District General Hospital Experience Research Articles

P239 A study to evaluate uptake of PROMS for IBD patients on Biologics: a sample United Kingdom district general hospital experience

Abstract Background In order to guide industry on medical product development, FDA developed an instrument to measure effectiveness as an endpoint of clinical trials. This patient oriented tool is called “Patient Related Outcomes Measures”. (PROMS). In 2009 NHS England adopted PROMS declaring that “the purpose is to collect information, from patients themselves, about how well the health service is treating them. Moreover “PROMs allows to understand the difference that healthcare interventions make to people’s quality of life”. Initially related to only certain surgical procedures, it eventually rolled out to many other conditions including IBD. This research looks at degree of success in implementation of PROMS for IBD patients on treatment with biologics in a sample district hospital of United Kingdom. Methods The IBD PROMs questionnaire is filled by patients themselves when treated with biologics. The questionnaire asks overall health status, treatment of bowel condition, effectiveness in controlling bowel condition, satisfaction with quality of treatment, Crohn’s and Colitis questionnaire CCQ12 and uses 12 dimensions: sleeping, appetite, energy level, rushing to the toilet, being bloated, incomplete emptying of bowels, blood in stool, generally unwell, faecal incontinence, nocturnal diarrhoea, passing wind and effect on leisure activity. It also has questions for patients with a stoma. We collected data from a sample district general hospital in United Kingdom for one year in retrospect and analysed the implementation of PROMS. We hoped at least 90% of patients would fill the PROMS questionnaire. Results 45 patients with IBD who were on biologics were recruited in the study. They had repeated admissions for treatment and we kept check points at 3, 6 and 12 month follow up treatments. There were 21 patients on infliximab, 23 on vedolizumab, and 1 on ustekinumab with overall total number of infusions being 352 due to their recurrent admissions for biologic treatment. A minimum of 45 PROM responses could have been achieved and maximum of 352 for good implementation. In our data only 4 were filled (8.89% of minimum and 1.1 of maximum required). Thus PROMS for IBD was not implemented to any useful extent. Conclusion Our study did not look at the outcomes, but simply whether the PROMS was utilised sufficiently for IBD patients on biologics. We demonstrated low uptake by one sample district general hospital of United Kingdom. Further studies to evaluate practice of other IBD units in the country would help to understand the situation better. There can be various reasons for this low uptake including lack of resource, not knowing importance of PROMS or deficient motivation in staff.

739 The Management and Outcomes of Patients with Fractured Neck of Femur During The COVID-19 Pandemic; A District General Hospital Experience

BackgroundThe UK announced a “lockdown” in response to COVID-19 on 23/03/2020, despite this NHS England did not anticipate a significant decrease in hip fracture cases. Early data from Europe had shown mortality rates of up to 30.4% in patients who develop COVID-19 and a hip fracture.MethodProspective study of patients presenting with a hip fracture between 23/03/2020 and 18/05/2020. Primary outcomes were 30-day mortality and COVID-19 status. Secondary outcomes were length of stay, discharge destination and readmission.Results50 patients identified, mean age 82. 49 patients underwent operation, 34 (69.4%) within 48 hours of admission. 14 Patients (28%) tested positive for COVID-19 within 30 days. 30-day mortality was 10% (n = 5). 2 patients who died were COVID-19 positive. Mean length of stay was 12.3 days. 7 patients (14%) re-admitted within 30 days, 4 with COVID-19.ConclusionsDespite extra strain on the hospital, we believe we achieved good outcomes for this cohort. Compared to previous NHFD data we decreased our length of stay and time to operation. 30-day mortality increased (8.4% in 2018) but we believe this to be expected in vulnerable patients during a pandemic. We hope to take lessons we have learnt during the pandemic into the post-pandemic era.

