients with absent IgA levels were selected as the control group. Results: 29 patients with XLA and 30 patients with CVID were analysed. 12 patients with XLA (41%) had suffered from recurrent conjunctivitis. No patients with CVID had documented episodes of recurrent conjunctivitis. The mean IgG trough levels were 10.78g/L for the cohort with XLA and 10.41g/L for patients with CVID. Discussion: We demonstrate here the common and perhaps unique susceptibility to conjunctivitis in patients with XLA. What is the underlying cause for the increased susceptibility? Since both groups in our study lacked serum IgA, it seems unlikely that absence of IgA antibodies is the culprit. The group with XLA and conjunctivitis averaged higher IgG trough levels, therefore, inadequate trough levels are also unlikely to be responsible.
Introduction: Many patients admitted with confirmed COVID-19 were found to have electrolyte disturbances. Aims: In this new era of COVID-19, we aimed to assess how this multisystem disease affects electrolytes & creatinine. In clinical practice, we noted patients were hypokalaemic with dysnatraemias. We explored potential aetiologies for this & assessed correlation with their clinical journey (e.g. prolonged hospitalisation, CPAP, critical care & death). We explored if age correlated. Methods: Records of all COVID-19 positive patients over a 3 month period were analysed. Each patients electronic care record was interrogated. Serum sodium, potassium, urea, creatinine, bicarbonate, chloride were recorded, as well as a peak sodium. Patients were subcategorised into those requiring CPAP, needing critical care admission & those who died. Results/Discussion: 332 inpatients tested positive for COVID-19 between 11/3/2020-17/5/2020. Average age was 69 (55% male). 37% had a sodium >/= 145mmol/L. 20% had a potassium
Introduction: Rapid deployment valves are of increasing popularity amongst surgeons. Aims: To compare conventional bioprosthetic with rapid-deployment valves used in aortic valve replacement. Method: A comparison of pre, intra and post-operative outcomes of 120 patients received a rapid-deployment AVR (RDAVR) between Sep2014-Sep2019, with a propensity matched group of patients who had conventional bioprosthetic AVR (Conv AVR). Results: RDAVR (n=120) was compared with Conv AVR (n=120).Both groups were matched in terms of baseline characteristics. However, RDAVR group included more elderly (>80 years) and females (40 vs 11 p
Introduction and Aim: The aim of this study was to investigate the impact of nasal deviation on the perception of the maxillary dental centreline position as judged by orthodontists, general dental practitioners (GDPs) and lay people. The null hypothesis states that there is no difference in perception of maxillary dental centreline position and smile aesthetics with varying degrees of nasal deviation and dental centreline. Methods: This was a cross sectional study which aimed to assess the impact of variations in the position of both the dental centreline and nose on facial aesthetics. An image of a smiling female was digitally manipulated with varying degrees of nasal deviation and dental centreline position. Multiple regression analysis was undertaken to assess the effect of these changes on the perceptions of attractiveness for each rater group. Results: Nasal deviation to the left by 1.5mm was perceived as more attractive if the dental centreline was also deviated to the left by 1.5mm by GDPs (95% CI, 0.4-13.5), orthodontists (95% CI, 7.6-20.0) and lay people (95% CI, 1.7-15.8). Discussion: Overall, there was a preference for the symmetrical dental centreline and nose position. GDPs and orthodontists were more sensitive to changes associated with the dental asymmetry, whereas lay people were more sensitive to nasal changes.
Introduction: In our centre, patients undergoing elective transurethral resection of prostate (TURP) and transurethral resection of bladder tumours (TURBT) require a preoperative group and hold (G+H). Local policies requiring pre-operative G&H were developed as TURP/ TURBT historically had a significant risk of bleeding. However, as intra-operative procedures have improved, the risk of bleeding has reduced [2]. Aims: Investigate the rate of blood transfusion in TURP and TURBT patients. Methods: We conducted a prospective analysis of all patients undergoing TURBT/TURP in a two-month period (19/09/2019-19/11/2019). 44 patients were identified using theatre lab lists and cross-referenced with the electronic labs system to confirm if blood products were issued. Patients requiring transfusion (n=2) were further investigated using patient notes to establish contributing factors and timing of transfusion. Results: 4.5% of those undergoing TURBT/TURP required a transfusion. 0% were intraoperative or emergency transfusions. All transfusions occurred over 48 hours postoperatively. Discussion: Our study found that pre-operative G&Hs do not improve patient outcomes. At a cost of £23.77/sample, there is potential to make significant savings without compromising patient care. Our results are in keeping with larger studies performed in other centres [3]. Pre-operative G&H could be performed selectively on those deemed higher risk at pre-operative assessment. Routine preoperative tests for elective surgery: summary of updated NICE guidance - BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3292Test (Published 14 July 2016) Cite this as: BMW 2016;354:i3292 https://www.bmj.com/content/354/bmj.i3292Test Rassweiler, J, Teber, D, Kuntz, R. Complications of transurethral resection of the prostate (TURP) – incidence, management and prevention. Eur Urol 2006; 50: 969-980. Smith, H., Falconer, R., Szczachor, J., & Ahmad, S. (2018). Routine preoperative group and save for TURP and TURBT – need and cost effectiveness. Journal of Clinical Urology, 11(1), 33-37.
Introduction / Aims: Primary aim of gaining quantitative data on levels of sedentary behaviour among GPs and GPSTs, to identify to what extent GP is a sedentary occupation. Secondary aim of gathering qualitative data regarding barriers and facilitators to reducing sedentary behaviour among GPs and GPSTs. Methods: Sequential, mixed-methods model. Stage 1: Online questionnaire based on the International Sedentary Assessment Tool distributed to GPs and GPSTs throughout Northern Ireland. Stage 2: Accelerometer study. Purposive, varied sample of 20 participants, based on questionnaire responses, comprising individuals with a range of demographic characteristics and sedentary behaviour. Accelerometers will be worn continuously on the middle of the thigh for a period of seven-days. Stage 3: Semi-structured interviews. Purposive, varied sample of 6 participants of the accelerometer study will be asked questions related to sedentary behaviour in the GP setting. Results and Discussion: Quantitative data will be analysed to determine current levels of sedentary behaviour in the GP setting. Qualitative data will be analysed thematically to determine barriers and facilitators to reducing sedentary behaviour in the GP setting. Study has been modified due to Covid-19 pandemic.
Introduction: Black and minority ethnic communities are at higher risk of mental health problems. Aims: We explore differences in mental health and the influence of social capital among ethnic minority groups in Great Britain. Methods: Cross-sectional linear and logistic regression analysis of data from Wave 6 (2014-2016) of the Understanding Society databases. Results: In unadjusted models testing the likelihood of reporting psychological distress (i) comparing against a white (British) reference population Indian, Pakistani, Bangladeshi and mixed ethnic minority groups recorded excess levels of distress; and (ii) increasing levels of social capital recorded a strong protective effect (OR=0.94: 95% CI 0.935, 0.946). In a subsequent series of gender-specific incremental logistic models-after adjustment for sociodemographic and socioeconomic factors Pakistani (males and females) and Indian females recorded higher likelihoods of psychological distress, and the further inclusion of social capital in these models did not materially alter these results. Discussion: More research on the definition, measurement and distribution of social capital as applies to ethnic minority groups in Great Britain, and how it influences mental wellbeing is needed.

