Clinic Letters Research Articles

BN SO26 - Predicting successful and safe day-case laparoscopic cholecystectomy: Validation of the Cholecystectomy as a Day Case (CAAD) score

Abstract Background Day case surgery is a major target for the NHS as it improves patient satisfaction and reduces financial costs. The CAAD score, using pre-operative variables from clinic letters and electronic sources, aids in selecting patients for day-case lists. This study assessed the validity of the CAAD score in predicting successful and safe day-case laparoscopic cholecystectomy (LC) at an isolated day unit. Method A retrospective analysis was performed on patients scheduled for elective LC between January 2020 and March 2022. Outcomes (same day discharge rate, length of stay, conversion to open, bile leak, mortality) were stratified by CAAD score (≤5, >5). Statistical analyses included Chi square and independent t-tests using SPSS 28.0. Results 58 patients were analysed.18/38 patients with CAAD ≤5 achieved same day discharge compared to 4/20 with CAAD >5 (p<0.05). 36 patients stayed for ≥1 day. The mean length of hospitalization was 1.38 days (range 1-2) for the 13 patients with CAAD ≤5. 15 patients with CAAD >5 stayed significantly longer i.e. 2.53 days (range 1-10) (p <0.05). Longer stay for scores >5 was due to difficult dissection (13%), conversion to open (13%) and drain insertion (7%). For scores ≤5, reasons were drain insertion, postoperative pain, nausea, and difficult dissection, each at 8%. No major complications were noted in either group. Conclusion The CAAD score is a predictive tool for successful and safe day-case LC, correlating lower scores with higher success rates and shorter hospital stays. Implementing the CAAD score can improve patient selection, potentially reduce unnecessary overnight stays, and support operational efficiency in isolated day units.

HPB SO26 - Evaluation of Theatre Database Accuracy in a Tertiary HPB Center According to NCIP Standards in the UK

Abstract Background The goal of creating the NCIP (National Clinical Improvement Programme) theatre data set discovery information system is to allow NHS Improvement to evaluate how theatre data can improve the attribution of surgical activities, as documented in Hospital Episode Statistics (HES) Admitted Patient Care (APC) data, to individual consultants. The success of NCIP is at risk due to the inaccurate attribution of existing activity data to consultants. Method The NCIP theatre database for the Hepato-Pancreato-Biliary (HPB) surgery department was compiled over a 12-month period (from April 2022 to April 2023) and analyzed based on the operating consultant recorded in the operative notes, clinical letters, and the Carfelow system (admitting office records). Results In Nottingham University Hospitals (NUH), 143 major liver and pancreatic resections were performed, including 38 Whipple’s procedures (both classic and Pylorus-preserving Pancreatico-Duodenectomy), 19 Distal Pancreatectomies, and 86 Liver resections. Of these, only 58 patients (40.6%) had correct entries in the NCIP database regarding the operating surgeon. The NCIP data inaccuracies for the operating consultant were 65.8% (25/38) for Whipple’s procedures, 57.9% (11/19) for Distal Pancreatectomies, and 56.97% (49/86) for Liver resections. Conversely, the NCIP data was 100% accurate concerning the assigned consultant on Careflow, which matches the clinical letters from the outpatient clinic. Conclusion The gap between the NCIP database and the admitting office database leads to inaccurate attributions of surgical activity. This hinders learning and improvement efforts essential for achieving program benefits and prevents providers from complying with license conditions and delivering efficient healthcare services. To ensure accurate HES data, admitting officers should request proper communication and accurate consultant codes from consultant secretaries to ensure accurate data across the different hospital systems

Lp(a) testing and LDL-C levels among australian ASCVD patients in 2022: a cross-sectional study from the advara heartcare network (PREVAIL)