419 Endovascular Aortic Repair of Abdominal Aortic Aneurysm Early Re-Intervention Outcome, A District General Hospital Experience

Abstract Introduction Endovascular repair (EVAR) transformed abdominal aortic aneurysm (AAA) management. However, it is associated with higher re-intervention rate compared with open repair. This audit evaluates the early re-intervention rate at Watford General Hospital relative to the 4-yearly average rate in the draft evidence review by NICE (16.89%). Method EVAR procedures performed in 2015 and 2016 were retrieved. The follow up was analysed to identify re-intervention procedures performed to address complications related to the initial EVAR or sac expansion. Results 108 patients underwent EVAR during the 2-year inclusion period. 21 re-interventions (19.4%) were recorded, irrespective of type or cause of re-intervention. 30 patients (28.6%) developed endoleak but only 17 (56.7%) had a re-intervention. Type 1 endoleak was the main cause for re-intervention (28.6%). The majority of re-interventions were executed endovascularly (57%). 47.6% of the re-interventions were done during the first year following EVAR. Conclusions Even though our re-intervention rate was relatively above the international average, EVAR is still considered safe for AAA repair with low morbidity and mortality. As re-interventions are frequently required, long-term surveillance is essential. Conversely, most of re-interventions can be performed with minimal morbidity. We recommend discussing all cases in a formal MDT before surgery and any re-intervention.

P076 Adherence to COVID-19 risk stratification during the peak of pandemic: a District General Hospital experience

Background/Aims During the peak of COVID-19 pandemic, there were growing concerns that rheumatology patients could have an increased risk of contracting coronavirus due to the immunosuppressive drugs that they were taking. British Society for Rheumatology (BSR) recommended in its risk stratification guide in March 2020 that vulnerable patients should be either shielded or isolated according to their level of risk. The purpose of this survey is to evaluate the compliance to the risk stratification advice among rheumatology patients in a single centre. Methods Risk stratification guidance was sent out to 401 patients recommending either to shield or to isolate. Patients were contacted over the telephone between 14 September and 18 October 2020 to ensure they had received a postal letter with risk stratification advice. If received, it was checked whether they had followed the guidance. Responses received from all participants were analysed. Results 93% (373) of patients confirmed that they had received the guidance; however, 8 patients suggested they hadn’t received and we were unable to contact 16 patients, despite trying multiple times. Four patients died but they did not have confirmed coronavirus. 267 confirmed they were shielding and 83 were isolating, but 21 patients decided not to follow the guidance despite the recommendation and two patients stopped taking the drugs due to fear of contracting the coronavirus. Total 258 females and 143 males with the mean age 59. Most common diagnoses were rheumatoid arthritis (227), psoriatic arthritis (97) and axial spondyloarthritis (59). It was noted that out of 7 patients who had symptoms suggestive of COVID-19, only three patients were confirmed to have COVID-19 positive PCR test. Three most commonly used drugs were Benepali (128) followed by Amjevita (100), then Rituximab (56). Conclusion Although uptake of postal communication was high in this study, it was difficult to establish how rapidly the guidance was delivered. We realise the need to employ better ways of communicating with the patients. Innovative ways such as text messaging and social media have an important role in the delivery of a rapid mass communication during the pandemic. It was reassuring to note that only a very small number of patients had COVID-19 among the patients who followed the government advice to either shield or isolate. But, it would be interesting to see whether the incidence of COVID-19 cases rise since rheumatology patients are no longer shielding. Disclosure S. Azam: None. E. Thompson: None. N. Costello: None. A. Ahmed: None. A. Nune: None. H. Ahmed: None.

Management of Asymptomatic Postmenopausal Women Referred to Outpatient Hysteroscopy Service with Incidental Finding of Thickened Endometrium – A UK District General Hospital Experience

The objective of this study was to review the management and outcome of asymptomatic postmenopausal women with increased endometrial thickness as there is lack of robust guidance for the same. Retrospective case series over a period of 2 years. District general hospital. Eighty-three. No prospective interventions were done. Only a review of the interventions done in an outpatient setting, namely, hysteroscopy and endometrial sampling, was carried out. Retrospective review of 1453 referrals to outpatient hysteroscopy service over a period of 2 years was carried out, and 83 patients referred with asymptomatic thickened endometrium on imaging were identified. Patients underwent hysteroscopy on the basis of the local policy, that is, if the endometrial thickness was more than 10 mm or in the presence of additional risk factors. The yield rate of endometrial cancer and atypical hyperplasia was 1.2% and 2.4%, respectively, among all patients (n = 83). The yield rate of endometrial cancer and atypical hyperplasia was 1.81% and 3.63%, respectively, among patients referred with endometrial thickness ≤10 mm after considering other risk factors. It is reasonable to use endometrial thickness of 10 mm or above as a cutoff threshold to offer endometrial biopsy or outpatient hysteroscopy for asymptomatic postmenopausal women. For asymptomatic women with endometrial thickness between 4 and 10 mm, decisions about further investigations should be made on a case-by-case basis, taking into account any risk factors for endometrial pathology. As this study had a reasonably good sample size, it can contribute toward formulation of robust guidance for management of postmenopausal women with asymptomatic endometrial thickening.

