Acute Setting Research Articles

OUTCOMES OF ACUTE ANKLE DISTRACTION FOR INTRA-ARTICULAR DISTAL TIBIAL AND PILON FRACTURES

IntroductionIntra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures.Materials & MethodsWe undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA).137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups.ResultsMean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years.PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17).ConclusionsThis pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures.

The Use of Animations Depicting Cardiac Electrical Activity to Improve Confidence in Understanding of Cardiac Pathology and Electrocardiography Traces Among Final-Year Medical Students: Nonrandomized Controlled Trial.

Electrocardiography (ECG) interpretation is a fundamental skill for medical students and practicing medical professionals. Recognizing ECG pathologies promptly allows for quick intervention, especially in acute settings where urgent care is needed. However, many medical students find ECG interpretation and understanding of the underlying pathology challenging, with teaching methods varying greatly. This study involved the development of novel animations demonstrating the passage of electrical activity for well-described cardiac pathologies and showcased them alongside the corresponding live ECG traces during a web-based tutorial for final-year medical students. We aimed to assess whether the animations improved medical students' confidence in visualizing cardiac electrical activity and ECG interpretation, compared to standard ECG teaching methods. Final-year medical students at Imperial College London attended a web-based tutorial demonstrating the 7 animations depicting cardiac electrical activity and the corresponding ECG trace. Another tutorial without the animations was held to act as a control. Students completed a questionnaire assessing their confidence in interpreting ECGs and visualizing cardiovascular electrical transmission before and after the tutorial. Intervention-arm participants were also invited to a web-based focus group to explore their experiences of past ECG teaching and the tutorial, particularly on aspects they found helpful and what could be further improved in the tutorial and animations. Wilcoxon signed-rank tests and Mann-Whitney U tests were used to assess the statistical significance of any changes in confidence. Focus group transcripts were analyzed using inductive thematic analysis. Overall, 19 students attended the intervention arm, with 15 (79%) completing both the pre- and posttutorial questionnaires and 15 (79%) participating in focus groups, whereas 14 students attended the control arm, with 13 (93%) completing both questionnaires. Median confidence in interpreting ECGs in the intervention arm increased after the tutorial (2, IQR 1.5-3.0 vs 3, IQR 3-4.5; P<.001). Improvement was seen in both confidence in reviewing or diagnosing cardiac rhythms and the visualization of cardiac electrical activity. However, there was no significant difference between the intervention and control arms, for all pathologies (all P>.05). The main themes from the thematic analysis were that ECGs are a complex topic and past ECG teaching has focused on memorizing traces; the visualizations enabled deeper understanding of cardiac pathology; and ECG learning requires repetition, and clinical links remain essential. This study highlights the value of providing concise explanations of the meaning and pathophysiology behind ECG traces, both visually and verbally. ECG teaching that incorporates relevant pathophysiology, alongside vignettes with discussions regarding investigations and management options, is likely more helpful to students than practices based solely on pattern recognition. Although the animations supported student learning, the key element was the tutor's explanations. These animations may be more helpful as a supplement to teaching, for instance, as open-access videos.

Radiographers' experiences in working with patients living with dementia in Norway – A qualitative study

IntroductionImaging departments are seeing an increase in the number of patients living with dementia (PWD), driven by the ageing population and diagnostic benefits offered by medical imaging. This study explored radiographers' experiences during imaging examinations for PWD. MethodsA semi-structured interview guide comprising questions about radiographers' experiences, knowledge concerning PWD, challenges faced, and departmental initiatives was developed. Eight radiographers were interviewed, four working in MRI or general imaging, including CT and four in nuclear medicine, at three hospital trusts in Norway. Data analysis was conducted using inductive content analysis as described by Elo and Kyngäs, following a three-step process of preparation, organising and reporting. The qualified radiographers coded, categorised, and defined the themes and sub-themes to report on the findings. ResultsThree main categories emerged: 1. Radiographers' experiences, which included overall challenges and the radiographers’ attitudes. 2. Measures undertaken, outlining the actions radiographers take during procedures, and 3.Competencies, highlighting the knowledge possessed by radiographers. Organisational challenges, such as the absence of overarching protocols and insufficient training for radiographers related to PWD, posed difficulties in effectively conducting procedures. Creating a calm environment, collaborating with caregivers, scheduling adequate time for examinations, and possessing good communication skills were viewed as facilitators for conducting examinations successfully. ConclusionRadiographers perceived imaging of patients living with dementia to be generally uncomplicated. However, challenges in planning for and communicating with patients, particularly for advanced examinations or acute settings, were reported. Establishing dementia-friendly departments and training radiographers in specific communication techniques could be beneficial. Implications for practiceThere is a need for more dementia-friendly imaging departments and communication training for radiographers working with PWD.

