Dunstable University Hospital Research Articles

6289667 Does one size fit all? A survey of anaesthetists’ approach to estimating blood volume in obstetric patients at Luton & Dunstable University Hospital

6289667 Does one size fit all? A survey of anaesthetists’ approach to estimating blood volume in obstetric patients at Luton & Dunstable University Hospital

Skin manifestations in patients with COVID-19: a prospective observational study during the first wave of the pandemic in the UK and review of the recent literature.

BackgroundCOVID-19 (SARS-CoV-2) is a viral infection that presents in heterogeneous forms with effects on multiple organ systems including the skin.ObjectivesThe objectives of this prospective observational study were to identify cutaneous lesions in confirmed COVID-19-positive patients admitted to a district general hospital in the eastern region of England, to determine the prevalence of these lesions and compare the findings with the current literature.Materials & MethodsThe study was conducted at the Luton and Dunstable University Hospital during the first peak of the pandemic in the United Kingdom to identify skin manifestations in patients infected with COVID-19. Several variables were taken into consideration and photographs of skin lesions were taken. Unlike previous similar studies, all patients included in this study had a positive nasopharyngeal PCR swab for SARS-CoV-2. All photographs were analysed by a dermatology consultant.ResultsA total of 93 patients were included in the study; 40% (n = 37) had cutaneous lesions but only 5.5% of the total patients (n = 6) presented with likely coronavirus-related skin changes. Lesions identified were pseudochilblain and purpuric/livedoid type. We also noted several coagulation abnormalities in these patients.ConclusionCOVID-19 can present with a variety of skin manifestations. Pseudochilblain lesions and purpuric livedoid lesions have been described in the literature and although the underlying mechanism is not fully understood, it is possible that these lesions represent thromboinflammatory processes as a result of the hypercoagulability state associated with COVID-19. More research is required to better understand the pathophysiology and epidemiology of these manifestations.Supplementary dataSupplementary data associated with this article can be found, in the online version, at doi: 10.1684/ejd.2022.4202.

Incidence of age migration of colorectal cancer in younger population: Retrospective single centred-population based cohort study

BackgroundThe positive correlation between the incidence of colorectal cancer and age is well known. However, current data demonstrates that there is noticeable age migration in the incidence of colorectal cancer towards young adults highlighting that this disease should no longer be considered to solely affect the elderly. The aim of the study is to analyse the changes in the trend for the age at which colorectal cancer presents, to identify if there is an appreciable age migration towards a younger population. MethodsThis is a retrospective observational cohort study on a single-centred population. Data was obtained from The Luton and Dunstable University Hospital Colorectal Cancer Database. It was analysed from three separate decades from the years 1999, 2009, 2019 and 2020. All patients newly diagnosed with colorectal cancer in these time periods were included in this study. Gender, anatomical site, and the stage migration was also analysed. ResultsA total of 598 patients were diagnosed with colorectal cancer in the specified time periods. The overall age-specific incidence rates had risen throughout the three decades. Notably the incidence rate had doubled between 1999 and 2009. In the younger adult population of <40 years, the incidence rate had risen seven-fold across three decades with a disproportionate increase among females compared to males. Stage migration is also analysed over the three decades with no evident difference in anatomical position of the tumour. ConclusionThere has been an upwards trend in the incidence of colorectal cancer among the younger population. This will have implications for investigation and screening in the future

Outcome of Colorectal cancer in Geriatric Patient

Background: Older surgical patients remain at increased risk of adverse postoperative outcome when undergoing both elective and emergency surgery. The needs of the older surgical patient are often substantially different from those of younger patients. As a surgeons we have dilemmas in appropriately treating elderly patients. Specifically, those with cancer have been shown to receive inappropriate care, being either undertreated or overtreated based on their chronological age rather than their degree of frailty. Aim:To evaluate outcome of patients diagnosed with colorectal cancer in patients aged 80 years and over. Methods:Retrospective study of all patients 80 years and above managed with colorectal cancer at the Luton and Dunstable University Hospital UK from January 2015 through December 2019 Results: In the study period 278 patients were diagnosed with colorectal cancer, Male 143 Female 135 ratio 1:1.05. Age range from 80 to 101years. 54.31% patients underwent surgical intervention. 15.10% had complications after surgery. 36.69% patients deemed unsuitable for resection surgery were treated with best supportive care palliatively. 57.19% patients were in ASAIII, 24.10% ASAII and 12.23% ASAIV. 46.40% patients died during the study period. Conclusion:Age on its own would not be taken as for less aggressive therapy; Careful assessment of the patient taking into consideration comorbidities, functional status and patient wishes are essential in decision making and choosing appropriate management plan. Curative surgery for colorectal carcinoma in the geriatric patients are well tolerated. Management of comorbidities preceding surgery may impact postoperative outcome.