Abstract Background The proportion of Australians with atherosclerotic cardiovascular disease (ASCVD) who meet secondary prevention low-density lipoprotein cholesterol (LDL-C) targets is uncertain, particularly among those undergoing lipoprotein(a) (Lp(a)) testing. This study describes the characteristics and achievement of LDL-C targets in ASCVD patients, both with and without Lp(a) tests. Methods A cross-sectional study was performed utilising secondary data from the Advara HeartCare cardiology network electronic medical records (EMR). Natural language processing (NLP) was used to extract data from clinical letters between 2011 and 2022 for patients attended during 2022. The 2022 baseline report captures clinical characteristics (i.e,. comorbidities, medications, lab values) in those with and without Lp(a) tests. Results In 2022, a total of 55,427 ASCVD patients were identified, predominantly male (65.1%) with a mean age of 71.2 (12.3). 61% had dyslipidaemia, 58.6% had hypertension, and 21.4% had diabetes. 72.7% were on statins, 19.4% on ezetimibe and 5.6% on PCSK9i. LDL-C information was available for 60.2% (33,381) of all ASCVD patients, with a mean LDL-C of 2.0 mmol/dL. 47.6% and 21.4% had LDL-C levels <1.8 mmol/dL and <1.4 mmol/dL respectively. Lp(a) test results were available for 2.6% (n=1,460) of ASCVD patients, with 87.7% having LDL-C information available, and a mean LDL-C of 1.9 mmol/dL. Among this group, 54.5% and 25.1% had LDL-C levels <1.8 mmol/dL and <1.4 mmol/dL respectively. Conclusions The study highlights suboptimal achievement of LDL-C targets among both ASCVD patients and those tested for Lp(a), underscoring the need to improve secondary prevention strategies and Lp(a) measurement in the ASCVD population.

Echo triaging works. How to use international guidelines

Abstract Introduction Transthoracic echocardiography (TTE) is the first-choice non-invasive imaging modality for the assessment of cardiac structure and function due to its wide availability, speed, cost-effectiveness and reproducibility. Therefore, there is exponential increase in demand in TTE across all specialties in medicine and surgery. Hence, it is important to carefully triage patients according to current international guidelines. Purpose To reduce inappropriate TTE scans by using guideline driven indications in triaging echo scans in the UK tertiary hospital. Methods Strict list of guidelines driven indications adapted to local practice was used for triaging echo requests which included both inpatient and outpatient TTEs. The 4 objectives: appropriateness, completeness of requests as well as impact of performed studies on the follow-up and patient management plan were assessed before and after implementation of new triaging tool. To ensure similar working and staff environment was sustained we studied the pattern of referrals in the same month of the year- September. The triage process was conducted by accredited physiologists. The same month was chosen to reflect true change of practice. Change in patient management and follow up were evaluated for a minimum duration of 6-months. Results Overall there were 1112 TTEs performed in September 2022 and 1081 - in September 2023. Prospective TTE referral triaging began in March 2023. We have studied and analyzed above criteria retrospectively. In 2022 there were 18% inappropriate requests; 37% of requests lacked sufficient clinical information and 10% of studies did not lead to change in management plan according to clinical letters. There was also high proportion of inappropriate requests for inpatients (9%). Within 6 months of implementation there was a significant improvement in the appropriateness (82% vs. 99%, p<0.001), with increase in supply of adequate clinical information (63.4% vs. 86.1%, p<0.001). However, there was no significant change using TTE study results in changing patient management (10%). All inpatients had 100% appropriate requests. Conclusion The implementation of triage criteria resulted in a significant improvement in TTE referrals: both in appropriateness and completeness of requests. However, some clinicians did not use echo in patient management plan. Future research on lack of use of TTE results in clinical practice might help to utilize the limited echo capacity to full.

Performance of ChatGPT and Dental Students on Concepts of Periodontal Surgery.