Should HLA and HPA-matched platelet transfusions for patients with Glanzmann Thrombasthenia or Bernard-Soulier syndrome be standardized care? A Dutch survey and recommendations.

Glanzmann thrombasthenia (GT) and Bernard-Soulier syndrome (BSS) patients require frequent platelet transfusions and hence have an increased risk for alloimmunization against donor Human Leukocyte Antigens (HLA) when no HLA-matching is performed. Knowing that Human Platelet Antigens (HPA) are located on the platelet glycoproteins that can be absent in these patients, preventive HPA-matching may also be considered. Uniform recommendations on this topic lack in transfusion guidelines making standard practice unclear, therefore, we aimed to provide a framework for matched platelet transfusions. We conducted a targeted literature search and a national survey of Dutch (pediatric) hematologists from July to September 2021. We found 20 articles describing platelet transfusion policies in 483 GT-patients and 29 BSS-patients, both adults and children. Twenty surveys were returned for full analysis. All responders treated patients with platelet disorders, including GT (n = 36 reported) and BSS (n = 29 reported). Of respondents, 75% estimated the risk of antibody formation as "likely" for HLA and 65% for HPA. Formation of HLA antibodies was reported in 5 GT and in 5 BSS-patients, including one child. Fifteen respondents gave preventive HLA-matched platelets in elective setting (75%). Three respondents additionally matched for HPA in GT-patients (15%). Main argument for matched platelet transfusions was preventing alloimmunization to safeguard the effectivity of 'random' donor-platelets in acute settings. Elective HLA-matching for GT and BSS-patients is already conducted by most Dutch (pediatric) hematologists. HPA-matching is mainly applied when HPA-antibodies are formed. Based on the current literature and the survey, recommendations are proposed.

Role of NT-proBNP and lung ultrasound in diagnosing and classifying heart failure in a hospitalized oldest-old population: a cross-sectional study.

Diagnosing and classifying heart failure (HF) in the oldest-old patients has technical and interpretation issues, especially in the acute setting. We assessed the usefulness of both N-terminal pro-brain natriuretic peptide (NT-proBNP) and lung ultrasound (LUS) for confirming HF diagnosis and predicting, among hospitalized HF patients, those with reduced ejection fraction (HFrEF). We performed a cross-sectional study on 148 consecutive patients aged ≥ 80 years admitted to our Internal Medicine and Geriatrics ward with at least one symptom/sign compatible with HF and NT-proBNP ≥ 125 pg/mL. We measured serum NT-proBNP levels and performed LUS and transthoracic echocardiography (TTE) on admission before diuretic therapy. We divided our cohort into three subgroups according to the left ventricular ejection fraction (LVEF): reduced (LVEF ≤ 40%), mildly-reduced (LVEF = 41-49%) and preserved (LVEF ≥ 50%). The mean age was 88±5 years. Male prevalence was 42%. Patients with HFrEF were 19%. Clinical features and laboratory parameters did not differ between the three subgroups, except for higher NT-proBNP in HFrEF patients, which also had a higher number of total B-lines and intercostal spaces of pleural effusion at LUS. Overall, NT-proBNP showed an inverse correlation with LVEF (r = -0.22, p = 0.007) and a direct correlation with age, total pulmonary B-lines, and intercostal spaces of pleural effusion. According to the ROCs, NT-proBNP levels, pulmonary B-lines and pleural effusion extension were poorly predictive for HFrEF. The best-performing cut-offs were 9531 pg/mL for NT-proBNP (SP 0.70, SE 0.50), 13 for total B-lines (SP 0.69, SE 0.85) and one intercostal space for pleural effusion (SP 0.55, SE 0.89). Patients with admission NT-proBNP ≥ 9531 pg/mL had a 2-fold higher risk for HFrEF (OR 2.5, 95% CI 1.3-4.9), while we did not find any association for total B-lines ≥ 13 or pleural effusion ≥ 1 intercostal space with HFrEF. A significant association with HFrEF emerged for the combination of NT-proBNP ≥ 9531 pg/mL, total B-lines ≥ 13 and intercostal spaces of pleural effusion ≥ 1 (adjusted OR 4.3, 95% CI 1.5-12.9). Although NT-proBNP and LUS help diagnose HF, their accuracy in discriminating HFrEF from non-HFrEF was poor in our real-life clinical study on oldest-old hospitalized patients, making the use of TTE still necessary to distinguish HF phenotypes in this peculiar setting. These data require confirmation in more extensive and longer prospective studies.