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المؤلفون: Blencowe, Natalie, Glasbey, James, Heywood, Nick, Kasivisvanathan, Veeru, Lee, Matthew, Nepogodiev, Dmitri, Wilkin, Richard, Allen, Sophie, Borakati, Aditya, Bosanquet, David, Chapman, Stephen, Chari, Aswin, Dunstan, Matt, Dyson, Edward, Edlmann, Ellie, Gardner, Matthew D., Harries, Rhiannon, Hunter, James, Kolias, Angelos G., Jamjoom, Aimun, McGrath, John, Mohan, Helen, Morrison, Rory, Nana, Gael, Pinho-Gomes, Ana-Catarina, McCain, Scott, Reynolds, Rhianon, Sheikh, Shafaque, Shalhoub, Joseph, Stimpson, Amy, Gijs van Boxel, Nicholas Symons, West, Malcolm, Wild, Jonathan, Baker, Daniel, Barmayehvar, Behrad, Bath, Michael, Beamish, Andrew J., Bhangu, Aneel, Canter, Richard, Clements, Joshua, Cotton, Arthur, Dabab, Nedal, Doherty, Daniel, Fitzgerald, J. Edward, Heywood, Emily, Johnston, Maximilian, Hickland, Patrick, Kamarajah, Sivesh, Hoo, Chris

المصدر: International Journal of Surgery ; volume 52, page 355-360 ; ISSN 1743-9191

الإتاحة: https://doi.org/10.1016/j.ijsu.2017.12.019Test
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المؤلفون: Caldwell, Shane, Clements, Jamie, McAllister, Ian, Corr, Michael, Waterfield, Thomas, McKenna, James, Fairley, Derek, Shields, Michael, Jackson, Simon, Cummins, David, McNaughten, Ben, Walker, Alison, Shaw, Timothy, Schroeder, Gunnar, Krasnodembskaya, Anna, O’Kane, Cecilia, Shirley, K, Williams, M, Parker, N, McLaughlin, L, Bond, R, Johnston, David, Hickland, Patrick, Allen, N., McKeever, M., O’Brien, S., Clements, B., Baba, Mohamad, Bouzan, Lorraine, Graham, Michael, McLaughlin, Ronan, Wilkinson, Emma, Collins, Julie-Ann, Konstantinidou, Sevasti, Malone, Cathy, McKinley, Nicola, McMahon, Sam, McNabney, Charis, Murphy, Bryan, Patterson, Timothy, Bonanos, Efstathios, Causey, Christine, Mashih, Claire, Arrowsmith, Lucy, Blakely, Megan, Blayney, Gillian, Elliott, Ashley, Empey, Julie-Anne, Ferreira, Pedro, Kennedy, Mark, McClenaghan, Lisa, McGuigan, Leanna, Nelson, Abigail, Sharkey, John Christopher, Sing, Vivian, Tan, Yi Hang, Todd, Matthew, Walsh, Keira

المصدر: The Ulster Medical Journal

مصطلحات موضوعية: Poster Presentations, Abstracts, Medical Education, Clinical Research, Oral Presentation, Quality Improvement