Feasibility of day case mastectomy: UK district general hospital experience

Background: Breast cancer is the most common type of cancer in the UK. Most women diagnosed with breast cancer are over 50, but younger women can also get breast cancer. About 1 in 8 women are diagnosed with breast cancer during their lifetime. An increasing number of women with unilateral breast cancer are opting for removal of both the affected unilateral and contralateral 'normal' breast (contralateral prophylactic mastectomy, CPM) when otherwise suitable for breast-conserving surgery. A number of studies investigating trends in the surgical management of breast cancer in the USA and Europe have highlighted that younger patients are increasingly being treated by mastectomy.

The critical push for traceability compliance: A District General Hospital experience

Blood remains one of the world’s vital substances. Blood and its products save millions of lives everyyear. Blood products are therapeutic and are derived from human whole blood, they are fragile,expensive and heavily freighted around the world. The continuing emergence of infectious agents isanother aspect affecting the blood safety. However, the global nature of the plasma industry had beenan example where blood products have crossed the boundaries.

Effective strategies in recruitment and clinical orientation programme to manage NHS junior doctor workforce shortfall: a district general hospital experience

There are significant vacancies of qualified medical professionals across the UK.1 This has partially been filled by locum doctors causing a major financial burden on the NHS.2 To address workforce shortages, the British government has proposed to open five new medical schools to expand national intake by 25%.3 The step rise in medical workforce is unlikely to be felt before 2025.3 International medical graduates (IMGs) currently contribute significantly towards the NHS care provision.4 Recently there …

Use of a novel device in the management of Percutaneous Endoscopic Gastrostomy Buried Bumper Syndrome. A district general hospital experience

Use of a novel device in the management of Percutaneous Endoscopic Gastrostomy Buried Bumper Syndrome. A district general hospital experience

Inguinal hernia repair in patients under and over 65 years of age: a district general hospital experience

The aim of this study is to compare outcomes of laparoscopic and open hernias in the over and under 65s at a district general hospital. Data were collected retrospectively on patients who underwent a unilateral inguinal hernia repair from 2012 to 2016. Only open mesh Lichtenstein repairs and laparoscopic transabdominal pre-peritoneal (TAPP) mesh inguinal hernia repairs were included. The dataset included patients' demographics and comorbidities, type of surgery (open vs. laparoscopic), presentation (elective vs. emergency), length of stay and postoperative complications. 255 patients comprised the study cohort. 126 (49%) patients were under 65 years and 129 (51%) were over 65. Laparoscopic surgery was performed in 149 patients (58%), while open technique was used in 106 (42%). A higher proportion of patients over 65 underwent open surgery compared to patients under 65 (55% vs. 28%, p ≥ 0.001). Patients over 65 had a higher ASA score (p = 0.0158) and more comorbidities (COPD, DM, Anticoagulation) when compared to younger patients. The number of postop complications were 13 (10%) in the over 65s compared to 14 (11%) in the under 65s (p = 0.94). There was no statistical difference in length of stay between the over and under 65 patients (p = 0.06). Despite more comorbidities in the over 65s, this study shows that there is no significant difference in complication rates between laparoscopic and open inguinal hernia repair irrespective of age category. Selection bias for the type of repair and the potential for an alpha error mean larger studies are required to show equivalence.

Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience.

Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas. The length of stay decreased from a median of 3 days (range 2–9 days; mean 3.32) preprotocol to a median of 2 days (range 2–3 days; mean 2.16) postprotocol ( p < 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p = 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes.