Can we predict colorectal cancer?

Background: Colorectal cancer is a common and lethal cancer worldwide, In the UK, it is the second most common cause of cancer death. 5% of UK population is at risk of colorectal carcinoma during lifetime. 30% of patients with colorectal cancer present with a metastatic disease. Detecting colorectal cancer is challenging patients may present with slight symptoms or asymptomatic. By the time patients becomes symptomatic, the cancer may be more advanced. Therefore, screening for colorectal cancer is recommended for people at average risk. Method: All patients diagnosed with colorectal cancer at the Luton and Dunstable University Hospital UK from January 2015 through December 2019 were retrospectively identified from the referral database created by colorectal specialist nurses in the colorectal service. Data were retrieved by detailed review of the hospital case notes, ICE/Evolve (Computer database for investigations and correspondence) including endoscopy; radiographic imaging; operative course and cancer follow up. Results: In the study period 976 patients were diagnosed with colorectal cancer, Male 52.6% (513) Female 47.4% (463). The mean age of 74.14 years (range, 25 to 101). Sixty six 6.76% patients were excluded from the study, therefore the percentages of studied participant were Male 53 % (482) and Female 47 % (428) ratio 1: 1.12. Incidence of colorectal cancer among young adult was low 1.75% (16) up to 39 years of age) and 94.61% are diagnosed in people over the age of 50 years, 60.43% are diagnosed in people aged 70 or over. Conclusion: Increasing awareness of the symptoms and signs of colorectal cancer be helpful and beneficial. Establish integrated care pathways, centralization of complex procedures and comparison of international cancer outcomes.

Impact of COVID-19 on Elective Colorectal Resections in a District General Hospital

Background: COVID-19 is a global pandemic having direct impact on elective surgical health care services, ultimately leading to short & long-term consequences. Aims: A single-center, retrospective study of prospectively collected data was conducted, aimed to identify the impact of COVID-19 pandemic on clinical outcome of elective time critical colorectal resections and analyse the mitigating strategies to reduce the adverse clinical outcome. Materials & Methods: Clinical data of patients who underwent time critical elective colorectal resections at our center in COVID era i.e. from mid-March 2020 till June 11, 2020 was collected and reviewed using Microsoft Excel sheet. Various parameters including tumour stage, type of approach, resection with/without stoma, length of hospital stay and overall complication rate were analysed. Results: Total 25 elective colorectal resections were performed. Majority (32%) had tumour in rectum, followed by sigmoid colon (28%) and caecum (16%). Laparoscopic approach was used in 16/25 cases (64%). 48% underwent anterior resection, while right hemicolectomy was performed in 36%. Stoma was fashioned in 13/25 cases (52%). Of 25, only two patients (8%) developed Covid-19 infection post-operatively, which was managed conservatively without any morbidity/mortality. Mean hospital stay was 5.7 days. 30-day mortality was zero in 17/25 patients (68%). Conclusion: Study highlights the importance of effect of COVID-19 on our routine colorectal surgical practice, providing insight into challenges faced by each member of health care team. However, we adopted new changes in our daily practice and managed to continue elective time critical resections, even in Covid pandemic without increasing the risk of morbidity/mortality. Funding Statement: None. Declaration of Interests: The authors declare that they have no conflict of interest. Ethics Approval Statement: This study was approved by the Colorectal department at Lutton and Dunstable University Hospital

P103 A survey of exercise preferences amongst a cohort of patients with spondyloarthritis