الوصف: Introduction: Pancreatitis is a common condition on the acute general surgical take. Common aetiologies in the UK include gallstones, alcohol excess and iatrogenesis. Hypothermia is scarcely documented in literature among the rarer causes of pancreatitis, and whilst little scientific literature exists to support this clinical observation, this case adds to the growing evidence for hypothermia as a clinically relevant risk factor for acute pancreatitis. Discussion: We present the clinical course of a 44 year-old male open water swimmer who was admitted to ICU for mechanical ventilation in view of hypoxic respiratory failure and severe hypothermia (27oC). Following cardiorespiratory stabilisation and uncomplicated extubation, the patient complained of sudden, severe epigastric pain, refractory to strong opiate analgesia. CT images were in keeping with acute pancreatitis. The patient was managed conservatively at ward level and made an uncomplicated recovery prior to discharge. Thorough clinical history and biochemical testing excluded all other typical aetiologies of acute pancreatitis. This case is unique from previous reports in literature, where the relationship between hypothermia and pancreatitis has been more ambiguous. It is essential to be vigilant in hypothermic patients and remember this uncommon link, as diagnostic delay may lead to serious local or systemic complications of pancreatitis.
Introduction: Differentiating between a bacterial infection and a self-limiting viral illness is challenging. Adrenomedullin (ADM) has many physiological roles and is reported to rise during severe infection. The novel biomarker Mid-regional proadrenomedullin (MR-proADM) is produced during the synthesis of ADM. It proportionally represents the level of ADM and is easier to measure. Aims: To assess the diagnostic accuracy of MR-pro-ADM in detecting bacterial infection in febrile children presenting to the Royal Belfast Hospital for Sick Children Emergency Department (ED) with a non-blanching rash. Methods: Prospective diagnostic accuracy study. Samples tested using the BRAHMS MR-proADM assay on Samsung LABGEO IB10® analyser. Results: 39 patients underwent MR-proADM testing. In all but 2 patients the MR-proADM was under 0.70nmol/l. The two patients with elevated MR-proADM levels were found to have sepsis and tonsillitis. At 0.70nmol/l cut-off MR-proADM demonstrated a sensitivity of 0.11 (95% Confidence Interval 0.02 to 0.35) and a specificity of 1.0 (95% Confidence Interval 0.80 to 1.0) for bacterial infection. Discussion: MR-proADM is highly specific for bacterial infections but lacks sensitivity. Given the physiological roles of ADM it maybe that MR-proADM is better suited as a prognostic marker of sepsis rather than as a diagnostic marker of bacterial infection.
Introduction: In a neonatal emergency, if intubation is indicated, it is imperative the correct equipment is collected promptly. Currently no neonatal intubation equipment guide exists. Aims: This study aimed to develop a Neonatal Intubation Flowchart (NIF) and test effectiveness of NIF 1 and NIF 2. Methodology: A prototype NIF was created (NIF 1). Using a simulation, a control group (n = 21) was compared to an intervention group (n = 24), employing NIF 1. These cohorts consisted of paediatricians, neonatal nurses and midwives. The outcomes measured were Percentage of Correct Equipment (PCE) collected and Time Duration (TD) to collect equipment. An improved NIF 2 was created and the simulation was repeated to an intervention group (n= 28) utilising NIF 2. Results: Between the control, NIF 1 and NIF 2, the PCE results were 59%, 87% and 96% respectively. The TD of the control, NIF 1 and NIF 2 showed a median of 90 seconds (Interquartile Range (IQR): 70.5 - 121.5), 140 seconds (IQR: 99.5 - 182) and 60 seconds (IQR: 53.5 - 73.5). Discussion: The NIF 2 improves intubation equipment collection, within a quicker time. Quicker and effective preparation aids quicker intubation which may limit hypoxic brain injuries.
Introduction: There is an urgent need to develop efficacious and tolerable therapies for Mycobacterium avium complex (MAC) pulmonary disease. Mesenchymal stromal cells (MSCs) have known antimicrobial properties against common bacteria but their effect on MAC species is not known. Aims: To determine the effect of MSCs on intracellular and extracellular M. avium. Methods: Human MSCs were infected with M. avium at a multiplicity of infection (MOI) of 2. Human monocyte- derived macrophages (MDMs) were also infected with M. avium at MOI of 2. After 4hrs, MSCs were added at a ratio of 1 MSC: 3 MDMs. After 24hrs and 72hrs, colony counts were performed on supernatants and cell lysates. Results: MSCs reduced total bacterial counts of M. avium by 24% at 24hrs (from 295x103/ml to 225x103/ml, p40% (from 381x103/ml to 209x103/ml, p70% after 72hrs (from 1050x103/ml to 314x 103/ml, p
Introduction: This study uses eye-tracking technology to objectively assess the differences in gaze behaviours between consultant and trainee ophthalmologists before and after a taught search strategy was introduced, while interpreting retinal images. Methods: Nine trainee and 10 consultant ophthalmologists were asked to interpret 6 retinal images before and after watching a 5-minute tutorial that suggested a search strategy. Participants were asked to complete questionnaires of clinical signs seen, appropriate retinopathy grade, and confidence. Eye movements were tracked during each interpretation. Results: Overall, trainees compared to consultants demonstrated more uncertain and unstructured gaze behaviours. Trainees eye gaze metrics compared to consultants included: longer interpretation time, 36.5s(SD=6.2) vs 31.4s(SD=4.2)(P=0.024), a higher visit count, 17.38visits(SD=5.13)vs 12.18visits (SD=2.64)(P=0.01), a higher proportion of fixation, 57.0%(SD=5)vs 50.5%(SD=5) (P=0.05) and a shorter time to first fixation, 0.232s(SD=0.10) vs 0.821sec(SD=0.77)(P=0.001), respectively. The teaching intervention did result in more focused gaze patterns in both groups. Pre-intervention and post- intervention mean proportion fixation on areas of interest were 38.6%(SD=6.8) and 51.8%(SD=13.9) for the trainee group, respectively, and 39.9%(SD=4.1)and 50.9%(SD=9.3) for the consultant group(P=0.01). Conclusions: Consultants used a more systematic and efficient approach than trainees in interpreting images. After the introduction of a suggested search strategy, trainees showed trends towards the eye gaze behaviours of consultants. The implication is that eye tracking may have future use in teaching programmes and objectively assessing different teaching strategies.
Introduction: Mycobacterium abscessus is an emerging multi-drug resistant pathogen, which is difficult to treat. There is a need for new antimicrobial strategies. Zafirlukast, a leukotriene receptor antagonist, inhibits growth of Mycobacterium tuberculosis, by inhibiting complexation between DNA and protein Lsr2. Lsr2 is present in M. abscessus. Aims: We aimed to investigate the effect of Zafirlukast on extracellular and intracellular M. abscessus growth. Methods: We examined Zafirlukast’s effect on free growth of M. abscessus, and survival of M. abscessus in infected THP-1 cell line derived macrophages. We measured colony- forming units per millilitre in broth, or supernatants and lysates, at 24 and 72 hours. Also, we investigated whether Zafirlukast reduced inflammation as assessed by interleukin-8 secretion (measured by ELISA) by infected THP-1 derived macrophages. Results were analysed by Kruskal-Wallis and Dunn’s tests. Results: At 24 hours, 100μg/ml Zafirlukast reduced M. abscessus free growth by 62% (p=0.0039), also reduced total M. abscessus growth in THP-1 derived macrophages by 94% (p=0.0062), and finally, reduced interleukin-8 concentration in supernatants from M. abscessus-infected THP-1 derived macrophages by 99% (p=0.0412). Discussion: Data suggest Zafirlukast may reduce growth of M. abscessus and modify M. abscessus-induced inflammation. Further work is required to assess the potential therapeutic role of Zafirlukast in treating M. abscessus infection.
Introduction: Sepsis represents a dysregulated host response to infection. Underlying mechanisms are unclear, but deficits in the function of monocytes, central to the innate immune system, are implicated. A heterogeneous condition, recent transcriptomic work has revealed two distinct sepsis-response signature profiles; immunosuppressed and immunocompetent, which are linked to outcome. Aims: We propose that these distinct profiles impact differentially on volunteer monocytes, and hypothesize that there will be differences in their phagocytic activity and phenotype when conditioned in plasma from patients in these two groups. We therefore aimed to validate a functional assay for this purpose using lipopolysaccharide (LPS) to represent ‘septic’ plasma. Methods: CD14+ monocytes were isolated from healthy volunteers, and incubated overnight in media and human plasma +/- 10ng/ml LPS. Surface phenotype and phagocytosis were assessed by flow cytometry. Results: LPS exposure decreased monocyte surface CD14, as previously reported, and PD-1, whilst phagocytosis of E.coli particles and expression of CD86, and expression of PDL-1 increased. Discussion: Our LPS model of ‘septic’ plasma/monocytes demonstrated the ability to alter monocyte phenotype and function, providing a positive control for subsequent analysis of patient samples.
Case Study: Small bowel malrotations are a rare congenital abnormality (symptomatic in 1 per 6000 live births 1). The majority of these present as a neonate or in early childhood (adult presentation between 0.0001% and 0.19%2,3). Our case is a patient with a rare form of malrotation, a reverse malrotation, presenting as an adult. An 18-year-old woman presented with 1 week of epigastric pain radiating through to her back. The pain had worsened in the 3 days preceding admission and was associated with vomiting. Bowels had been opened the previous day with no diarrhoea, mucus or blood reported. On examination the patient had a tender epigastrium and RUQ with associated guarding. Biochemical tests were unremarkable; WCC, CRP, LFT and Amylase all grossly normal. CT demonstrated small bowel volvulus and incomplete obstruction with a “whirlpool sign” of the small bowel mesentery. At Laparotomy the transverse colon was found running through the small bowel mesentery, ultimately a Right hemicolectomy with end ileostomy was performed. Discussion: Cases of malrotation are rare and there is often a delay in diagnosis. We hope the discussion generated by this report will improve the diagnosis of intestinal malrotation and therefore improve outcomes for patients.
Case study: Ocular cicatricial pemphigoid (OCP) is an autoimmune disease that affects the conjunctiva. It is a subtype of mucous membrane pemphigoid (MMP), a disease that affects the skin and the mucous membranes. Initial signs and symptoms can overlap with other conditions such as pseudomembranous conjunctivitis. OCP is sight threatening and requires systemic steroids and immunosuppression while pseudomembranous conjunctivitis is self-limiting. We present the case of a 72 year-old gentleman with multiple attendances to eye casualty with red eyes. He was initially diagnosed with pseudomembranous conjunctivitis before developing cicatricial conjunctivitis and mouth ulcers. The conjunctival biopsy confirmed the diagnosis of OCP and the patient was started on oral steroid and immunosuppressive therapy. Discussion: The diagnosis of OCP was delayed in our case and affected one eye more than the other. Extra-ocular signs and positive direct immunofluorescence can help differentiate OCP from other cause of chronic conjunctivitis. Early diagnosis is important as immunotherapy takes few weeks to achieve maximal effect. A step-wise approach was used in this case, starting with oral Dapsone and escalating to oral Mycophenolate. Close monitoring of the patient will continue under the joint care of the ophthalmology and rheumatology team.