Colonoscopic miss rate for colorectal cancer: a district general hospital experience

Background: The aim of the study was to review our post-colonoscopy colorectal cancer (PCCRC) diagnoses rate and compare it to national standards, to identify any common factors in our missed cancer cases and create a policy for capturing missed cancers data.Methods: We analyzed retrospectively collected data on patients with colorectal cancer from January 2015 to July 2017. Patients who had a previous colonoscopy within 3 years of diagnosis were then identified. We excluded colonoscopies done within 6 weeks of diagnosis or repeat colonoscopies due to poor bowel preparation.Results: 503 colorectal cancer patients were identified. 135 (26.8%) were initially diagnosed without a lower GI endoscopy. 30 had a negative colonoscopy 6 weeks to 3 years prior to diagnosis. Only 10 patients (2.7%) were true missed lesions (false negative colonoscopy). Male/female: 5/5. Mean age was 68.4 (49-80). 9 patients had good or satisfactory bowel preparation. 50% of lesions were found during follow-up or treatment of a different lesion. Average time from false negative scope to diagnosis was 20.3 months (4-31). Sites of missed lesions are left colon- 4, low rectum- 3, caecum- 2 and transverse colon- 1.Conclusions: Our PCCRC rate is below the GUT recommended target of &lt;5% and well below the national average 8.5%. We identified no common features across all missed cases. Contrary to other published data, right sided lesions were less common with no female predominance. We recognize the limitations of access to only local trust data. We propose to monitor PCCRC rate annually, present this at clinical governance meetings and review each case individually as an adverse event.

Colorectal Cancer Stratification in the Routine Clinical Pathway: A District General Hospital Experience

Colorectal cancer (CRC) has many subtypes with different prognoses and response to treatment. Patients must be characterized to access the most appropriate treatment and improve outcomes. An increasing number of biomarkers are required for characterization but are not in routine use. We investigated whether CRC can be stratified routinely within a small district general hospital to inform clinical decision making at local multidisciplinary team meeting/tumor board level. We evaluated mismatch repair (MMR) and EGFR signaling pathways using predominantly in-house immunohistochemical (IHC) tests (MSH2, MSH6, MLH1, PMS2, BRAF-V600E, Her2, PTEN, cMET) as well as send away PCR/NGS tests (NRAS, KRAS, and BRAF). We demonstrated that many of the tests required for personalized treatment of CRC can be done locally and timely. Send away tests need to be requested shortly after cut-up and this needs to be firmly established in the tissue pathways for the results to be considered at multidisciplinary team meeting/tumor board. We have shown that MMR IHC combined with BRAFV600E IHC is practical and easy to perform in a small district general hospital, has full concordance with DNA-based tests and satisfies the latest NICE requirements for the identification of potential Lynch syndrome patients. We provide a framework for the interpretation and presentation of test results. It is a practical classification that clinical pathologists can use to communicate effectively with the clinical team. It is broadly based on molecular subtyping, firmly focused on treatment decisions and dependent on the panel of molecular tests currently available.

192 Inflammatory conditions make up a larger proportion of the rheumatologist case load compared with 15 years ago: a district general hospital experience

192 Inflammatory conditions make up a larger proportion of the rheumatologist case load compared with 15 years ago: a district general hospital experience

CT as a tool for endobronchial stent size estimation: a district general hospital experience

CT as a tool for endobronchial stent size estimation: a district general hospital experience

27. Neo-adjuvant Chemotherapy (NAC) Can We Predict PCR or Poor Response; A District General Hospital Experience and Results

Introduction: NAC is not suitable for all patients and treatment decision should be based on individual patient characteristics and tumour biology. The aim of this study was to see if our experience at Shrewsbury & Telford NHS Trust (SATH) can help guide patient suitability.

Preoperative magnetic resonance imaging (MRI) versus surgical histology on circumferential resection margin – a district general hospital experience

Category: GI/GU

Precision colonic onco-surgery: A district general hospital experience

Precision colonic onco-surgery: A district general hospital experience

Barrett’s oesophagus – are endoscopies reported according to the minimum recommended parameters set by british society of gastroenterology guidance? An Irish district general hospital experience

Barrett’s oesophagus – are endoscopies reported according to the minimum recommended parameters set by british society of gastroenterology guidance? An Irish district general hospital experience

Revision surgery following extended latissimus dorsi flap and implant based breast reconstruction– a District General Hospital experience

Introduction: Extended latissimus dorsi (ELD) flap breast reconstruction has been a very well-established reconstruction modality after mastectomy. Although recently number of ELD flap operation has decreased due to popularity of implant based reconstruction we found rate of revisional surgery were less with ELD reconstruction. Rates of revisional surgery have been quoted between 30% - 75% in the literature. After 5 years we evaluate our rates of revision surgery.