As a large language model, chat generative pretrained transformer (ChatGPT) has provided a valuable tool for various medical scenarios with its interactive dialogue-based interface. However, there is a lack of studies on ChatGPT's effectiveness in handling dental tasks. This study aimed to compare the knowledge and comprehension abilities of ChatGPT-3.5/4 with that of dental students about periodontal surgery. A total of 134 dental students participated in this study. We designed a questionnaire consisting of four questions about the inclination for ChatGPT, 25 multiple-choice, and one open-ended question. As the comparison of ChatGPT-3.5 and 4, the question about the inclination was removed, and the rest was the same. The response time of ChatGPT-3.5 and 4 as well as the comparison of ChatGPT-3.5 and 4' performances with dental students were measured. Regarding students' feedback on the open-ended question, we also compared the outcomes of ChatGPT-4' and teacher's review. On average, ChatGPT-3.5 and 4 required 3.63 ± 1.18 s (95% confidence interval [CI], 3.14, 4.11) and 12.49 ± 7.29 s (95% CI, 9.48, 15.50), respectively (p < 0.001) for each multiple-choice question. For these 25 questions, the accuracy was 21.51 ± 2.72, 14 and 20 for students, ChatGPT-3.5 and 4, respectively. Furthermore, the outcomes of ChatGPT-4's review were consistent with that of teacher's review. For dental examinations related to periodontal surgery, ChatGPT's accuracy was not yet comparable to that of the students. Nevertheless, ChatGPT shows promise in assisting students with the curriculum and helping practitioners with clinical letters and reviews of students' textual descriptions.

Parkinson’s Disease Medications Prescribing and Falls Assessment in Older Persons Movement Disorder Clinic

Abstract Background Parkinson’s Disease is a progressive neurodegenerative movement disorder. It is the second most common neurodegenerative condition after Alzheimer’s. The movement disorder clinic for Older Persons is well established in the Mater Hospital for years. Patients are followed regularly, and multiple domains are assessed including UPDRS (Unified Parkinson’s Disease Rating Scale), medications, and falls. Methods A retrospective audit of patient’s clinic letters was performed for a sample of 48 patients over a 5months period. Inclusion criteria was; idiopathic Parkinson's Disease and ≥ 65 years old. Exclusion criteria was; atypical parkinsonism and virtual consultations. The audit had two sections; medications profile and falls assessment. A retrospective audit of patient’s clinic letters was performed for a sample of 48 patients over a 5months period. Inclusion criteria was; idiopathic Parkinson's Disease and ≥ 65 years old. Exclusion criteria was; atypical parkinsonism and virtual consultations. The audit had two sections; medications profile and falls assessment. Results Of the total number of 48 patients audited, 65% were females and 35% were males. The majority (83%) of patients were ≥75yrs of age, and 17% age 65-75yrs, with mean age of 83years old. 68.8% didn’t have the year of diagnosis documented. 88% were on levodopa/decarboxylase inhibitor, 29% on MAOB-I (6% only on it as first line), 17% on dopamine agonist, 2% on Amantadine. 83% of the patients had assessment of falls reflected on history taking and lying (sitting)/standing BP documentation. Of which 60% had no falls, and 21% had evidence of postural drop. Conclusion Most of the patients attending the clinic were 75 years of age or older. Levodopa combined with a decarboxylase inhibitor was the most commonly used medication in this cohort of patients. The majority of patients had falls assessments conducted and documented. However, for most patients, the year of diagnosis was not recorded.

8 Year Follow up of Patients Diagnosed with Dementia in a Tertiary Memory Service

Abstract Background Approximately 64,000 people live with dementia in Ireland with an expected increase to 150,000 by 2045. Time to presentation with symptoms of cognitive decline varies between cases. The heterogenous nature of dementia makes estimations of an individualised trajectory of decline challenging. Methods Retrospective analysis was undertaken patients (n=17) of those diagnosed with dementia in 2016 whereby outcomes were discernible from records of the organisation. Data were extracted from the clinic Excel database, Patient Information Management System and Electronic Patient Record portal. Diagnosis was verified using the clinic letter at time of diagnosis. Data was processed using Microsoft Excel. Results Mean age was 77 (range 64-84). Diagnostic breakdown was AD 35.2% (n=6); AD/VaD 41.1% (n=7); VaD 23.5% (n=4). Average survival was 64.8 months (range 16-100). The group averaged 6.2 medicines and 4.3 comorbidities – most common cited were Hypertension (13%) Osteoporosis (8.3%); Hypercholesterolaemia &amp; IHD (6.9%); Hypothyroidism &amp; T2DM (5.5%). Average Emergency Department admissions was 2.5 episodes with average 5 admissions. 5 remain alive, 12 RIP – 6 (LTC); 5 hospital and 1 at home. Two live at home, 3 in LTC. Average time living within their own home was 61.1 months (those who died in LTC) and 43.4 (those who died in Hospital). Longest length of admission pre death was 18 days (3-18). Conclusion A diagnosis of dementia affords a level of anxiety with regard to the future. The provision of a roadmap of decline is difficult as the journey of each patient is unique. Within this cohort, patients tended to live at home for long periods of time regardless of their age and despite multiple co morbidities. Where patients were admitted prior to their death, this was usually close to the end of their life. A valuable focus of hope should be placed on enjoying and living the years of possible life after diagnosis.

