Imperial College Healthcare NHS Trust Research Articles

Outcomes Following Paediatric Tonsillectomy From a UK Tertiary Centre: Imperial College Healthcare NHS Trust's Experience During the COVID-19 Pandemic.

Background Paediatric tonsillectomy ranks among the most frequently performed surgical procedures globally. The substantial volume of these operations underscores their considerable impact on healthcare systems and resource allocation. Recent guidelines in the United Kingdom have emphasized the safety and feasibility of performing tonsillectomies as day-case surgeries. The interplay of medical necessity, high incidence, and evolving guidelines underscores the importance of continually evaluating and optimizing tonsillectomy practices. This study assesses the outcomes of paediatric tonsillectomies at a UK tertiary centre during the COVID-19 pandemic and the implementation of day-case guidelines. Methodology A retrospective analysis was conducted on patients under 18 years of age who underwent tonsillectomy between April 2021 and September 2022. Data on postoperative events until discharge and re-attendance within 14 days were recorded. High-risk subgroups were analysed: subgroup A (two years of age and weighing 12-15 kg), and subgroup B (severe obstructive sleep apnoea (OSA) on polysomnography defined as an apnoea/hypopnoea index >30 events per hour). Binary logistic regression assessed whether age, weight, sex, or procedure time predicted extended hospital stay (more than one night) or the need for oxygen. Day-case tonsillectomy guidelines were created after multi-disciplinary team approval. Results A total of 117 patients underwent tonsillectomy, with a median age of four (n = 72 male). OSA/sleep-disordered breathing accounted for 88% (n = 103), and 68% (n = 70) underwent a preoperative sleep study. Same-day discharge rate was 26% (n = 31). Postoperatively, 86 patients were admitted; 44 required overnight oxygen saturation monitoring, 35 for weight extremes, and seven for poor oral intake. Of those admitted, 70 (81%) patients remained well overnight, and 76 (88%) patients were discharged the next day. In subgroup A (n = 17), the average weight was 13.4 kg; two had transient desaturations. Fourteen were discharged the next day. In subgroup B (n = 34), four had transient desaturations with a further two requiring oxygen. Weight (p = 0.071) within the 'extended hospital stay model' and procedure time (p = 0.052) within the 'need for oxygen' model approached significance for predicting outcomes. Conclusions This study offers early insights into paediatric tonsillectomy outcomes during the COVID-19 pandemic at a tertiary centre. Although the same-day discharge rate was lower than the national average, most patients, including high-risk groups, remained clinically stable and were discharged within 24 hours.

Characteristics and outcomes of atrial fibrillation detected before and after acute ischemic stroke.

Atrial fibrillation (AF) can be known before the stroke (KAF) or be newly detected after stroke (AFDAS). It is unknown whether the outcome of stroke differs between KAF and AFDAS. We performed a propensity-matched analysis to investigate the outcome of patients with AFDAS and their counterparts with KAF. We analysed a consecutive series of patients enrolled into the EIDASAF study, a single centre, retrospective study of ischemic stroke patients with a diagnosis of AF before or after the event who had been admitted to the Hyperacute Stroke Unit of Imperial College Healthcare NHS Trust between 2010 and 2017. Overall, our cohort included 959 patients with AF and acute ischemic stroke. After propensity score matching, 547 patients were matched (404 KAF group and 143 AFDAS group). The rates of in hospital death and of haemorrhagic transformation were significantly higher in KAF patients compared to AFDAS patients. Logistic regression analysis did not reveal a statistically significant influence of AF subtypes on the outcome of death. However, in logistic regression analysis KAF was associated with increased probability of haemorrhagic transformation (OR 9.64; CI 1.29-71.68, p = 0.022) after the index event. KAF is associated with an increased risk of haemorrhagic transformation but not of death when compared to AFDAS.

O-203 Comparing viable and non-viable IVF early pregnancy measurements: does knowledge of gestational age using date of ET potentially change miscarriage diagnosis guidelines in IVF patients