Case Study: A lady who was 7 weeks pregnant presented to the Emergency Department at 4am with her partner. She had been out for dinner with friends at 7pm and developed severe vomiting and diarrhoea from 10pm. Whilst in the waiting room she fainted & was faecally incontinent so was brought into a bed. On examination she was clammy and had generalised abdominal tenderness. Observations were normal except a Heart Rate of 105BPM. Initial haemoglobin on her Venous Blood Gas was 145. The obstetrics registrar was called - he could not see an intrauterine pregnancy. Her VBG was repeated showing a haemoglobin of 85. She was rushed to theatre and had 2 Litres of blood in her abdomen. Discussion: Ectopic pregnancy should be considered in any female who presents with abdominal pain. All women presenting with abdominal pain should have a pregnancy test performed. Pregnant women should also have an ultrasound scan to confirm intrauterine pregnancy. This is a potentially life threatening condition if not managed promptly. This case highlights how it can present with atypical features which mimicked gastroenteritis. It also highlights that initial bloods can be normal. This lady survived.
Case Study: This patient had a normal delivery with a postpartum haemorrhage of 800ml. Her haemoglobin was 94g/L on discharge. She was a Jehovah’s Witness and refused transfusion of blood products. She was readmitted day 8 following delivery with sepsis. Ultrasound showed a 9x4cm area of retained placental tissue. Her haemoglobin on readmission was 82g/L. Instead of immediate intervention the patient was reviewed weekly to assess for infection and there was multidisciplinary input including pre-operative counselling, anaesthetic review and completion of an advance directive. She was admitted 8 weeks postpartum for resection of retained tissue. Her haemoglobin was 135g/L and intravenous tranexamic acid bolus and infusions were given prior to the procedure. Hysteroscopy showed adherent placental tissue on the right lateral wall and posterior wall of the uterus. As there was moderate bleeding following tissue resection a urinary catheter with 20ml saline was inserted into the uterus. Discussion: Hysteroscopic resection of retained placental tissue is relatively new however has been supported by the literature and warrants further trials. When compared with uterine curettage it may reduce blood loss and long term complications such as Ashermans syndrome.
Case Study: A 35 year old female self-detected a lump in left breast July 2017. Triple assessment confirmed node positive, triple negative, infiltrating ductal carcinoma. No evidence of distant metastases on staging investigations. Completed six cycles of neo-adjuvant chemotherapy 08/01/2018 and left partial mastectomy and ANC 05/02/2018. Presented 5 days post-surgery with headache, photophobia, nausea, vomiting; CT Brain was normal - discharged. Admitted to Oncology 11 days later with ongoing symptoms; Normal examinations; MRI Brain and whole Spine normal; LP – cytology confirmed epithelial cells consistent with metastases from a primary breast carcinoma; Rapid decline with death on 11/05/2018. Discussion: Early breast cancer carries an excellent prognosis when treated with neo-adjuvant chemotherapy and surgery. Commonest sites for metastases include bone, lung, liver, brain and leptomeningeal involvement usually occurring months to years post initial diagnosis. Leptomeningeal metastases alone are very rare especially early in the natural history of the disease. Diagnosis requires a high clinical index of suspicion. Gold standard Investigations include T1-W MRI scan of brain and spine with gadolinium enhancement and CSF analysis. Treatment options are limited with continued debate over the effectiveness of systemic chemotherapy, radiotherapy and intra-thecal chemotherapy. Life expectancy following diagnosis of leptomeningeal metastasis is measured in terms of weeks.
Case Study: A 41-year old male athlete presented acutely to the Royal Victoria Hospital emergency department with sustained resting typical angina chest pain 30 minutes following completion of an ultra-triathlon. 12-lead ECG demonstrated hyper acute t waves in precordial leads V3 and V4. Serial high-sensitivity Troponin T assays were elevated at 186 – 330 – 603ng/L respectively. Invasive coronary angiography demonstrated acute LAD dissection and significant thrombus burden with TIMI 3 flow distally. Optical coherence tomography (OCT) confirmed coronary dissection. A 6.0(width)/18 (length) mm Herculink bare metal stent was deployed following catheter thrombectomy, with a successful angiographic result. Following 3 months of dual antiplatelet therapy he remains on life-long Aspirin. At 1 year he has had no further major adverse cardiovascular events (MACE), angina free (CCS class 0) and exercising regularly. Discussion: Spontaneous coronary artery dissection (SCAD) is a rare and clinically challenging cause of acute myocardial infarction most commonly affecting younger patients with low risk of atherosclerotic heart disease. The low incidence of SCAD has resulted in a paucity of information on optimal treatment. Our case highlights a challenging case successfully treated with percutaneous coronary intervention including intra-coronary imaging, and antiplatelet therapy.
Introduction: Trauma contributes significantly to adolescent morbidity and mortality. Currently a dearth of literature exists, specific to this field in the UK. This study aims to highlight the epidemiology of UK adolescent trauma. Methods: TARN (Trauma Audit Research Network) records all trauma cases which meet pre-specified criteria. Adolescents were defined as 10-24 years old as per recent literature. TARN data from English sites over a ten-year period (2008-2017) were included in this analysis. Results: TARN recorded 26,330 trauma cases, 5,266 aged between 10-15 years and 21,064 aged between 16-24 years. Median age was 19.4 years (IQR 16.7-21.7 years). There was a 2.2-fold increase in the annual number of cases reported during this period with an increase in the number treated in MTCs (44% 2008 vs 73% 2017). Trauma was more likely to occur between 08.00 and 00:00 (77.4%), at weekends and between April and October. Mortality rate was 4.4% (4.47% in 16-24 year old group and 3.84% in 10-15 year old group). Road traffic collision (RTC) was the leading cause of adolescent trauma (52%). Intentional injuries accounted for 19.8%; 16.2% alleged assault and 3.6% suspected self-harm. Conclusions: There has been an increase in reported adolescent trauma. RTC and intentional injuries, including stabbings are leading aetiologies. Health care professionals need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable group.
Background: Informed consent is an integral component of good medical practice. Many have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a ‘core outcome set’ to evaluate interventions designed to improve the consent process for surgery. Part of that process involves reviewing outcomes that have been reported in existing research that reportedly capture the quality of a consent process. Aims: To systematically review all qualitative studies to determine which factors determine the quality of informed consent for surgery as viewed by patients and clinicians. Methods: This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. The study protocol has been registered on the International Prospective Register for Systematic Reviews (PROSPERO ID: CRD42017077101). Results: Searches of the databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2014 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers. These findings were divided into 12 categories and ultimately 6 synthesised findings. These synthesised findings were; trust, knowledge, patient characteristics, situational factors, choice and the model patient. Discussion: This qualitative meta-aggregation is the first to examine the issue of informed consent. The review has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been previously been examined in informed consent research. This review forms the basis for the development of a core outcome set to evaluate interventions designed to improve the consent process for surgery.
Introduction: Nowadays most people use the Internet to access health-related information. Aim: To objectively analyse online information regarding vertigo, in terms of quality, readability and reliability. Methods: The term vertigo was searched using the most popular search engines. The top 30 websites were analysed. The readability was assessed using Flesch-Kincaid Reading Ease score (FRES) and Simple Measure of Gobbledygook score (SMOG). The quality and reliability were analysed using DISCERN instrument, JAMA criteria and presence of Health on the Net (HON) Foundation seal. Results: The websites Nhs.uk, Patient.info and NIdirect.gov.uk had the highest readability scores. The average FRES score was 48 which correlates to the reading ability of a college student. Thirteen websites had the HON seal and most websites met 2 out of 4 JAMA criteria. The websites Cks.nice.org, Nhsinform.scot and Menieres.org.uk had the highest DISCERN scores and average DISCERN score was 41. Discussion: On average, information online about vertigo is difficult to read and is of fair quality. The highest ranked websites on search engines are not always the most reliable. Clinicians should be aware of available health information online and advise patients accordingly.
Introduction: Studies have shown that disease recurrence after LLETZ is higher in patients with positive resection margins; however rates vary possibly due to technique and extent of margin cautery. We analysed patient records to determine if margin status affected test of cure (TOC) rates. Methods: 100 margin positive LLETZ specimens and 103 margin negative specimens were identified in the WHSCT for high grade CIN (CIN 2/3) from January 2016- June 2017. Case records were examined to determine TOC post excisional therapy. Results: Of 203 patients who had LLETZ for high grade CIN 5% of patients were immunocompromised (n=10).6 cases had co-existing CGIN (4 in margin positive group). 63% of the margin positive group and 68% of the margin negative group had negative TOC (p=0.22). 7% of the margin positive group and 3% of the margin negative group required repeat excision (p=0.09). DNA rates for TOC were 10% and 5% in the margin positive and negative groups, respectively. Discussion: Our results show that after TOC smears post LLETZ for high grade CIN margin status of the LLETZ specimen made no significant difference to the outcome. This is perhaps due in part to the treatment technique involving cautery of the residual margins.