Bridging The Gap: Between an Older Adult Attending The Ambulatory Day Unit and An Acute Hospital Presentation

Abstract Background Older adults attending the ambulatory day units within the hospital group have a comprehensive geriatric assessment (CGA) completed. This identifies the older adult’s functional, physical, social, environmental and psychological baseline, in order to develop and implement a coordinated plan of care and follow up. The CGA is the gold standard in caring for older adults who are frail or at risk of frailty (HSE, 2016). The units are off site from the main hospital, therefore valuable information may not be available to the acute hospital. Valuable information from the CGA can provide the older adult’s functional and cognitive baseline and prevent unnecessary duplication of assessments and increased length of stay. Methods Plan-Do- Study-Act (PDSA) cycle was used. A questionnaire was produced to ascertain acute care staff’s understanding of; whether an older adult is attending the ambulatory unit? Would this information and a review by the RANP Gerontology be beneficial? A Registered Advanced Nurse Practitioner (RANP) Gerontology Pathway was developed. Education was provided to nursing, and the wider multidisciplinary team. An alert sheet was introduced and provided to older adult attending the ambulatory day units. The alert was for the older adult to produce, if attending or admitted to the acute hospital. This initiates the RANP pathway. Older adults are then seen by the RANP at source of admission. Clinic letters with baseline is documented in the Healthcare record, including advice plan and follow-up. Post-implementation questionnaire and verbal feedback were obtained. Results Positive feedback from older adults, family and staff. Avoidance of unnecessary duplication of assessments, data sharing, optimization of plan of care, treatment and rehabilitation potential. Effective discharge planning, reduction of unnecessary transfer to residential care. Conclusion Bridging the gap promotes positive outcomes: Reducing length of stay, positive impact on overall wellbeing, and an organizational cost containment.

Annotation of epilepsy clinic letters for natural language processing

BackgroundNatural language processing (NLP) is increasingly being used to extract structured information from unstructured text to assist clinical decision-making and aid healthcare research. The availability of expert-annotated documents for the development and validation of NLP applications is limited. We created synthetic clinical documents to address this, and to validate the Extraction of Epilepsy Clinical Text version 2 (ExECTv2) NLP pipeline.MethodsWe created 200 synthetic clinic letters based on hospital outpatient consultations with epilepsy specialists. The letters were double annotated by trained clinicians and researchers according to agreed guidelines. We used the annotation tool, Markup, with an epilepsy concept list based on the Unified Medical Language System ontology. All annotations were reviewed, and a gold standard set of annotations was agreed and used to validate the performance of ExECTv2.ResultsThe overall inter-annotator agreement (IAA) between the two sets of annotations produced a per item F1 score of 0.73. Validating ExECTv2 using the gold standard gave an overall F1 score of 0.87 per item, and 0.90 per letter.ConclusionThe synthetic letters, annotations, and annotation guidelines have been made freely available. To our knowledge, this is the first publicly available set of annotated epilepsy clinic letters and guidelines that can be used for NLP researchers with minimum epilepsy knowledge. The IAA results show that clinical text annotation tasks are difficult and require a gold standard to be arranged by researcher consensus. The results for ExECTv2, our automated epilepsy NLP pipeline, extracted detailed epilepsy information from unstructured epilepsy letters with more accuracy than human annotators, further confirming the utility of NLP for clinical and research applications.

Evaluation of the Effectiveness of Virtual Telephone Consultations Against Traditional Face-to-Face Consultations in Spine Surgery Using an Objective Metric.