Abstract Background Dry exercise and hydrotherapy are well-recognised components of axial spondyloarthritis management. The National Ankylosing Spondylitis Society (NASS) provides advice on appropriate exercise and available venues. This study aimed to determine the most popular type of exercise among spondyloarthritis patients under the care of the Luton &amp; Dunstable University Hospital, which serves an ethnically diverse population. Methods A survey was sent to 124 patients with axial and/or peripheral spondyloarthritis, asking preferences regarding dry and wet exercise (hydrotherapy), and whether they were aware of NASS. Answers were aggregated and analysed using Microsoft Excel. Results 56/124 patients responded to the survey, corresponding to a response rate of 45%. 30 (54%) were male and 26 (46%) were female. The mean age of respondents was 50 years, with 31/56 patients (55%) aged under 50. Represented ethnic groups included White British (36 patients), White Other (4), White Irish (3), Pakistani (4), Bangladeshi (3), Black Caribbean (3), Indian (2) and Asian (1). 43 (77%) patients were Caucasian (White British, Other and Irish), and 13 (23%) were non-Caucasian. Regarding survey non-respondents, 45/68 (66%) were Caucasian and 23/68 (34%) were non-Caucasian. A larger proportion of non-Caucasians did not respond to the survey. 23/36 (64%) non-Caucasians did not respond compared to 45/88 (51%) Caucasians. 42 patients (75%) preferred both dry exercise and hydrotherapy; 11 (20%) preferred dry exercise only and 3 (5%) preferred hydrotherapy only. 26 patients (46%) were aware of NASS. 30 (54%) were not aware of NASS. More females than males preferred both types of exercise or hydrotherapy only (25 females vs. 17 males: 3 females vs. no males respectively). More males preferred dry exercise only (9 males vs. 2 females). 14 females were aware of NASS compared to 12 males. Analysis of ethnic groups showed that similar proportions of Caucasians and non-Caucasians were aware of NASS (20/43 (47%) Caucasians vs. 6/13 (46%) non-Caucasians). A larger proportion of Caucasians preferred both types of exercise (33/43 (77%) Caucasians vs. 9/13 (69%) non-Caucasians). A larger proportion of non-Caucasians preferred dry exercise only (8/13 (62%) non-Caucasians vs. 3/43 (7%) Caucasians. Conclusion Most patients in Luton prefer both dry exercise and hydrotherapy, of which a larger proportion are Caucasian. A larger number of females prefer both types of exercise or hydrotherapy alone compared to males. Non-Caucasian patients prefer dry exercise. Most patients are not aware of NASS. In response to this survey and the service development needs of this group of patients, dedicated Tai Chi exercise classes, with integrated education on NASS, were implemented. Given the overall preference for both dry exercise and hydrotherapy, information gleaned from this survey will prove helpful to commissioners, for consideration of funding for hydrotherapy which is not currently available in Luton. Disclosures A. Owusu-Agyei None. A. Verdiyeva None. S. Norris None. E. Morris None. K. Hennessy None. M. Chan None.

EP39 Assessing the differences in times to general practitioner presentation and diagnosis, and outcomes, for axial spondyloarthritis patients in different ethnic groups