0488 Exploring Study Recruitment Trends in the Acute Post-Stroke Setting

0488 Exploring Study Recruitment Trends in the Acute Post-Stroke Setting

0486 Performing Polysomnography in the Acute Post-stroke Setting

0486 Performing Polysomnography in the Acute Post-stroke Setting

Transcatheter knocking of a stuck mechanical tricuspid valve.

Immobilisation of mechanical valve leaflets can be a life-threatening complication. In the acute setting, medical therapy can be attempted but is not always successful. We present the first described case of a patient with a mechanical tricuspid valve with recurrent leaflet immobilisation that was able to be mobilised using a transcatheter knocking technique.

The Effect of Neurodevelopmental Disorders on the Prognosis of Children Undergoing Heart Transplantation: A Retrospective Analysis of the National Inpatient Sample 2011–2019

Background: Many international governing bodies recommend against heart transplantation in patients with severe cognitive-behavioral disabilities, however no clear criteria are offered to define severity. Patients with neurodevelopmental disorders may face systematic discrimination when being evaluated for transplant. We set out to investigate whether children with neurodevelopmental disorders that undergo heart transplantation have poorer in-hospital outcomes compared to neurotypical children. Methods: A retrospective analysis of the National Inpatient Sample database was conducted to identify pediatric patients with neurodevelopmental disorders who underwent heart transplantation from 2011–2019. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to investigate the association between the documented presence of a neurodevelopmental disorder and in-hospital outcomes in children undergoing heart transplantation. Results: We identified a weighted sample of 3770 pediatric cardiac transplant patients, of whom 245 (6.5%) had a documented diagnosis of neurodevelopmental disorder. There was no significant difference in the odds of major adverse cardiovascular events (all-cause mortality, stroke complications or myocardial infarction), surgical complications, infection, venous thromboembolic events, delirium/restraint use, or cardiac dysrhythmia. Patients with neurodevelopmental disorders had lower overall length of stay (44.0 days interquartile range (IQR): 16.0–90.0 vs. 57.08 days IQR: 22.0–112.0, p &lt; 0.050), and cost of stay ($956,031 IQR: 548,559.0–1,801,412.0 vs. $1,074,793 IQR: 599,089.8–2,129,086.0, p &lt; 0.050). Patients with neurodevelopmental disorders had significantly lower odds of acute transplant complications (adjusted odds ratio (aOR): 0.39, 95% confidence interval (CI): 0.21–0.74, p &lt; 0.050) vascular complications (aOR: 0.36, 95% CI: 0.19–0.66, p &lt; 0.050) and acute kidney injury (AKI) (aOR: 0.52, 95% CI: 0.33–0.83, p &lt; 0.050). Conclusions: These data suggest that patients with neurodevelopmental disorders have overall similar if not potentially improved post-transplant outcomes in the acute setting compared to neurotypical patients, possibly secondary to selection bias in the patient selection process.