Abstract Study question In IVF pregnancies with known embryo transfer (ET) dates, can gestational age as well as ultrasound measurements be used to diagnose miscarriage? Summary answer Early pregnancy measurements vary at fixed gestational ages based on ET. However, there is a specific time cut-off where an empty gestational sac indicates miscarriage. What is known already Current guidelines state that when ultrasound findings show a pregnancy of unknown viability, a repeat scan must be performed either 7 or 14 days later (depending on the presence of an embryo or gestation sac size) to confirm viability, irrespective of the LMP based gestational age. This definition only considers ultrasound measurements, and even when the pregnancy dates thought to be certain and based on day of ET date, there are no exceptions to this guidance. Study design, size, duration This was a retrospective cohort study within a London tertiary unit, Wolfson Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust over a 36-month time period. We collated data from both fresh and frozen cycle IVF pregnancies over four years: Jan 1st 2019 to December 31st 2021. Participants/materials, setting, methods In this unit, patients undergoing fresh or frozen IVF cycles, have an embryo transfer at Day3-6 of development. We included any patient with a confirmed intrauterine pregnancy at first scan (5-8 weeks gestation) for analysis of pregnancy outcomes. The data collected included date of embryo transfer (ET), embryo age at transfer, and early pregnancy measurements using ultrasound. The endpoint was viability at the 11-14 week dating scan. Main results and the role of chance 1161 IVF embryo transfers were included in the study, 677 (58.3%) frozen and 484 (41.7%) fresh cycles. 892 (76.8%) remained viable at 11-14 weeks and 269 (23.2%) were non-viable. Pregnancies resulting in viable pregnancies had a range of CRL (≤16mm) and empty mean gestation sac diameter (MSD) (≤11mm) measurements at each expected age by ET date (≤8 weeks gestation). At 49 days CRL varied from 1mm to 17mm, and at 42 days empty MSD measurements varied from 7 to 18mm. This shows that a range in embryo and gestation sac sizes will be seen in subsequently shown to be viable pregnancies despite the apparent exact gestation being known based on ET. This may relate to both differing embryo growth rates and timing of implantation. A Kolmogorov-Smirnov test was applied to compare the viable and miscarriage cohort CRL measurements in relation to expected age by ET. The result: 0.610, p-value=1.33 x10-15, demonstrated a significant difference in embryo size between viable and non-viable pregnancies with known ET dates. All pregnancies where the scan showed an empty gestational sac (n = 157) at 47 days gestation by ET date, had a 100% positive predictive value with a 100% specificity (CI:90.1-100.0) for miscarriage. Limitations, reasons for caution The sample was powered to 0.9, significance level 0.05. Analysis demonstrated 100% positive predictive value with 100% specificity (CI:90.1-100.0), to confirm miscarriage with an empty gestation sac ≥47days age by ET date. A larger cohort size from different centres is needed to reduce the confidence interval and confirm the findings. Wider implications of the findings There is significant variation in CRL and MSD size between viable pregnancies of the same gestational age by ET. However, we found >47 days gestation an empty gestation sac resulted in miscarriage. If confirmed in larger studies this may permit women to be given an earlier definitive diagnosis of miscarriage. Trial registration number Audit registration GRM_104 Imperial Healthcare NHS Trust

P083 Introduction of a gout pathway in a London NHS trust

Abstract Background/Aims Gout is a major cause of morbidity with a significant increase in UK hospitalisation identified over the last decade due to acute flare. Patient and physician education alongside a treat-to-target approach with urate-lowering therapy (ULT) are fundamental in its management. Despite being commonly encountered by clinicians, a survey conducted at Imperial College Healthcare NHS trust (ICHNT) demonstrated 49% of responders did not feel confident managing the condition. This project aimed to create a guideline for the management of acute gout at ICHNT to aid prompt diagnosis and effective management. Increasing the proportion of patients commencing ULT through engagement with local primary care networks was prioritised to improve patient outcomes and reduce subsequent hospital attendances. Methods A trust wide guideline for the management of acute gout was created with input from stakeholders (including emergency and acute medicine physicians) and informed by rheumatology clinicians and current guidelines. Latest recommendations from NICE, BSR and EULAR were consulted alongside local guidelines in place across London. An emphasis was placed upon education and initiation of ULT to improve management of acute and chronic gout to prevent future hospital attendances. Staff within the rheumatology department were consulted to agree on timing of ULT initiation and an effective pathway for implementation. Results Through review of local, national and international guidelines, discrepancies in gout management were identified, most notably variation in the timing of ULT initiation (e.g. during the acute presentation, after flare resolution or after subsequent flare). This was reflected in the practice of clinicians within the rheumatology department at ICHNT. Agreed consensus brought the trust guideline predominantly in line with current NICE guidance for management of acute gout with ULT commenced in patients 2-4 weeks after resolution of flare. Initially, this led to delegation of ULT initiation to general practitioners, however, this resulted in concerns over treatment delays and added pressure on an already stretched service. Follow-up within secondary care was also considered, but capacity issues exist. As a next step, a pilot for a pharmacy-led follow-up service within primary care is planned using standardised protocols supported by secondary care. Conclusion The implementation of a local guideline on the management of acute gout is helpful for clinicians from a non-rheumatology background to facilitate prompt diagnosis and effective management of this common, but often poorly treated, condition. A successful pathway to prevent future flares is more challenging, not only due to discrepancies in current guidelines on timing of ULT initiation but also in creating capacity for follow-up and treatment implementation. This continuing project aims to explore alternative pathways such as a pharmacy-led service that improves patient outcomes and reduces future burden upon healthcare services. Disclosure E. Mabey: None. H. Wilson-Morkeh: None. B. Ellis: None.