Abstract Background There is a documented delay to diagnosis of axial spondyloarthritis. The Luton &amp; Dunstable University Hospital Rheumatology department looks after an ethnically diverse population of patients with the condition. This study aimed to compare time from symptom onset to general practitioner (GP) presentation, time from symptom onset to diagnosis, and response to treatment between different ethnic groups. Methods 124 patients with axial spondyloarthritis, according to the Luton &amp; Dunstable University Hospital Infoflex database, were identified. 24 patients were excluded due to a peripheral spondyloarthritis diagnosis. A retrospective case note review of 100 case records was undertaken. Data were analysed using Microsoft Excel. Results The mean age was 44 years. 64 (64%) patients were male and 36 (36%) were female. Ethnicity breakdown showed 58 White British patients; 12 Pakistani; 7 White Other; 6 Bangladeshi; 5 White Irish; 5 Asian; 4 Indian and 3 Black Caribbean. There were 70 Caucasian (White British, Irish or Other) and 30 non-Caucasian patients. Based on available data for 57 patients, the median time of symptom onset to GP presentation was 48 months. Based on available data for 49 patients, the median time of symptom onset to diagnosis was 53 months. The mean time of symptom onset to GP presentation was 93 months in Caucasians vs. 66 months in non-Caucasians. The mean time of symptom onset to diagnosis was 91 months in Caucasians vs. 70 months in non-Caucasians. 12 patients presented within one year of symptom onset. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) data were available for 7/12 patients who presented within one year of symptom onset and 25/45 patients who presented after one year. Following NSAIDs or biologics, there was a larger decrease in the first measured BASDAI for those who presented within one year of symptom onset (Mean BASDAI decrease: 2.77 vs. 2.06). BASDAI data were available for 43/70 Caucasian patients and 18/30 non-Caucasian patients, regardless of time of presentation. The mean decrease in first measured BASDAI was smaller in Caucasian patients vs. non-Caucasian patients (Mean BASDAI decrease: 2.49 vs. 2.66). BASDAI data were available for 5/7 Caucasian and 2/5 non-Caucasian patients presenting within one year of symptom onset. The mean BASDAI decrease was 5.65 in non-Caucasian patients vs. 1.62 in Caucasian patients. BASDAI data were available for 15/26 Caucasian and 10/19 non-Caucasian patients presenting after one year of symptom onset. Mean BASDAI decrease was 2.26 in non-Caucasian vs. 1.93 in Caucasian patients. Conclusion There is a shorter mean time of symptom onset to GP presentation and diagnosis in non-Caucasians compared to Caucasians. There is a higher response to treatment in patients who present within one year of symptom onset, supporting the hypothesis that early diagnosis leads to better outcomes. Disclosures: A. Owusu-Agyei: None. A. Verdiyeva: None. M. Chan: None.

Visual outcomes of Descemet Membrane Endothelial Keratoplasty at a Single Surgeon United Kingdom Centre

AbstractPurposeDescemet Membrane Endothelial Keratoplasty (DMEK) is a partial thickness corneal graft which involves replacing a recipient’s Descemet’s membrane and endothelium with healthy tissue. Main advantages include rapid visual recovery, fewer higher order aberrations and low rejection rate. However, DMEK is technically challenging and requires advanced surgical skills. The aim of the audit was to assess visual outcomes of DMEK performed at Luton and Dunstable University Hospital (L&amp;D), United Kingdom.MethodsData was collected retrospectively from April 2015 to November 2018. 57 eyes were analysed (31 male, 26 female). Patient demographic data were collected, as well as indication for surgery and pre‐operative visual acuity. Post‐operative follow‐up visits were analysed, including assessment of visual acuity, complications and graft failure and rejection.ResultsPre‐operative visual acuity (Snellen chart) ranged from worse than 6/60 to 6/6. At an average of 6 months post operatively 87% of patients achieved 6/12 vision or better. At 1 year post procedure 59% of patients achieved 6/6 vision or better. At 2 years follow‐up 63% of patients achieved 6/6 vision or better. The most common DMEK related complications were steroid induced raised IOP (n = 9), partial graft detachment or dislocation (n = 8) and need for re‐bubbling (n = 7). 5 patients were listed for Descemet Stripping Automated Endothelial Keratoplasty (DSAEK).ConclusionsMost patients undergoing DMEK procedure in L&amp;D Hospital achieve 6/12 vision or better from 6 months onwards. Outcomes at 6 months, 1 year and 2 years are in‐line with the guidelines set by the Royal College of Ophthalmologists and previously published data. These are re‐assuring findings which suggest that more advanced corneal techniques can be carried out at single surgeon sites. Future work should aim to collect long term data on outcomes.

Initiation of parenteral nutrition in critically ill patients

Retrospective cross-sectional single centre study was done to determine the current intensive treatment unit (ITU) practice on initiation of parenteral nutrition (PN) and to compare ITU practice with regards to PN against the standard agreed by the East of England critical care network of United Kingdom. All the patients who met the criteria and was admitted to the ITU of Luton and Dunstable University Hospital, United Kingdom from 1 st of October to 31 st December 2017 were included in the study. Out of the 100 patients in the study, only 10% were initiated on PN during the ITU stay. All those who received PN were at higher risk of malnutrition as assessed by the malnutrition universal screening tool (MUST) score. The mean days of ITU stay was 3.4 prior to initiating parenteral nutrition. The mean ITU stay of PN group was 8.7 days vs 4.47 in the other group. The ITU and hospital mortality was higher in PN group at 30% and 50%.