Poetry Workshop in the Acute Inpatient Psychiatric Setting: Feasible, Acceptable, and Significantly Beneficial

Objective: We investigated the feasibility and acceptability of establishing a therapeutic poetry writing workshop in an acute inpatient psychiatric setting, as well as the impact of participation on measures of mood, hope, and recovery orientation. Methods: Participants were recruited from the inpatient psychiatric units of an academic medical center. As a pre/post measure of effect of the poetry intervention, participants completed the Herth Hope Index (HHI) and the Mental Health Confidence Scale (MHCS) at baseline and follow-up, as well as a Brief Mood Survey (BMS) immediately before and after each instance of participation in the poetry workshop. Student’s t-tests were used to assess for changes on HHI, MHCS, and BMS, as well as to compare the before vs after in these metrics for individuals who attended only one workshop session versus those who attended two or more sessions to assess for dose-dependent effect of the intervention. Workshop participants also optionally completed a satisfaction survey of their qualitative experience of the group. The protocol for leading a workshop is described in detail. Results: There was a statistically significant improvement in multiple subscales of mood according to the pre- and post-measures on the BMS. Results of the HHI indicated a trend toward increased hopefulness. Results of the MHCS showed statistically significant improvement in participants’ confidence in managing day-to-day life with a mental illness. Results of satisfaction surveys indicate that participants had an overwhelmingly positive experience of the group. Conclusions and Implications for Practice: Workshops designed to foster writing and sharing poetry in a group format are likely to be clinically helpful to improve mood for patients in an acute inpatient psychiatric setting. Future research may examine the adaptability of this intervention for outpatient and virtual settings. Impact and Implications: We conducted a poetry workshop for patients in an acute inpatient psychiatric unit. Participation in the workshop even just once provided a statistically significant and clinically meaningful improvement in multiple subscales of mood and confidence in managing day-to-day life with a mental illness. Our study describes in detail the protocol for a mental health clinician to recreate a similar poetry workshop in their own clinic or hospital.

Cangrelor for neurointerventional procedures: A systematic review.

Thromboembolism is a complication of neurointerventional procedures that requires patients to be placed under antiplatelet therapy. Current options for antiplatelet therapies have a delayed onset of action that prevents a rapid door to puncture transition for patents presenting in acute settings. Cangrelor (Kengreal, Chiesi, USA) is an intravenous P2Y12 platelet inhibitor approved in percutaneous coronary interventions that has an immediate onset of action and half-life between 2 and 6 min. Thus, the goal of this study is to report on the safety, effectiveness, and indications for using Cangrelor in neurointerventional procedures. A systematic review of studies describing the use of Cangrelor in neurointervention was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was conducted on PubMed, Ovid Medline, and Embase databases through June 2023. Seventeen studies with 314 patients met inclusion criteria. The most common indication for Cangrelor use was acute ischemic strokes: 70% followed by aneurysms 27.4%. The Infusion protocol varied from 5 to 30 μg/kg bolus and 1 to 4 µg/kg/min infusion with 30 μg/kg bolus and 4 µg/kg/min infusion being reported in 64.7% of studies. Intra-operative platelet reacting unit levels were below 200 in all the studies that reported it, and the percentage of hemorrhagic, thromboembolic, and deaths occurrence in this patient cohort was respectively 11.1%, 4.8%, and 8.6%. Cangrelor appears to be a promising P2Y12 platelet inhibitor for neurointerventional procedures. However, large, randomized trials are needed to determine the full range of its effects in neurointerventional procedures.

A rhPDGF-BB/bovine type I collagen/β-TCP mixture for the treatment of critically sized non-union tibial defects: An in vivo study in rabbits.