Coronavirus disease 2019 (COVID-19) proved to be a catalyst in the paradigm change from face-to-face (F2F) to virtual consultations in trauma and orthopaedics. This study evaluates the efficacy of telephone consultations versus F2F reviews in an elective spine clinic. In this retrospective study, the clinic lettersfrom elective spinal clinics were conducted over one month.Patients with lumbar spine pathology were included, divided into telephone and F2F groups, and further categorized into new referrals and follow-ups. The Ashford Clinic Letter Score (ACLS) was used to assess the efficacy of consultations. Results: Out of 126 spinal patients reviewed, 92 met the inclusion criteria. Of these, 47 were F2F and 45 were telephone consultations. The mean satisfaction scores for all patients were 7.60 for F2F and 7.42 for telephone consultations, with no significant difference (p=0.202). New patient satisfaction scores were 7.64 for F2F and 7.35 for telephone (p=0.284), and follow-up scores were 7.58 for F2F and 7.48 for telephone (p=0.530). The results showed that there was no difference between face-to-face and virtual consultations. Telephone consultations are nearly as effective as F2F consultations in elective spine clinics, particularly for follow-up patients. The findings support the viability of telemedicine as an economical and efficient alternative method instead of traditional F2F consultations in orthopaedic practice. Further research is needed to explore patient satisfaction and outcomes in other spinal pathologies and to optimise patient stratification for telemedicine.

WP4.9 - Audit on writing outpatient clinic letters in the general surgery department at a tertiary care hospital

Abstract Background Clinic letters are crucial medical notes for a patient’s medical history and medico-legal purposes. We assessed the quality of clinic letters with the guidelines from the Academy of Medical Royal College suggested for writing a clinic letter. Method A retrospective collection of data was done from January – May 2023 and a total of 166 clinic letters were collected by independent authors and then analysed to avoid any bias in the collection. Results Multiple parameters were poorly documented and are mentioned in increasing order of missing data – Plan for patient/carer (37.5%), Care planning arrangements (44.6%), Complications (67.5%), Anaesthesia issues (89.4%), Allergies (94%), Diagnosis (94%), Time (99.4%), Preferred name (100%) and Personal identifiers (100%). These findings were presented in the clinical governance meeting and to improve the quality of the clinic letters, we created a generic clinic letter including mandatory parameters suggested by the guidelines. Conclusion There were a few parameters missing from the analysed clinic letters. An adequate intervention after being discussed in the clinical governance meeting, in the form of a generic clinic letter has been introduced. A repeat cycle is planned in 3-5 months to assess the improvement in the quality. There was a lack of documentation, which improved after the intervention advised by QIP. A teaching session for new junior doctors is planned at the induction session, to strengthen the importance of frailty documentation.

FP7.13 - Is There A Difference In Anastomotic Leak Rates Requiring Re-Operation Following Emergency Right Hemicolectomy Between Colorectal And Non-Colorectal Surgeons?

Abstract Aim Right sided colonic cancers can often obstruct and present as an emergency. The decision to perform an anastomosis following the right hemicolectomy resection is often multifactorial. This study explores whether there are differences in leak rates between colorectal and non-colorectal surgeons in the context of emergency right hemicolectomy operations performed for malignancy. Methods A retrospective study was conducted at a 3-site Trust in South-East England between 2017 and 2022. Theatre and Infoflex Cancer records were used to obtain patients who had undergone an open right hemicolectomy for malignancy and their operating surgeon. Discharge summaries and clinic letters were then used to ascertain return to theatre for an anastomotic leak. Results There were 281 patients who had undergone an emergency right hemicolectomy in this time interval. There was a 152:129 female:male ratio. 17 out of 37 patients had an anastomosis undertaken by an Upper Gastrointestinal Surgeon. 2 out of the 17 (12%) had an anastomotic leak. 129 out of 244 had an anastomosis undertaken by a Colorectal Surgeon. 17 of the 129 (13%) had an anastomotic leak. There was no significant difference between the leak rates between colorectal and non-colorectal surgeons (p=0.888). Conclusion The study shows that there is no statistical difference in right hemicolectomy anastomotic leak rates between colorectal and non-colorectal surgeons in the emergency setting.