PMS66 - IMPROVING PATIENT AND FINANCIAL OUTCOMES IN THE NHS: EARLY ARTHRITIS SERVICE INCREASES PATIENT SATISFACTION WHILST SAVING COSTS

The Luton and Dunstable University Hospital NHS Foundation Trust rheumatology department established a centralised, patient-focussed and multidisciplinary Early Arthritis Service (EAS) to achieve key financial and clinical outcome targets the department was failing to meet. The EAS aimed to increase the department’s capacity to accommodate referrals from general practitioners (GPs) and other sources, decrease the time between diagnosis and starting therapy, establish standardised treatment algorithms and reduce biologic use. The EAS was established in January 2016 and comprised the following: introduction of a dedicated referral proforma and early arthritis (EA) educational programme for GPs, pooling of all sources of referral, running of 6 EA clinics per week with availability of ultrasound and longer appointments, funding of a Clinical Nurse Specialist to achieve prescriber status, introduction of a standardised approach to the early initiation of therapy and timely review of treatment outcomes. The introduction of the EAS was associated with improved clinical outcomes (EA patients achieving a Disease Activity Score 28 (DAS28) <3.2 in 2015: 38.0% [N=113] vs 78.5% [N=220] in 2016) and overall patient experience (mean waiting time for EA patients’ first appointment in 2015: 12 weeks vs 2.5 weeks in 2016; 74.0% [N=102] of patients recommended the rheumatology service in 2015 vs 92.0% [N=167] in 2016). The total cost associated with introducing the EAS was ∼£201,362. Use of biologics decreased from 26.0% to 5.6% between 2015 and 2016, resulting in a cost saving of ∼£394,932. Other cost savings associated with the EAS included reductions in the overall cost/patient seen (2015: £198.88; 2016: £74.98) and not running any premium rate initiative clinics to meet waiting list targets (saving ∼£26,500 in 2016). Efficiency gains from the introduction of the EAS have improved patients’ health and overall satisfaction with their treatment, whilst saving costs at this NHS Trust.

Re: Pre‐operative investigations in patients undergoing oral and maxillofacial procedures

Oral SurgeryVolume 11, Issue 1 p. 89-89 Letter to the Editor Re: Pre-operative investigations in patients undergoing oral and maxillofacial procedures G. Vithlani, G. Vithlani Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorP. Shah, P. Shah Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorR. Patel, R. Patel Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorT. Mirza, T. Mirza Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this author G. Vithlani, G. Vithlani Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorP. Shah, P. Shah Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorR. Patel, R. Patel Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this authorT. Mirza, T. Mirza Oral and Maxillofacial Surgery, Luton and Dunstable University Hospital, Luton, UKSearch for more papers by this author First published: 26 January 2018 https://doi.org/10.1111/ors.12276Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume11, Issue1February 2018Pages 89-89 RelatedInformation

1 Setting up a cardiac ct service – pearls and pitfalls

Introduction CT coronary angiography is being increasingly recognised as an important non-invasive modality for the assessment of coronary artery disease, especially in light of the new NICE guidance. Providing this service in a busy District General Hospital has its challenges and developing the service can be an interesting journey for Radiologists and Cardiologists. Luton and Dunstable University Hospital (L&D) is a large district general hospital in Bedfordshire serving a population of 320,000. The Cardiac CT service was set up in March 2015. Methods We retrospectively analysed the first 578 studies performed at the L&D. We reviewed various audits and consequent improvements that were made to the service at various points to increase productivity including Radiographer training and technical support for complex case assessment. We also measured our waiting lists to assess the service demand over time since setting up the service. Results The service was initially set up as a single session once a week with 2–3 patients per session. This grew steadily over the past two years to two sessions per week with 5–6 patients per session reported by 3 Radiologists and 3 Cardiologists. The waiting list has risen from one week to six since the introduction of new NICE guidelines. We are now hoping to move to a 5 day service. Conclusion Introducing a relatively high demand service to a busy DGH Radiology department can be difficult. Careful time management, training and planning are required with regular audit of scan quality, time for scanning and reporting.