Introduction: Burnout in doctors has been widely reported on. However, there is limited information in the literature on resilience in doctors. Despite this, workshops and seminars are offered by organisations for clinicians to attend to improve their personal resilience. These may not benefit doctors if they are already highly resilient individuals. Aims: To measure resilience, professional quality of life and coping mechanisms in doctors. Methods: During a 4-week period all medical staff within a single NHS trust in Northern Ireland were invited to complete an online survey that was made up of three validated psychological tests. Results: 283 doctors across a wide range of specialties and grades responded. Mean resilience was 68.9, higher than population norms. 100 (37%) doctors had high burnout scores. Burnout was positively associated with low resilience, low compassion satisfaction, high secondary traumatic stress and more frequent use of maladaptive coping mechanisms, including self-blame and substance use. Non-clinical issues in the workplace were the main factor perceived to cause low resilience in doctors. Discussion: Despite high levels of resilience, doctors had high levels of burnout and secondary traumatic stress. As doctors already have high resilience, improving personal resilience further may not offer much benefit to professional quality of life.
Introduction: Osteoporotic acetabular fractures in the frail elderly patient are associated with high levels of morbidity and mortality. Aims: We describe the results of a coned hemipelvic acetabular reconstruction and total hip replacement as the treatment of these fractures. Methods: We have prospectively monitored a series of fifteen patients (16 cases) with a mean follow-up of 22 (12-42) months. Results: The mean age was 79 (67-87), and mean ASA score 3.3 (3-5). Thirteen had low-energy injuries, two had high-energy injuries. Mean operative time was 94 minutes. There were seven minor post-operative complications. Fourteen of 15 patients were full weight bearing day one post-operatively. Mean length of hospital stay was 13 (5-27) days. Preoperative mobility status was maintained in 8 patients. At one year mean Harris hip score was 73.13, Merle d’Aubigné score 12.7 and mean EQ-5D score 0.59 (data from 10 patients). Mortality at 30 days was 0%, and 7% at 1 year. There have been no thromboembolic events, dislocations or deep infections. Discussion: The coned acetabular prosthesis minimises operative time and bypasses the fracture, creating an immediately stable construct that allows immediate weight bearing. Early results show an acceptable complication rate, satisfactory patient reported outcomes and excellent survivorship.
Introduction: FFRCT can determine the functional significance of stenosis and guide safe deferral of invasive angiography, however intermediate prognostic implications have not been assessed. Aims: The study aim was to examine the prognosis of fractional flow reserve derived from coronary computed tomography (FFRCT) in routine clinical practice. Methods: Patients referred for FFRCT analysis with stable chest pain at a single centre between October 2015 and June 2017 were retrospectively included and followed up for rates of vessel related late (>90days) unplanned revascularization, MI, and cardiac mortality. Results: 200 (mean age 62.4±10.0 years) patients were sent for FFRCT analysis. A Cox Regression model was used to determine hazard ratios from FFRCT status. FFRCT+ patients were significantly more likely to undergo invasive angiography (p
Introduction: Skin cancer incidence is rising in Northern Ireland (NI)1. The Department of Health, Social Services and Public Safety’s (DHSSPSNI) ‘Skin Cancer Prevention Strategy and Action Plan (2011-2021)’2, aims to reduce skin cancers by raising awareness of the dangers of ultraviolet radiation. Target groups include children and outdoor sports participants. Aim: We surveyed NI sports clubs to gauge whether such messages are reaching members. Methods: Links to sun-safety material accompanied surveys emailed to 562 clubs (158 complete; 75 partially complete). Results: Amongst 158 complete responders, highest responding clubs included Gaelic football (54%), running/ athletics (10%) and golf (9.5%). 67% were unaware of the DHSSPSNI strategy ;< 6% recall receiving promotional material. The majority of clubs provide no sunscreen; 5% supply free sunscreen and 2.5% offer it for special events. Considering future sun-safety promotion, 129/158 clubs would use the material accompanying the survey. Discussion: Evidence shows that safe-sun and skin cancer education does not always lead to behavioural change3,4. Club-level health policies result in healthier behaviours5, with those connected to regional bodies being more inclined to partake. NI clubs are willing to promote sun-safety. They propose better use of social media to target members, with the literature suggesting improved member websites6. Future campaigns could target governing bodies to encourage member-clubs to promote sun-safe behavior.
Introduction: Traditional outcome measures (e.g. mortality, length of hospital stay) may not provide a full depiction of patients’ post-operative state, especially for low-risk interventions such as inguinal hernia repair. Patient reported outcomes (PRO) are becoming increasingly common as primary outcomes in clinical trials. Aims: The aim of this study is to report and summarise the PROs in randomised controlled trials (RCT) comparing laparoscopic versus open inguinal hernia repair techniques. Methods: A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. PubMed, Embase, SCOPUS, Cochrane Library and four clinical trials registries were searched. Identified publications were independently reviewed by two authors. Results: 7,129 records were identified, resulting in 53 RCTs being selected. In total 17,148 patients were identified and 18,004 hernias were repaired. After meta-analysis the laparoscopic group was associated with significantly less post-operative pain, except that reported within 2 weeks post- operatively. Numbness and patient reported satisfaction was also significantly better in the laparoscopic group. Discussion: This study reflects the most up-to-date evidence available for the surgeon to council their patient. It was constrained by the heterogeneity of outcome reporting.
Introduction: The recently updated NICE guidelines regarding investigation and treatment of stable ischaemic heart disease advise CTCA for investigation of chest pain and reserve non-invasive ischaemia tests for patients with known coronary artery disease. In practice, choice of investigation often depends on local availability and expertise and options for non-invasive ischaemia testing include DSE, MPI and CMR. This audit aimed to assess safety outcomes and sensitivity/specificity of stress CMR in Northern Ireland. Methodology: A retrospective audit of patients undergoing CMR from 1st Jan 2016 - 1st January 2017 was undertaken. For patients with a positive CMR, findings at angiography were assessed. For patients with a negative study, the electronic care record was reviewed to assess incidence of adverse outcomes including acute coronary syndrome and mortality. Results: In total, 74 patients were included in the audit. Follow-up was undertaken from 14-26 months. Twenty nine (39.2%) had a positive CMR. Of the 45 stress CMR negative patients, no patient had myocardial infarction or mortality during follow-up. Of the 29 CMR positive patients, 20 (68.9%) had invasive angiography, of which 19 (95.0%) had PCI and 1 (5.0%) had bypass surgery. The remaining 9 patients were felt inappropriate for angiography due to comorbidities. Sensitivity was 0.96 for coronary artery disease according to post CMR angiogram. Discussion: Stress CMR correctly identified patients with obstructive coronary disease which required further therapy with a high degree of sensitivity. Patients with negative studies appear to have a low risk of cardiac events in the short to medium term.
Introduction: A survey of Emergency Medicine Trainees indicated that the progression from lower into higher specialty training (HST) is a stressful transition. Aims: Our aim was to develop a course which met the needs of our trainees based on the feedback obtained from our survey. Methods: We developed a one day course which simulated a busy night shift. The candidate was required to manage simulated patients and the rest of the department represented on a “board”. It tested their ability to prioritise, delegate, lead and managing other staff, deal with difficult situations and maintain situational awareness. Results: Feedback showed improved confidence in managing staff, giving advice, delegating appropriately, making decisions and dealing with difficult situations. All trainees felt the course would improve patient safety and would recommend the course to other trainees. Discussion: The transition into HST is stressful. Our survey identified that the reasons underpinning this are in relation to leadership & management skills and non-technical skills. We showed how a simulated teaching session could help provide a “safe” environment to learn these skills and provide strategies for overcoming common problems. Overall this improved leadership skills, confidence and patient safety.
Introduction: In recent years, clinical negligence claims are a growing reality for dental professionals. Defence organisations report both increasing claim numbers and higher levels of compensation being awarded. Aim: We aim to undertake root cause analysis of negligence claims reported on by a single consultant oral to improve understanding of the root causes and to direct quality improvement activities. Method: Claims were identified between 1993 and 2015 through consultant records and a systematic approach taken to review each case to determine both active and latent factors contributing to the claim. Results: 30 negligence cases were identified with 53% of claimants being male and the most common age group 31-40 (33%). Extractions were the most frequent cause of claims. Other reasons included misdiagnosis, patient injury and complications of treatment. Several latent and active contributing factors were identified for each including organisational (30%), task (97%) and communication (57%) factors amongst others. Discussion This study highlights that the cause for dental negligence claims is often multifactorial. It reinforces an often significant variation in recollection and perception of events by both complainant and dentist. Communication frequently features as a factor although other organisational and task factors also play a significant role. Many root causes identified are preventable or modifiable and therefore measures can be put in place to reduce the impact of these and ultimately risk of negligence and negligence claims.
Introduction: Previous literature identifies authenticity and the holistic nature of the long case as advantages; however its unreliability makes it unsuitable for summative assessment. The views of students are not well represented in existing research. Aims: To ascertain the views of medical students on the value of the long case. Methods: A questionnaire and focus groups were used to discover students’ views on a rheumatology long case. Eighty- six percent of 106 students returned questionnaires and 19% attended focus groups. Qualitative thematic analysis was undertaken. SPSS® was used for statistics. Results: There was overwhelming support for the long case (92% in favour). Students reported it provided them with a ‘real’ encounter and ‘integrated’ their learning. There were mixed opinions on the educational value of the long case. Opinions that it was ‘unfair’ were prominent in focus groups. There was frequent mention of practical difficulties completing the case. Views on the importance of feedback were expressed. Discussion: Students used the terms ‘real’, ‘integrated’ and ‘fair/unfair’ when describing the long case which correspond to the academic terms ‘authentic’ ‘holistic’ and ‘reliable’. We may improve students’ experience by minimising practical obstacles and maximising the quality of feedback.