WP1.8 - No, we can’t repair your hernia: An audit to assess pre-operative optimisation for umbilical hernia repair

Abstract Aims The European Hernia Association recently published guidelines which clearly outline the importance of pre-operative optimisation for those undergoing elective umbilical/epigastric hernias. The main factors of importance are: smoking cessation and BMI &amp;lt;35. This audit aimed to identify if we are adequately optimising our patients. Methods We retrospectively evaluated all elective umbilical hernia repairs from 1st January 2022- 31st December 2022 within a district general hospital setting. Clinic letters and pre-operative records were used to ascertain smoking status, BMI and diabetic control (HbA1c). Results 60 umbilical hernias were performed in our district general hospital setting from 1st January 2022- 31st December 2022. Of these patients, 12% (N=7) were known smokers and 13% (N=8) had a BMI of over 35 documented. Additionally, only in 15 cases, was there clear documentation of the patient smoking status. Out of these patients, 9 were subsequently found to be non-smokers and 6 remained smokers despite being given smoking cessation advice. Furthermore, in 10% (N=6) of these cases, there was poor diabetic control (HbA1c &amp;gt; 48), which was not addressed in clinic pre-operatively. Conclusion Patient factors such as smoking, obesity and diabetic control have been shown to significantly increase the rate of post-operative wound infections and complications. Patients are not being adequately optimised for elective procedures which puts them at increased risk of complications and increases the burden on limited NHS resources.

SUS 2 - Routine histological examination of haemorrhoidal tissue – an unnecessary environmental and economic expense?

Abstract Background Modern, less invasive methods of haemorrhoid treatment, such as haemorrhoid artery ligation and radiofrequency ablation, are increasingly employed. These do not yield specimens for histological analysis. However, when open haemorrhoidectomy is performed, even in the absence of suspicious operative features and in low-risk patients, the haemorrhoid specimen is routinely sent. This has both environmental and financial costs in an increasingly pressured NHS, and negatively impacts sustainability with no clinical advantage. Methods We retrospectively studied 112 open haemorrhoidectomies performed at our UK hospital from February 2018 to June 2023, reviewing clinic letters, operation notes and post-operative histology. Aims To assess the frequency of incidental pathology identified during routine histological assessment, and the associated financial costs and carbon footprint generated. Results 112 open haemorrhoidectomies were performed in the 5-year study period. In total, two patients with risk factors for AIN/Anal cancer were identified. There were no documented concerns of abnormal intra-operative findings. Histology mainly revealed haemorrhoid tissue alone (103) and benign polyps (8). AIN3 was detected in one of the high-risk patients. The cost per histology specimen was £93.32 (Total cost £10,451.84). Each specimen is estimated to generate 0.29kg of Carbon Dioxide equivalents (Total 32.48kg CO2e). Conclusion Routine histological assessment of haemorrhoidectomy specimens is time-consuming, expensive and has an avoidable carbon footprint for a low detection of incidental pathology. Our study suggests that histology should be reserved for patients with risk factors for AIN/Anal cancer, or concerning intra-operative findings. Larger scale studies, and development of national guidelines would aid clinician decision-making.

LLM-AIx: An open source pipeline for Information Extraction from unstructured medical text based on privacy preserving Large Language Models.

In clinical science and practice, text data, such as clinical letters or procedure reports, is stored in an unstructured way. This type of data is not a quantifiable resource for any kind of quantitative investigations and any manual review or structured information retrieval is time-consuming and costly. The capabilities of Large Language Models (LLMs) mark a paradigm shift in natural language processing and offer new possibilities for structured Information Extraction (IE) from medical free text. This protocol describes a workflow for LLM based information extraction (LLM-AIx), enabling extraction of predefined entities from unstructured text using privacy preserving LLMs. By converting unstructured clinical text into structured data, LLM-AIx addresses a critical barrier in clinical research and practice, where the efficient extraction of information is essential for improving clinical decision-making, enhancing patient outcomes, and facilitating large-scale data analysis. The protocol consists of four main processing steps: 1) Problem definition and data preparation, 2) data preprocessing, 3) LLM-based IE and 4) output evaluation. LLM-AIx allows integration on local hospital hardware without the need of transferring any patient data to external servers. As example tasks, we applied LLM-AIx for the anonymization of fictitious clinical letters from patients with pulmonary embolism. Additionally, we extracted symptoms and laterality of the pulmonary embolism of these fictitious letters. We demonstrate troubleshooting for potential problems within the pipeline with an IE on a real-world dataset, 100 pathology reports from the Cancer Genome Atlas Program (TCGA), for TNM stage extraction. LLM-AIx can be executed without any programming knowledge via an easy-to-use interface and in no more than a few minutes or hours, depending on the LLM model selected.