Non-union during healing of bone fractures affects up to ~5% of patients worldwide. Given the success of recombinant human platelet-derived growth factor-B chain homodimer (rhPDGF-BB) in promoting angiogenesis and bone fusion in the hindfoot and ankle, rhPDGF-BB combined with bovine type I collagen/β-TCP matrix (AIBG) could serve as a viable alternative to autografts in the treatment of non-unions. Defects (~2 mm gaps) were surgically induced in tibiae of skeletally mature New Zealand white rabbits. Animals were allocated to one of four groups-(1) negative control (empty defect, healing for 8 weeks), (2 and 3) acute treatment with AIBG (healing for 4or 8weeks), and (4) chronic treatment with AIBG (injection 4 weeks post defect creation and then healing for 8 weeks). Bone formation was analyzed qualitatively and semi-quantitatively through histology. Samples were imaged using dual-energy X-ray absorptiometry and computed tomography for defect visualization and volumetric reconstruction, respectively. Delayed healing or non-healing was observed in the negative control group, whereas defects treated with AIBG in an acute setting yielded bone formation as early as 4 weeks with bone growth appearing discontinuous. At 8 weeks (acute setting), substantial remodeling was observed with higher degrees of bone organization characterized by appositional bone growth. The chronic healing, experimental, group yielded bone formation and remodeling, with no indication of non-union after treatment with AIBG. Furthermore, bone growth in the chronic healing group was accompanied by an increased presence of osteons, osteonal canals, and interstitial lamellae. Qualitatively and semiquantitatively, chronic application of AI facilitated complete bridging of the induced non-union defects, while untreated defects or defects treated acutely with AIBG demonstrated a lack of complete bridging at 8 weeks.

Middle Meningeal Artery Embolization in the Acute Subdural Hematoma Setting (P8-2.006)

Middle Meningeal Artery Embolization in the Acute Subdural Hematoma Setting (P8-2.006)

IPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center.

There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting. Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis. Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Return to Work in Breast Cancer Patients following an Interdisciplinary Rehabilitation Program in a Community-Based Cancer Rehabilitation Center: A Pilot Study.

Despite curative treatment and discharge from acute hospital settings, breast cancer patients often have cancer- and treatment-related morbidity which impairs them from returning to work. Hence, the role of community-based return to work rehabilitation programs is important to help these patients transition back to work. This was a retrospective cohort study involving patients with breast cancer conducted at a community-based cancer rehabilitation center. Patients were involved in an interdisciplinary vocational rehabilitation program involving physiatrists, occupational therapists, physiotherapists and social workers. We recruited 63 patients for this study cohort, with 46 (73.0%) patients ≤ 60 years old. After undergoing the rehabilitation program, there were 37 (58.7%) participants who successfully returned to work. These participants returned to work at either within 6 months (27.0%), 12 months (29.7%) or 24 months (43.2%) after enrollment into the program, with a majority enrolling in white collar jobs. Multivariate regression analysis revealed that significant negative factors for return to work were advanced stage of cancer (p = 0.004), along with clinically significant fatigue, measured on the Brief Fatigue Inventory (p < 0.001). However, perceived work ability (p = 0.020) was found to be a positive factor.

The Role of Language Barriers on Hospital Outcomes in Culturally and Linguistically Diverse Patients following Trauma Admission

(1) Background: Patients who experience acute traumatic injury requiring hospitalisation represent a vulnerable population. The trauma patient often experiences multi-system injuries and complex physiology. Additionally, there are complex socio-ecological issues that impact the care and outcomes of trauma patients. Of interest, culturally and linguistically diverse populations with language barriers experience worse outcomes in trauma settings. This scoping review evaluates the current evidence on language barriers in this population and the influences on outcomes for trauma patients. (2) Methods: A scoping review was performed following a computer-assisted search of the Medline, Embase and Cochrane Central databases. Papers that evaluated the impact of the language barrier in culturally and linguistically diverse populations and outcomes in acute trauma settings were included. (3) Results: A literature search identified eight articles that were eligible for inclusion. Overall, there was no robust evidence to suggest that such populations were disadvantaged in terms of length of hospital stay and overall mortality. However, studies did identify that these populations were at higher risk of disability and poor mental health outcomes, experienced communication barriers more often and had lower social functioning. (4) Conclusions: This scoping review demonstrates that individuals admitted due to trauma who are from culturally and linguistically diverse backgrounds experience more significant disadvantages concerning psychological and functional outcomes. It is posited this is due to their inability to communicate their complex needs in trauma, however more robust and rigorous research is required to better characterise this effect.