The beneficial hepatic effects of glucagon‐like peptide 1 receptor agonists in patients with diabetes and metabolic dysfunction‐associated steatotic liver disease are independent of weight loss

AbstractBackgroundMetabolic dysfunction‐associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide. Despite resmetirom being recently approved for treatingnon‐cirrhotic MASH patients in the United States of America (but not elsewhere), weight loss and lifestyle remain the first line and mainstay for treating the condition. Glucagon‐like peptide 1 receptor agonists (GLP‐1RAs) have shown promise in MASLD treatment, as they promote significant weight loss.AimsIn this study, we assessed the effect of long‐term GLP‐1 therapy on liver disease severity in a cohort of patients with Type 2 diabetes and MASLD.Materials and methodsIn this retrospective observational study, we included all new MASLD patients seen in the liver clinic (Imperial College Healthcare NHS Trust) from January 2010 to May 2022. Demographic, anthropometric and clinical data were collected at baseline and at the most recent follow‐up.Results779 patients were included. Among those with Type 2 diabetes mellitus (T2DM) (n = 335), 94 (28%) were prescribed a GLP‐1RA for a median period of 38 (1–171.2) months. In those on GLP‐1RA, there was a significant improvement in BMI (33.1 vs. 34.9 kg/m2, p = 0.005), alanine aminotransferase (ALT) (37 vs. 58 IU/L, p = 0.009), HbA1c (58 vs. 61 mmol/lL, p = 0.006) and CAP score (331 vs. 354 dB/m, p = 0.0001) at the end of follow‐up. Finally, among those who were treated with GLP‐1RA, 37 patients had <5% weight loss over a median of 38 (10–134) months. In this group, there was also a significant reduction in ALT (32 vs. 58 IU/L, p = 0.0001), AST (30 vs. 36 IU/L, p = 0.004) and CAP score (329 vs. 349 dB/m, p = 0.05) compared with those who lost >5% weight. In this real‐life cohort of patients with diabetes and MASLD, treatment with GLP‐1RA was associated with greater weight loss and hepatic fat reduction. Of note, a reduction in fat content was observed also in those who did not lose weight.ConclusionTreatment with GLP‐1RA should be favoured when treating patients with co‐existing diabetes and MASLD.

Attendance at remote versus in-person outpatient appointments in an NHS Trust.

With the growing use of remote appointments within the National Health Service, there is a need to understand potential barriers of access to care for some patients. In this observational study, we examined missed appointments rates, comparing remote and in-person appointments among different patient groups. We analysed adult outpatient appointments at Imperial College Healthcare NHS Trust in Northwest London in 2021. Rates of missed appointments per patient were compared between remote versus in-person appointments using negative binomial regression models. Models were stratified by appointment type (first or a follow-up). There were 874,659 outpatient appointments for 189,882 patients, 29.5% of whom missed at least one appointment. Missed rates were 12.5% for remote first appointments and 9.2% for in-person first appointments. Remote and in-person follow-up appointments were missed at similar rates (10.4% and 10.7%, respectively). For remote and in-person appointments, younger patients, residents of more deprived areas, and patients of Black, Mixed and 'other' ethnicities missed more appointments. Male patients missed more in-person appointments, particularly at younger ages, but gender differences were minimal for remote appointments. Patients with long-term conditions (LTCs) missed more first appointments, whether in-person or remote. In follow-up appointments, patients with LTCs missed more in-person appointments but fewer remote appointments. Remote first appointments were missed more often than in-person first appointments, follow-up appointments had similar attendance rates for both modalities. Sociodemographic differences in outpatient appointment attendance were largely similar between in-person and remote appointments, indicating no widening of inequalities in attendance due to appointment modality.

Improving nurses' digital literacy and engagement with digital workflows through a data-driven education model.

A digitally literate nursing workforce can support the delivery of safe, effective care and improve patient outcomes. However, digital literacy among nurses is variable. Electronic patient records (EPRs), which require the digital documentation of all patient encounters, can be used to generate data that will inform strategies to improve patient care and patient safety. Nurse leaders at Imperial College Healthcare NHS Trust acknowledged that although ward nurses were providing excellent patient care, there were gaps in their digital documentation of that care. To address the issue, the trust implemented a model of education informed by data analytics and aimed at developing nurses' digital skills and increasing their engagement with digital workflows. This article describes how applications extracting data from the EPR system are used to identify nurses' digital literacy training needs and how a team of digital clinical practice educators delivers targeted educational strategies to meet those needs.