Triptan non-response in a London tertiary headache centre: What can we learn? A retrospective study.

Triptans revolutionized the acute treatment of migraine; however, varied responses to triptans, as a result of poor efficacy and tolerability, are reported. A standardized definition of triptan non-response was recently proposed by the European Headache Federation (EHF). There is currently limited data available on the prevalence of triptan non-response. We used clinic letters over a two-year duration to evaluate the triptan response and triptan efficacy or tolerability failure, or both, in a London-based tertiary headache service. In total, 419 adult migraine patients (females: 83.8%, age: 46 ± 18years, chronic migraine: 88.5%) were included in a service evaluation. In line with the EHF definitions, "triptan non-response" was seen in 63.8% of patients (264/414), whereas 37.7% of patients (156/414) had failed at least two triptans (EHF "triptan resistant") and 4.6% of patients (19/414) had failed at least three triptans, including a subcutaneous formulation (EHF "triptan refractory"). Notably, 21.3% of patients (88/414) had failed at least three triptans inclusive and exclusive of subcutaneous triptan use. Advancing age (p < 0.001) and the presence of medication overuse (p = 0.006) increased the probability of triptan response, whereas an increased number of failed preventives (p < 0.001) and the use of calcitonin gene-related peptide monoclonal antibodies (p = 0.022) increased the probability of triptan non-response. The largest proportion of patients responded to eletriptan (49.5%), followed by nasal zolmitriptan (44.4%) and rizatriptan (35.7%). Our findings highlight an alarming prevalence of triptan non-response among adult migraineurs receiving treatment in a London-based tertiary headache service. It is imperative for clinicians to explore methods to optimize acute medication efficacy, whether this comprises changing to a triptan with a superior response rate, advocating for early intervention or considering alternative acute medication classes, such as gepants or ditans.

Primary closure of fasciotomies has a reduced complication rate following compartment syndrome in the paediatric population.

Currently no guidance exists within the literature regarding diagnostic criteria or the long-term outcomes for paediatric patients with acute compartment syndrome (ACS). We conducted a retrospective cohort study reviewing all cases of paediatric ACS managed at a single tertiary referral centre with the aim of characterising the factors responsible for the eventual outcomes. The patient cohort was identified retrospectively by interrogating the hospital coding system for all paediatric patients between January 2014 and November 2022. The electronic emergency department, inpatient and operative notes as well as clinic letters for each patient were reviewed and data collected regarding presentation, associated injuries, management and subsequent complications plus length of follow-up. The data was analysed to determine if differences in presentation or management affected long term outcome. The final cohort consisted of 34 patients with a mean age of tenyears at the time of presentation. The mean time from presentation to fasciotomy was 27.6h (range 3.0 - 66.6). There was an overall complication rate of 37.5% with a mean follow-up period of 21months. Patients who had direct closure of their fasciotomy wounds had a significantly lower complications rate and fewer operations compared to those who healed via other wound coverage methods or secondary intention (p < 0.05). Significantly higher complication rates were observed in patients who were unable to have direct wound closure following emergency fasciotomy. This information may be utilised to rationalise long term treatment plans and in counselling of patients and parents.

Optimizing statin prescriptions for people living with HIV: Evidence for improved communication and shared care between primary care and specialist HIV services.