Aim: A General Surgery firm of a District General Hospital noted an opportunity to improve knowledge and skills for Foundation Year Doctors caring for surgical patients with Peripherally Inserted Central Catheter lines. Shift pattern demands prevented trainees from attending a single education session. Our aim was to improve confidence and knowledge through education with Trust Specialist Nurses. Methods: An initial questionnaire was circulated amongst Foundation Doctors working in Surgery to determine baseline familiarity and confidence with PICC lines. Following education, the questionnaire was recirculated. Results: Pre-education - 14 responses received. 100% encountered a patient with a PICC. 57% had taken blood from a PICC without formal training. 64% encountered difficulty drawing a blood sample from a PICC. The average level of confidence was 6/10. 100% felt they would benefit from formal training on PICC lines. Following formal education: Average level of confidence was 7/10 – demonstrating a 10% increase. Average rating for quality of teaching was 9/10. Conclusion: This unique, combined medical education and patient safety QI project confirmed issues in Junior Doctor training. Results demonstrated simple education can increase confidence in PICC management. As a result, Doctors can deliver safer care for this group of patients.
Introduction: Many surgeons write directly to patients with updates on their care. The readability of this correspondence was not subject to the same standards expected from other patient literature. New guidance on patient correspondence has further highlighted this issue. Aim: To show results from a study we undertook regarding readability in January 2018 and to highlight some of this new guidance. Methods: One hundred consecutive letters written directly to patients from the General Surgery Department, Ulster Hospital in December 2017 were analysed. The Simplified Measure of Gobbledygook (SMOG) was calculated for each letter. Results: The mean SMOG was 11.23. 82% of letters were classified as difficult to read. Discussion: Only 3% of letters included in our initial study were considered ‘easy to read’. Although new guidance does not specify a target age for readability, it does give some advice; this includes words to avoid, sentence length, and avoidance of medical jargon. As part of an ongoing quality improvement project we hope to demonstrate improvement in the readability of patient correspondence.
Introduction: Anaemia is a key contributor to poor obstetric outcome including increased mortality from obstetric haemorrhage. It is associated with fetal death and premature delivery and UK antenatal prevalence is 24.4%. Aims: To review the diagnosis, treatment and follow up of antenatal anaemia and determine the incidence of avoidable anaemia and transfusion at delivery. Methods: A proforma based upon national guidelines was completed following a chart review of mothers with antenatal anaemia who delivered in the Ulster hospital over a one- month period. Results: Of the 22 patients haemoglobin was checked at 28 weeks in 86%. Oral iron was prescribed when indicated in 50% of patients, with 1/3 experiencing a significant delay. 13% received dietary counselling and of those applicable only 7% were referred to secondary care. 31% were appropriately followed up with a 45% adequate response to treatment. There was a 4.5% incidence of avoidable red cell transfusion and 41% avoidable anaemia at delivery. Discussion: To summarise, 31% of patients with confirmed anaemia received oral iron at the correct dose resulting in avoidable anaemia and transfusion at delivery. This review represents substandard practice and creates baseline data for a quality improvement project which is ongoing.
Aims: To determine the presentation, management, waiting times and conversion to SCC of Oral Epithelial Dysplasia (OED) at the School of Dentistry (SOD). Methods: A retrospective review of cases of OED referred to the SOD between March 2011 and July 2017. Hard copy and electronic patient records were used. Results: Overall 45 patient records were reviewed over the time (24 male and 21 female). Over 84% of patients were aged over 50 on referral. Most lesions were located on the tongue or floor of mouth (82%) with almost half appearing as homogenous white patch lesions (69% asymptomatic). Just under one third were referred on the red flag pathway. Management of lesions varied between monitoring (60%), surgical removal, referral or laser excision. Overall 9 of the 51 lesions were re-biopsied and a diagnosis of OSCC made. No link was made between degree of dysplasia and likelihood of conversion. Discussion: OED occurred most frequently in patients over 50 and appears strongly linked to factors such as excessive alcohol intake and smoking. Characteristics of the presenting lesion vary and as such so does triage grade on referral. Management of lesions varied depending on histopathology, clinical findings and risk factors. 20% of lesions later converted to OSCC. Using these findings we aims to formulate a management protocol for these patients in conjunction with histopathology and our head and neck surgery colleagues which will be applicable to both the oral surgery and oral medicine department in the school of dentistry.
As a rheumatology trainee I was aware that for those patients with raynauds syndrome, who were being assessed for an underlying connective tissue disease, there was no facility to perform capillaroscopy. Capillaroscopy is a non-invasive method of examining the nail bed capillaries of patients to assess for any abnormalities. This allows for earlier diagnosis and treatment for those with scleroderma and it also can facilitate discharge of those patients with primary raynauds with normal capillaroscopy findings. My aim was to create a nurse led capillaroscopy clinic for the Belfast Trust by August 2018. I was able to secure funding in order to learn how to perform capillaroscopy in May 2017 and successfully completed a capital funding bid to secure a video capillaroscope for the Belfast Trust. After developing my skills in the procedure I was able to encourage one of our specialist nurses, Donna Torrens, to learn the skill herself. We have now completed 6 capillaroscopy clinics at RVH, reviewing 20 patients (16 Female: 4 Male) who were referred via our online form. For those seen 4 patients were given a connective tissue disease diagnosis, 2 patients had their disease staged, 7 patients were able to be discharged from rheumatology services and the remaining 7 patients require ongoing review due to either abnormal capillaroscopy findings or concerning history. The service shall now continue as a nurse led service.
Introduction: The UK National Vascular Registry (NVR) records and publishes outcomes for procedures performed by vascular consultants. It aims to audit and improve vascular patient care. Difficulty in extracting data from patient notes have led to incomplete entries and underreporting of results. Aims: To improve the accuracy of data entry into the NVR for all patients undergoing carotid endarterectomies (CEAs) at a Regional Vascular Centre. Methods: A total of 5 PDSA cycles were completed. Data was collected over four months from consecutive CEA patients. Deficiencies in data entries were analysed. At month two, a new proforma was introduced highlighting the key data components required for the NVR database along with further sections for MDT input and inpatient note keeping. Staff were unaware that notes were being audited. Data completion rates were then compared. Results: There was a significant improvement in completion of NVR entries after pro forma introduction; admission details improved from 48% to 98% completion and demographics from 68% to 99%. Discussion: The proforma has resulted in an improvement in the accuracy and completion of NVR data entries for CEA patients permitting outcome data to be audited to ensure high standards of patient care.
Introduction: The current pathway is that these patients are referred to a spinal specialist. This generally requires an ambulance trip, often long since the N. Irish population is covered by a single spinal centre. Aim: We propose treatment can be done locally on selected patients. Methods: Retrospective study of new referrals seen in the spinal clinics at the Royal Victoria hospital between October 2017 and March 2018 - 395 patients. The segmental kyphotic angle was compared between imaging at diagnosis and in clinic. We’ve excluded patients: younger than 65yo; with neoplastic/ metastatic fractures; with associated myopathy/neuropathy; clinic letter not typed (n=2). N = 109 patients Results: 20% discharged at 1st encounter. Spinal bracing fitted on 45% but no patients offered surgical intervention. Mean segmental kyphotic angle increased 5.25°. Discussion: There was a minimally significant increase in the mean segmental kyphotic angle. Surgical intervention was not necessary for any of the patients, being analgesia and physiotherapy the treatment modalities chosen. We believe this patient group can be managed locally and only referred to a specialist if meeting defined criteria. This should be less cumbersome for all.
Introduction: Head and neck patients are subject to national requirements to establish a diagnosis by 31 days. Timely communication is key to assisting this. Red flag signposting of letters in medspeech is key step in process. Prior to this project the majority of letters for red flag patients were being dictated as routine and so typing of the dictations could vary between 1 - 4 weeks depending on the secretarial support. One of the issues we faced was clinicians can remove patients from the red flag process and thus think red flag dictation was unnecessary. Aims: To ensure that by start of July 2018, 75% of Red Flag patient Letters are graded correctly in dictation with 100% graded correctly by end of September 2018 Resulting dictations will thus be typed within 24hrs of seeing the patient This complies with the trust’s standard operating procedure, and ensures efficiency within our systems Methods: Baseline data collection to confirm that improvement was required. PDSA 1 Email to OMFS team. PDSA 2 Audit Reminder. PDSA 3 2nd Email to OMFS team. PDSA 4 Notice on Computers. Results: Aim: 75% compliance. Overall steady rise in compliance after every PDSA cycle. Median Prior to first intervention 33% (Week 1-15) Median after PDSA cycle 1= 50% Median after PDSA cycle 2= 49% Median after PDSA cycle 3= 58% Median after PDSA cycle 4= 66% Discussion: Unfortunately we didn’t reach our aim compliance. I feel that we made a substantial improvement in the practises of the staff and that over time we will be able to reach out aim of 75% compliance for red flag dictations.