Education: build it and they still don't come

Education: build it and they still don't come

Determining the opinions and importance of written handover for patient safety: a questionnaire based study.

Objective Handover is the communication of clinical information to support the transfer of patient care. It is a major contributing factor to patient safety. It can be provided verbally or in a written format. This study determines the opinions and importance of written handover for patient safety, postulating that it has a critical role in ensuring safety and has justification for implementation where not present. Method An online questionnaire comprising of ten questions was sent to doctors in September 2014 at Luton and Dunstable University Hospital. Answers to questions were provided as a drop down menu with free text or as a single row rating scale. Data was exported onto, and analysed using statistical software. Frequency and percentage of answer choices were derived for each question. Results The majority of respondents were Doctors of Consultant/Professor grade (51.3%). Those that did have written handover stated that it was accurate with regards to patient clinical details (45%) and that inaccurate handover does impede quality of care and clinical management (61.7%). Where not present, the majority of 28.3% of respondents strongly agreed that handover would improve patient safety and staff familiarity with patients. Conclusion Opinions from the study conducted suggest that written handover is a very powerful communication tool by which patient safety can be ensured. Implementation and maintenance of it locally and nationally is a possible logistical challenge. Further studies can be done in order to determine its effectiveness once standardised and implemented within this study location, and at other care units.

Determination of Opinions Regarding Written Handover and Its Importance for Patient Safety: A Questionnaire-Based Study

Introduction: Handover is the communication of clinical information to support the transfer of patient care and is a major contributing factor to patient safety. Handovers can be provided verbally or in a written format. This study aimed to determine the opinions regarding written handover and its importance, postulating that it has a critical role in ensuring patient safety and has justification for implementation where not present. Materials and Methods: An observational online questionnaire comprising ten questions was sent to doctors at Luton and Dunstable University Hospital in September 2014. Answers to the questions were provided as free text or single row rating scale in a drop-down menu. The data were exported into SPSS to be analysed. Frequency and percentage of the answer choices were derived for each question. Results:The majority of respondents were physicians (51.3%). Those who had written handover stated that it was accurate with regards to patients’ clinical details (45%) and that inaccurate handover impedes quality of care and clinical management (61.7%). In cases where patient handover was not present, 28.3% of the respondents strongly agreed that handover could improve patient safety and staff familiarity with patients. Conclusion: The results suggest that written handover is a very powerful communication tool through which patient safety can be ensured, and its local and national implementation and maintenance are a possible logistical challenge. It is recommended to conduct further studies on this issue to determine its effectiveness once standardised and implemented within this study location, and at other care units.

Do &amp;ldquo;trainee-centered ward rounds&amp;rdquo; help overcome barriers to learning and improve the learning satisfaction of junior doctors in the workplace?

Ward rounds are widely considered an underutilized resource with regard to medical education, and therefore, a project was undertaken to assess if the initiation of “trainee-centered ward rounds” would help improve the confidence, knowledge acquisition, and workplace satisfaction of junior doctors in the clinical environment. Data were collated from junior doctors, registrar grade doctors, and consultants working in the delivery suite at Luton and Dunstable University Hospital in Luton over a 4-week period in March–April 2013. A review of the relevant literature was also undertaken. This pilot study found that despite the reservations around time constraints held by both junior and senior clinicians alike, feedback following the intervention was largely positive. The junior doctors enjoyed having a defined role and responsibility during the ward round and felt they benefited from their senior colleagues’ feedback. Both seniors and junior colleagues agreed that discussing learning objectives prior to commencing the round was beneficial and made the round more learner-orientated; this enabled maximal learner-focused outcomes to be addressed and met. The juniors were generally encouraged to participate more during the round and the consultants endeavored to narrate their decision-making, both were measures that led to greater satisfaction of both parties. This was in keeping with the concept of “Legitimate peripheral participation” as described by Lave and Wenger. Overall, trainee-centered ward rounds did appear to be effective in overcoming some of the traditional barriers to teaching in the ward environment, although further work to formalize and quantify these findings, as well as using greater sample sizes from different hospital departments and the inclusion of a control group, is needed.