Our objective was to assess the numbers of eligible people living with HIV attending one HIV clinic and receiving statins, the factors increasing the likelihood of statin prescription, the knowledge and involvement of primary care in cardiovascular risk prevention in people living with HIV, and the barriers to and drivers of shared care between general practitioners (GPs) and an HIV centre. This was a retrospective case note review identifying cardiovascular risk, medications, and communication between the HIV clinic and GPs via an electronic survey of GPs identifying their knowledge about statin indications in people living with HIV. In total, 62% of GPs were unaware of the indication for statins in people living with HIV aged >40 years. A total of 33% of patients received statins, rising to 61% of patients with independent indications for statins. 92% of all statin prescriptions were provided by the GP. Statins were recommended in 25% of clinic letters but were not prescribed in 72% of these cases. There was discordance between antiretrovirals prescribed by the HIV clinic and those documented on the GP record in 60% of cases and in 40% of non-antiretroviral medications. Our results indicate that GPs can engage people living with HIV in cardiovascular risk reduction measures but may not consider HIV a cardiovascular risk. Written communication alone is insufficient to improve safe patient care. Shared HIV care needs bidirectional shared medical records. Ongoing work needs to ensure that HIV is recognized as an independent cardiovascular risk factor.

Hypertension evaluation and management in new young patients: are we doing our female patients a disservice?

Purpose Cardiovascular disease (CVD) is one of the leading causes of death in women, largely underpinned by hypertension. Current guidelines recommend first-line therapy with a RAAS-blocking agent especially in young people. There are well documented sex disparities in CVD outcomes and management. We evaluate the management of patients with newly diagnosed hypertension in a tertiary care clinic to assess male–female differences in investigation and treatment. Methods Clinic letters of all new patients under the age of 51 attending the Glasgow Blood Pressure Clinic between January and December 2023 were reviewed. The primary outcomes measured were first-line treatment choices, deviations from guideline-recommended treatment, investigations for secondary hypertension, and documentation of female-specific risk factors and family planning advice. Secondary outcomes included clinical characteristics such as systolic and diastolic blood pressure at referral and at the new patient appointment, age at diagnosis, age at first appointment, and the number of antihypertensive drugs prescribed at referral. Results One hundred and five (59:46, M:F) new patient encounters were reviewed after sixteen exclusions for non-attendance and inappropriate clinic coding. Choice of first line antihypertensive agent did not vary between sexes with no deviation from guideline-recommended medical therapy. Men, however, had more biochemical investigations conducted for secondary causes across all ages. This was greatest in those under 40 years old. There was suboptimal documentation of female-specific risk factors (obstetric and gynaecological history), contraceptive drug history and family planning with 35%, 20%, and 15.6%, respectively. Conclusion In 2023, women under 51 years of age seen in a tertiary care hypertension clinic received similar first-line treatment to their male peers. However, relevant female-specific histories were suboptimally documented for these patients. Whilst therapeutic approaches in men and women appear to be similar in this clinic, there are opportunities to improve CVD prevention in women, even in a specialised clinic setting.

CT-guided steroid injections for the diagnosis and management of piriformis syndrome

Objectives: Piriformis syndrome (PS) is an extra-spinal tunnel neuropathy affecting the sciatic nerve. While typically diagnosed clinically, with confirmation through exclusion of other conditions, accurate diagnosis remains challenging. This study assesses the clinical outcomes of computed tomography (CT)-guided corticosteroid injection for suspected PS, considering its potential role as both a diagnostic and a therapeutic intervention. Materials and Methods: We conducted a retrospective review of 32 patients suspected to have PS, based on clinical presentation and examination findings, who underwent CT-guided steroid injections between July 2013 and February 2020. Effectiveness was evaluated qualitatively through clinic letters from patient reviews with a mean follow-up of 5 months (range 3–7) Results: Thirty-two patients received 44 injections. The cohort had an average age of 45 years, with many being physically active. Initial follow-up showed that 56% experienced pain relief, though 16% of these cases were short-lived. About 19% reported partial benefit, while 31% reported no improvement. Repeat injections were performed on nine patients, with some undergoing up to two repeat procedures. About 47% of patients were discharged following injections, repeats, or surgery, while 53% required further specialist input. Conclusion: CT-guided corticosteroid injections appear to be a valuable management tool for diagnosis and treatment of PS, particularly when conservative management fails. However, the long-term benefits are inconsistent, highlighting the need for a more standardized treatment pathway. Given the high degree of diagnostic uncertainty and lack of accurate diagnostic tools for PS, we propose the use of local anesthetic and steroid injections as a diagnostic approach, as well as a management option.