Introduction NI has one BSGE Endocentre established in 2014 with a team of gynaecologists, colorectal and urology surgeons and one nurse. Aims To determine symptoms and QOL outcomes for women with severe endometriosis since Endocentre was established and patient feedback on current services. Methods BSGE endometriosis database was analysed (previous surgery or hormonal therapy, symptoms and pre- and post-surgery quality of life (QOL) measures). Telephone questionnaires about endometriosis services were undertaken. Results 60 patients on database had QOL score (EQUVAS numeric 0-100 score) recorded. 37% used hormonal therapy pre-surgery, 62% had previous surgery for endometriosis. Most common hormonal therapy was COCP (15%) Most prevalent symptom was menstrual pain (81%). Average pre- surgery QOL score was 57, with average scores at 6 months, 12 months and 24 months post-operatively 67, 71 and 57. Telephone questionnaire (17 patients), 88% attended gynaecology before the endometriosis clinic, 35% noticed improvement since then. Feedback was positive (88%). All felt a patient support group would be beneficial. Discussion On average patients had improved QOL scores at 6 months and 12 months post-operatively. Based on patient feedback, the first endometriosis support group in the Northwest is being established, run by charity and the Patient Client Council.
Introduction Heart failure symptoms are non-specific therefore diagnosis can be challenging. If suspected, the European Society of Cardiology recommends that natriuretic peptide (NP) levels are measured prior to requesting an echocardiogram, as patients with normal NP levels are unlikely to have heart failure and do not require echocardiography. Aims: To ascertain how often an NT-ProBNP is checked prior to requesting an echocardiogram for left ventricular (LV) function assessment. Methods: We reviewed 44 echocardiogram requests submitted between May-October 2017. We used ECR to see if an NT-Pro BNP had been requested beforehand, and how these results correlated. Results: Of 25 inpatient requests, 23 had an NT-ProBNP checked beforehand, compared with 8 out of 19 outpatients. When analysed by grade, the majority of requests came from general practitioners. No patients with normal NT-ProBNP values were shown to have LV dysfunction. Discussion: In the majority of patients in whom LV dysfunction was suspected, echocardiographic assessment was normal. Therefore, a test which can reliably exclude LV dysfunction has significant potential to reduce unnecessary referrals, which would in turn reduce waiting list pressures, patient anxiety and hospital spending. Recommendations for improvements are discussed.
Aim: Evaluating time from admission acute gallstone pancreatitis to cholecystectomy. Method: UK working party guidelines for management of acute pancreatitis. “All patients should undergo definitive management during same admission or within 2 week period.” All coded diagnosis of gallstone pancreatitis Ulster hospital Dundonald admissions 2016. Dataset: Discharge date, ERCP/Surgery, repeat admissions prior to surgery, mode of procedure and 30 day readmission/morbidity/mortality. Results: 51 patients 47 deemed surgically fit. 14.9% had same admission cholecystectomy; 43.5% performed within guideline 2 week period. 96.1% diagnosed MRCP, 2% CT, 2% USS only. 33.3% positive MRCP findings all underwent ERCP Cause of delay: 15% failed or delayed ERCP, 5% required repeat imaging,14% no noted medical/surgical cause 21% Repeat pancreatitis admissions: 27% before ERCP, 36% After ERCP and 36% no evidence of choledocholithasis. 88% performed Laparoscopically, 9.5% lap conversion to open 11% 30 day readmission rate following surgery, 7% with post operative pancreatitis Conclusions: 43.5% had surgery performed within guidelines period. Delays majorly observed due to ERCP availability; however 14% had no medical/surgical reason. Therefore waiting list factors may have had some effect. Delay to surgery is thought to have directly affected rate of readmission with pancreatitis.
Introduction: Within the Mater Hospital admission packs there is a 1 page discharge summary sheet for consultants to fill in when patients are fit for discharge. This ensures vital information eg final diagnosis and review information is communicated. This document was however rarely used. Aims: Increase use of IDD by medical consultants to 90% Methods: - Information session for all medical staff about changes and to gather feedback - All medical consultants emailed to ask for support - Layout of page streamlined - Document changed to yellow paper and moved to front of admission pack - GPs surveyed on what is important in a discharge letter Results: 4 PDSA cycles carried out. Before changes implemented (first audit) 8% were filled out from a random sample of 5 per ward. Improved to 36% on first re-audit, 44% second and 52% on the third. A further re-audit 2 years later (March 2018) showed implementation was at 37%. Discussion: Change can be slow! Project overall a success and improving discharge accuracy has obvious benefits for patient care in community as well as making discharge letters a more accurate document for ECR reference.
Introduction: Nice Guideline 53 recommends standards for the transition of care between inpatient mental health facilities and community follow-up. GP`s should receive discharge summaries within 7 days. At baseline 0% of letters were completed within this timeframe within the T&F. Aim: Discharge summary should to be completed within 7 days for at least 60% of patients in the T&F hospital, and to achieve this within 12 months. Method: The baseline data for all patients admitted and discharged in the 8 months prior were also gathered prior to any intervention. 5 PDSA Cycles were used to introduce a new discharge trolley to each inpatient ward, a new discharge checklist introduced. The letter itself was restructured in a way that made it easier to read and easier to complete. Results: Changes implemented correlated with an improvement from 0% of letters complete within 7 days to over 80% completed. The mean time taken for community teams receiving letters improved from 51 days to 4 days. Discussion: This project attained sustained improvement. Microsystems meetings at a local level also allowed a time allocated to focus on this project within a QI minded approach.
Aim: To reach 90% adherence to DVANI ADHD guidance in East Belfast OPC Background: According DVLA’s guidance, patients with ADHD must notify DVLA/DVANI of their condition. According to DVLA and GMC, it is medical professionals’ responsibility to advise patient to do so. Measures Process: Staff and patient education, use of checklist, information leaflet. Outcome: % of patients per month informed by medical team to notify DVANI of their diagnosis of ADHD Results: Cycle 1 (baseline): 33.3% of patients were advised by medical staff to notify DVANI Cycle 2 (staff educated):56% of patients were advised Cycle 3 (Update existing ADHD checklist to include driving): 75% of patients were advised Cycle 4 (Educate admin staff and update existing checklist): 100% of patients were advised Cycle 5 Questionnaire given to patients and aim to co-produce driving advice leaflet following focus group Conclusion: It is the legal duty of ADHD patients to notify DVANI of diagnosis however it is the responsibility of medical professionals to advise patients to do so. 100% of patients were informed by medical staff to notify DVANI by education and updating the physical health ADHD checklist.
Introduction: Angiosarcoma of the breast and anterior chest wall are extremely rare malignant endothelial cell neoplasms that develop either spontaneously or secondary to radiotherapy treatments. To date lack of published data is limiting best practice guidelines. Aims: To describe incidence, management and outcome of breast angiosarcomas within Northern Ireland as part of the national Breast Angiosarcoma Surveillance Study (BRASS). Methods: An electronic chart review of Northern Ireland patients with histologically confirmed breast angiosarcomas between 01/01/2000 and 31/12/2015. Results: Nine cases (all female) were identified with mean age of 57 at diagnosis. Primary angiosarcomas occurred only with younger patients. 77.8% were secondary angiosarcomas (mean time ∼ six years from receiving radiotherapy to diagnosis). None was discussed by the sarcoma multidisciplinary team (MDT). Seven of the nine patients received surgery (five with curative intent). Chemotherapy was offered to those with non-resectable disease and adjuvant radiotherapy followed inadequate margin of resection. Local recurrence was high with poor survival (shortest three months). Patients with > five year survival had no local recurrence. Discussion: Owing to small sample size, a collaborative approach is required to produce valuable data that shapes future studies and practice guidelines. These cases should all be discussed at sarcoma MDT meeting.
Introduction: As volunteer doctors in Kiwoko Hospital Uganda we demonstrated a lack of uniformity in antibiotic prescription amongst healthcare professionals for the same diagnoses through clinical audit. The WHO is very clear regarding prudent antibiotic prescription by healthcare professionals and its role in reducing the problem of antimicrobial resistance. Aims: Improving patient safety by ensuring the most appropriate antibiotic is chosen for a given illness. Methods: Based on Uganda Clinical Guidelines 2016 and medications available locally, an accessible antibiotic protocol was devised, printed and placed on four of the wards with education for medical staff. The same exclusion criteria were used as the initial audit and same parameters were measured following introduction of the protocol. In total 228 cases were used. Results and Discussion: An improvement was demonstrated in uniformity of antibiotic prescription with the ‘correct’ choice rising from 17% to 41% following introduction of protocol. The hospital management has introduced the protocol to a number of different clinical areas as a result of the QIP. Anti-microbial resistance is everyone’s responsibility and this intervention resulted in improvement in suitable empirical choice of antibiotic in a low resource setting.
Introduction: Challenge: Mental Health Bed Crisis, Bed Occupancy >110%, Reliance on out of Trust beds Safety issues, Difficulties engaging carers, Cost Aims: Decrease bed occupancy to 85% Decrease length of stay by 30% Increase service user/staff satisfaction Methods: Solution: Purposeful Inpatient Admission (PIpA) Based on the Toyota Production System Model Used in healthcare in the Virginia Mason Medical Centre Key features: Patient’s experience central Replaces batched decision making with continuous flow Standardised processes for each step Continuous monitoring of changes/outcomes Formulation and purposeful treatment plan within 72 hours of admission Patient’s journey mapped out on a Visual Control Board Daily report out instead of weekly ward round Daily tasks board Delays immediately identified and escalated Results: ‘Green’ bed status (>5 available beds) for 24 consecutive days 85% Bed occupancy (Royal College of Psychiatrists’ recommendation) >30% reduction in length of stay Reduction in violent incidents No complaints during pilot Increased staff satisfaction Discussion: Conclusion/Next steps Aims met (bed occupancy/length of stay/satisfaction) Sustain improvements in bed occupancy and length of stay Implementation to remaining general adult acute wards.