Valid consent in the acute hospital setting: perspectives of patients and members of the public

BackgroundPeople who interact with healthcare services have an ethical and legal right to control their own lives, to make informed decisions, and to consent to what happens to them. For consent to be considered ethically and legally valid, three key criteria must be met: consent must be given voluntarily; people must be sufficiently informed of all options; and people should have capacity to make the decision to give or withhold their consent.AimThis study set out to explore, through the use of surveys, the perspectives of patients and public in relation to consent.MethodSurveys were developed for patients and the public and administered paper based (patients) and through social media (public).ResultsOne hundred and forty surveys were posted to patients, with a 38% response rate; 104 responses were received from the public. Ninety-six percent of patients were satisfied that the decision they made was informed; 100% felt they had made a voluntary decision; 98% felt the clinician seemed knowledgeable about the procedure. What matters most to the public were being informed about the risks associated with the proposed procedure and being assured that whatever choice they make they will receive the best care possible.ConclusionsThe results highlight interesting similarities and differences in relation to consent between members of the public thinking about a possible treatment, surgery, or procedure and those patients who have actually been through the process in the past 12 months. Recommendations have been developed on the basis of these findings to co-design improvements in consent practices.

Evaluation of community nurse-led traumatic tube displacements.

Home enteral tube feeding (HEF) has many benefits and is largely safe practice. Some complications have historically required intervention in the acute setting, including traumatic displacement of feeding tubes (i.e. internal bumper/balloon removed intact), and evidence to support the safe replacement of these tubes in the community is lacking. To address this, a service enabling community homecare nurses (CHN) to replace traumatically displaced feeding tubes was designed and evaluated. Adult patients presenting with a traumatically displaced feeding tube over 29 months were included in the service evaluation. Baseline characteristics and outcomes at day 1, 7 and 6 months post-replacement were recorded. A total of 71 tube replacements were performed by CHNs in 60 patients. No clinical complications were recorded at any follow-up points. A simple cost analysis estimated savings of £235 754.40. These results suggest that nurse-led replacement of traumatically displaced feeding tubes in adults in the community is low-risk and offers potential cost savings.

Recurrent Vision Loss in a Patient with Giant Cell Arteritis while on High Dose Corticosteroids

Giant cell arteritis (GCA) is a chronic vasculitis that can lead to permanent vision loss. In this case we describe a patient with permanent monocular vision loss from GCA, managed with long-term glucocorticoids, who presented with elevated erythrocyte sedimentation rate and acute visual loss. This patient was promptly given intravenous steroids, with initial improvement, however, she again experienced acute vision loss on the fourth day of treatment. Given the rare nature of this recurrent GCA-related vision loss during treatment, a broader workup was pursued without an alternative cause identified. Temporal biopsy was not performed due to concern of a false-negative in the setting of chronic steroid use. In this report we discuss the long-term monitoring and management of GCA, recurrence in the acute treatment setting, and present evidence related to diagnosis of GCA in the context of long-term steroid use.

Clinical psychologists' experience of facilitating team case formulation in acute and crisis mental health settings

Background: Team case formulation is recommended clinical practice for managing patients' challenging behaviour in acute psychiatric settings. There are limited standardised protocols for case formulation and research lacks insights from facilitators. This predominantly qualitative study aimed to explore facilitators' experience of team case formulation in acute psychiatric settings to understand this practice and inform future approaches. Methodology: Clinicians with experience of facilitating team case formulation were recruited. Quantitative data was collected using visual analogue scales. Qualitative data was collected through in-depth semi-structured interviews and analysed using thematic analysis. Results: Participants were ten clinical psychologists. Findings highlighted benefits of team case formulation, including increasing staff understanding of patients' challenging behaviour and support for staff. Participants reported that a variety of models and approaches are used, which provide different ways of understanding complex presentations and challenging behaviour. Challenges to delivering case formulation included disruptions to sessions, unclear roles and expectations, and limited attendance, preparation time, and patient involvement. Challenges with dissemination and follow-ups to case formulation included lack of communication and agreement amongst staff and difficulties putting intervention plans into practice due to lack of resources. Conclusion: Team case formulation has benefits for staff and patients. While case formulation appears to enhance psychological-mindedness of staff, promote a person-centred approach, improve ward-culture, and reduce patients' challenging behaviours, there is a need to increase resources, consistency in approaches, collaboration between staff, and evaluation of outcomes. Findings from this study have the potential to inform frameworks for team case formulation.