PWE-065 Stopping biological therapy in patients with inflammatory bowel disease: a 5 year review of a single centre–s experience

<h3>Introduction</h3> With the recent NICE guidelines giving clearance for the use of infliximab, golimumab and adalimumab in moderate-severe ulcerative colitis, there is a general fear held by the Clinical Commissioning Groups (CCGs) that the cost of biological therapy is about to rapidly escalate. Cheaper biosimilars will soon join the market place, but already many CCGs have restricted funding to just 1 year and advocate stopping if the patient is in clinical remission. Given these funding restrictions we assess the outcomes seen in those patients stopping biological therapy. <h3>Method</h3> A 5 year retrospective review was made of the 94 inflammatory bowel disease (IBD) patients that have been treated with biologics at the Luton and Dunstable University Hospital. Data was obtained from the National IBD Registry, Evolve (the hospital’s electronic note system), and ICE (the hospitals results system). Full remission was defined as asymptomatic patients with near normal inflammatory markers and complete mucosal healing or minimal endoscopic inflammation only. <h3>Results</h3> There were 94 IBD patients treated with biological therapy between January 2010 and December 2014. Biologics were stopped in 49 patients, of which 36 were deemed to be in full remission. Biological therapy was also stopped because of treatment failure requiring surgery (eg.colectomy) in 6, 2 were in remission but needed surgery for subsequent colorectal cancer, 3 patients fell pregnant (all initially in clinical remission, although 2 subsequently flared and were restarted), the injection was too painful for 2, 1 was non-compliance and 1 had an infusion reaction. In the group of 36 that achieved full remission (25CrD, 2CrD Fistulae, 9UC), 31 (86%) of them stayed in remission after stopping their biologics, with an average follow up time of 13 months (4–42 months), at the point of writing this abstract. Of the 5 patients in remission that flared, 2 CrD patients flared post-delivery, 1 UC patient flared, and 2 CrD patients flared with the complications of fistulae and/or strictures requiring surgery. Of the 13 patients who weren’t in remission on stopping the biologics, only 2 of them settled into remission using alternative therapies. <h3>Conclusion</h3> Provided patients are in a full remission our data supports an efficacy of 86% in stopping biological therapy and then managing patients on traditional immunosuppressor therapies, at least in the first year. Caution must however be observed, as 2 of the unpredictable relapses that did occur on stopping biological therapy resulted in young patients having to undergo surgery. A greater overall success rate may have been achieved with tighter initial case selection by gastroenterologists with a specialist experience in IBD or through open discussions at a Biologics MDT. <h3>Disclosure of interest</h3> None Declared.