الوصول الحر: https://explore.openaire.eu/search/publication?articleId=pmc_________::ead7c6144596a0578250586fac44b08fTest
http://europepmc.org/articles/PMC8130193Test

المؤلفون: Hickland, Patrick¹ (AUTHOR) phickland01@qub.ac.uk, Goodland, Christopher¹ (AUTHOR), Zachariah, Sunil¹ (AUTHOR), E Murphy, Lynn¹ (AUTHOR), Neil, Martyn¹ (AUTHOR)

المصدر: European Journal of Orthopaedic Surgery & Traumatology. Jan2023, Vol. 33 Issue 1, p159-165. 7p.

مصطلحات موضوعية: *CLAVICLE fractures, *RETROSPECTIVE studies, *TREATMENT effectiveness, *COMPARATIVE studies, *FRACTURE fixation, *DESCRIPTIVE statistics

مستخلص: Purpose: Clavicle fractures in the lateral third are associated with more complications. Various methods of internal fixation exist; however, there is no consensus which should be employed. The purpose of this study was to evaluate the outcomes of these various methods in our regional trauma unit. Methods: We performed a retrospective review of patients who underwent internal fixation of a lateral clavicle fracture in our unit between 1 August 2014 and 31 July 2019. Demographic and outcome data were extracted from electronic care records and imaging systems. Results: In total, 44 patients were included, with the following demographics: mean age 26 years, 63.6% male, 65.9% high-energy injury, 68.2% Neer II fracture. The following operations were performed: hook plate fixation (HPF) = 10, locking plate fixation (LPF) = 16, coracoclavicular ligament reconstruction (CCLR) = 12, and LPF + CCLR = 6. Patients having LPF had a significantly larger post-operative coracoclavicular distance (7.6 mm vs 13.5 mm, p < 0.01), and trends towards a lesser decrease in CCD (9.9 mm vs 12.6 mm, p = 0.37) and incomplete ACJ reduction (50.0% vs 89.3%, p = 0.11). There was a significantly higher re-operation rate after HPF (100% vs 23.5%, p < 0.01). There were no differences in time to union or duration of follow-up. Conclusion: In our unit there is no clearly favoured method of internal fixation of lateral clavicle fractures. When LPF is used, there should be consideration of concomitant CCLR. The high rate of re-operation after HPF is concordant with previous research. [ABSTRACT FROM AUTHOR]

المؤلفون: Hickland, Patrick, Goodland, Christopher, Zachariah, Sunil, E Murphy, Lynn, Neil, Martyn

المصدر: European Journal of Orthopaedic Surgery & Traumatology ; volume 33, issue 1, page 159-165 ; ISSN 1432-1068

مصطلحات موضوعية: Orthopedics and Sports Medicine, Surgery

الإتاحة: https://doi.org/10.1007/s00590-021-03173-zTest

المؤلفون: Hickland, Patrick

مصطلحات موضوعية: microalgae

الوصف: Many species of microalgae have attracted attention from industrial biotechnology with the goal of harnessing specific physiological traits in applications including fuel, food, feed and high value medicinal products. However, to realise their full potential certain species will require optimisation through engineering. This study focussed on molecular tool development to address bottlenecks hindering the engineering of two microalgal species: the green alga *Chlorella vulgaris* and the marine diatom *Phaeodactylum tricornutum*, both exhibit rapid growth rates and high density cultures making them prominent candidates for use in numerous applications. Work in this thesis was sponsored by the algal biotechnology company Algenuity, Stewartby, Bedfordshire. Progress in engineering of *Chlorella* has been slowed by the lack of reliable transformation protocols. In this study transformation protocols based on electroporation and biolistics were investigated with the goal of reliably transforming Algenuity’s proprietary *C. vulgaris* strain. The literature surrounding these transformation methods was systematically reviewed and informed the protocol development process. RNAseq analysis of the closely related species *Chlorella variabilis* informed the design and assembly of a Golden Gate (GG) based *Chlorella* MoClo toolkit including promoters, terminators and antibiotic resistance genes. Regulatory elements from a *Chlorella* virus and *Chlamydomonas reinhardtii* were also included in the toolkit. From these parts antibiotic resistance cassettes were assembled and used in trials to develop an electroporation or biolistic transformation protocol for *C. vulgaris*. Attempts to transform the proprietary strain by these means were unsuccessful but a transformation technique based on *Escherichia coli* conjugation was successfully employed enabling the characterisation of the parts assembled. Results of conjugative transformation suggest that use of the *C. reinhardtii* RbcS2 intron1 in antibiotic resistance CDS reduces ...

وصف الملف: application/pdf

العلاقة: https://www.repository.cam.ac.uk/handle/1810/362641Test; https://doi.org/10.17863/CAM.104724Test

الإتاحة: https://doi.org/10.17863/CAM.104724Test
https://www.repository.cam.ac.uk/handle/1810/362641Test

المؤلفون: Hickland, Patrick, Gargan, Phyl, Simpson, Jacquie, McCabe, Niamh, Costa, Janitha

المصدر: The Journal of Maternal-Fetal & Neonatal Medicine ; volume 31, issue 22, page 3002-3008 ; ISSN 1476-7058 1476-4954

الإتاحة: https://doi.org/10.1080/14767058.2017.1362382Test

المؤلفون: Hickland, Patrick, Lakshmipathy, Gokul R., McCollum, Kirsten, Mullan, Kathryn

المصدر: The Ulster Medical Journal

مصطلحات موضوعية: Abstracts

الوصول الحر: https://explore.openaire.eu/search/publication?articleId=pmc_________::cf2b81099d4909fb4c3a5faddfd14339Test
http://europepmc.org/articles/PMC5849988Test

المؤلفون: Gargan, Phyl, Simpson, Jacquie, McCabe, Niamh, Hickland, Patrick, Costa, Janitha

المصدر: Journal of Maternal-Fetal & Neonatal Medicine; Nov2018, Vol. 31 Issue 22, p3002-3008, 7p

مصطلحات موضوعية: BREECH delivery, HEALTH counseling, CESAREAN section, MATERNITY nursing, TERTIARY care

مستخلص: Objective: In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012.Methods: Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015.Results: There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic.Conclusions: A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined. [ABSTRACT FROM AUTHOR]

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