PWE-063 Local experience of using tacrolimus as rescue therapy in resistant ibd

<h3>Introduction</h3> Tacrolimus is a macrolide immunosuppressant. By inhibiting the transcription of interleukins (ILs) such as IL-2, tumour necrosis factor-α (TNF) and interferon-gamma, it exerts a powerful and selective suppression of T-cell function. Oral Tacrolimus has been used in patients with refractory ulcerative colitis, but its role in Crohn’s disease has not yet been determined, especially when compared with alternative approaches such as anti TNFs.¹We reviewed the clinical outcomes of a small but growing cohort of resistant IBD patients where Tacrolimus was started as rescue therapy. <h3>Method</h3> The National IBD Registry was used to identify all IBD patients at the Luton and Dunstable University Hospital presently being treated on Tacrolimus. A retrospective review of these patients was then performed using data held on our National IBD Registry, Evolve (in-house hospital electronic records system) and ICE (hospital results system). A comparison was made of the data collected pre and post Tacrolimus therapy e.g. ESR, CRP, faecal calprotectin, Harvey Bradshaw Index (HBI) for Crohn’s patients and modified UC Disease Activity Index (UCDAI) for ulcerative colitis patients. <h3>Results</h3> The Luton and Dunstable University Hospital IBD Registry and Patient Management System now contains the clinical details of 3002 IBD patients. Of these a total of 10 patients had been started on Tacrolimus, 2 had Crohn’s and 8 had ulcerative colitis (3 Pan UC, 1 left sided UC and 4 distal UC). These patients had been started on Tacrolimus for a range of reasons including; failure of a range of standard therapies, multiple drug sensitivities, patients refusing biological therapy, failure of biological therapy, biological funding issues, steroid dependancy, steroid contraindications and refusing admission for IV steroids. All patients improved on Tacrolimus, with reductions seen in the average HBI from 7.5 to 4.5, and in the average mUCDAI scores from 7.9 to 3.5. A decrease was also seen with the average CRP pre and post Tacrolimus therapy decreasing from 24.4 to 9.7, and with the ESRs from 30.2 to 7.8. No adverse reactions have been experienced to date. <h3>Conclusion</h3> Our results suggest that Tacrolimus is a highly effective immunomodulator therapy, and a useful addition to the IBD therapeutic armoury, particularly in those with difficult or resistant UC or Crohn’s disease. We have been impressed with its speed of action and ease of dose adjustment. Further studies are required to assess its longterm safety profile and use in Crohn’s disease. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Landy J, Wahed M, Peake ST, Hussein M, Ng SC, Lindsay JO, Hart AL. Oral tacrolimus as maintenance therapy for refractory ulcerative colitis-an analysis of outcomes in two London tertiary centres. <i>J Crohns Colitis</i>. 2013;<b>7</b>(11):e516–21. doi: 10.1016/j.crohns.2013.03.008. Epub 2013 Apr 25

PWE-064 The clinical outcomes of a personalised approach to the management of patients taking thiopurine medication, using metabolite assessments

Introduction A significant number of patients with inflammatory bowel disease (IBD) are treated with thiopurine drugs. Typically patients are commenced on starting doses of Azathioprine (AZA) or 6-Mercaptopurine (6-MP) and these are titrated up to 2.5 mg/kg and 1.25 mg/kg respectively, provided this is tolerated. Measurement of thiopurine metabolites (TPM), 6-Thioguanine nucleotide (6-TGN) and 6-Methylmercaptopurine nucleotide (6-MMPN), has proved useful in improving therapeutic efficacy, minimising unwanted side effects and identifying non-compliance. The aim of this study was to use TPM analysis to help guide the management of patients within our immunomodulator service, at the Luton and Dunstable University Hospital, taking thiopurine drugs. Method The gastroenterology department identified 406 patients with IBD who were taking thiopurine drugs. Letters were sent out on mass to these patients in December 2014 requesting a blood test for TPM before the end of January 2015. The patient’s samples were sent to Birmingham City Hospital for measurement of 6-TGN and 6-MMPN. A thiopurine management algorithm was designed to help clinicians understand these TPMs and direct them on how best to act on these results. Results Of the 406 patients who were sent TPM test requests, 200 attended prior to the end of January. These included 156 patients taking AZA and 44 taking 6-MP. The results for 6-TGN and 6-MMPN determined a change in management for 124 patients (62%), with only 76 patients (38%) classified as having an ‘accurate dose’ of AZA or 6-MP. Non-compliance with thiopurine therapy was evident for 15 patients (7.5%), and a further 5 patients phoned the IBD nurses directly admitting non-compliance. The dose of AZA or 6-MP was increased for 28 patients (14%) and decreased for 71 patients (35.5%). Thiopurine therapy was stopped in 10 patients (5%) due to significantly high levels of 6-TGN or 6-MMPN. A number of patients were classified as being ‘too sensitive’ to the thiopurine drugs with high concentrations of 6-MMPN. Based on the results of 6-TGN and 6-MMPN the drug used by 1 patient was changed from AZA to 6-MP. Conclusion The assessment of thiopurine metabolites directly led to the dose adjustment of AZA and 6-MP in 62% of patients tested. The measurement of 6-TGN and 6-MMPN enables appropriate personalised thiopurine dosing, following a simple thiopurine management algorithm, to optimise their therapy. Non-compliance is easy to identify and patients who preferentially metabolise thiopurine drugs to the hepatotoxic metabolite 6-MMPN had their therapy stopped, enabling initiation of alternative treatment modalities. Further work would be necessary to assess whether this reduces complications in the long term. Disclosure of interest None Declared.