Radioactive iodine treatment outcomes at imperial college healthcare NHS Trust

Radioactive iodine treatment outcomes at imperial college healthcare NHS Trust

THU642 Progression To Cirrhosis And All-cause Mortality Are Increased In Postmenopausal Women With NAFLD

Abstract Disclosure: C. Izzi-Engbeaya: None. P. Eng: None. A. Dunin-Borkowska: None. R. Forlano: None. B.H. Mullish: None. G. Sigon: None. V. Lin: None. T. Tan: None. M. Yee: None. P. Manousou: None. W.S. Dhillo: None. Background: Up to 30% of adults worldwide are estimated to have Non-alcoholic Liver Disease (NAFLD), ranging from hepatic steatosis alone to steatohepatitis and cirrhosis. Due to underlying metabolic and hepatic pathology, patients with NAFLD require specialist input from Endocrinologists and Hepatologists. Worryingly, postmenopausal women with NAFLD are more likely to progress to advanced fibrosis and experience more frequent liver decompensation events than men, but the causes of these disparate outcomes are incompletely understood. Methodology: We performed a retrospective cohort study utilising a database of consecutive patients managed in the multidisciplinary Metabolic Endocrinology and Hepatology Clinic at Imperial College Healthcare NHS Trust (London, UK) who had their first clinic review between January 2009 and December 2020. NAFLD was diagnosed clinically or histologically. Clinical, biochemical and histological data were collected up to December 2022. Postmenopausal women were defined as women aged ≥55 years at their initial clinic visit. Cirrhosis was diagnosed based on a combination of clinical and radiological features or based on histology, when available. Multivariate logistic regression was performed to identify variables independently associated with cirrhosis. Statistical significance was set at p<0.05. Results: 739 patients were included in this study (n=286 female, n=244 White, median (IQR) age: 52 (42-60) years), with a median follow-up of 6 (3-8) years. All-cause mortality was highest amongst postmenopausal women (proportion who died during follow-up: men <55y 2% vs men ≥55y 9% vs women <55y 0.8% vs women ≥55y 14%, p<0.0001). Postmenopausal women (n=153) had increased risks of cirrhosis when compared to age-matched men (cirrhosis: OR 2.8 (95%CI 1.1-7.2), p<0.05). Postmenopausal women had lower ALT levels at initial clinic review (median (IQR) ALT IU/L: women ≥55y 48 (30-73) vs men ≥55y 54 (41-77), p <0.05), and lower alcohol intake than age-matched men (p<0.0001). Similar proportions of postmenopausal women and age-matched men had a baseline fibrosis stage ≥2 (82% vs 78% respectively, p=0.55). Initial prevalence of obesity (p=0.63), type 2 diabetes (p=0.15), cardiovascular disease (p=0.21), as well as use of GLP-1 receptor agonists (p=0.17) and SGLT2 inhibitors (p>0.99) were similar between these two groups. There were insufficient data on reproductive hormone use for this variable to be included in the analyses. Conclusions: Despite presenting to a specialised secondary care clinic with similar co-morbidities, liver fibrosis stage, and receiving similar treatments, being a postmenopausal woman in our diverse cohort is associated with worse outcomes than being a man aged ≥55years. Therefore, tailored and/or personalised management strategies may be required to improve outcomes in postmenopausal women with NAFLD. Presentation: Thursday, June 15, 2023

Management of Small Bowel Neuroendocrine Tumours: 10 Years' Experience at a Tertiary Referral Centre.

Neuroendocrine tumours (NET) arising from the small bowel are clinically challenging and are often diagnosed at advanced stages. Disease control with surgery alone can be demanding. Multimodal treatment concepts integrating surgery and non-surgical modalities could be of benefit. Retrospective review of consecutive adult patients with SB NET treated at Imperial College Healthcare NHS Trust between 1 January 2010 and 31 December 2019. Data regarding clinicopathological characteristics, treatments, and disease trajectory were extracted and summarised. Overall and progression/recurrence-free survival were estimated at 5 and 10 years. 154 patients were identified, with a median age of 64 years (range 33-87); 135/154 (87.7%) had stage III/IV disease at diagnosis. Surgery was used in 125 individuals (81.2%), typically with either segmental small bowel resection (60.8%) or right hemicolectomy (33.6%) and mesenteric lymphadenectomy for the primary tumour. Systemic and/or liver-directed therapies were used in 126 (81.8%); 60 (47.6%) had more than one line of non-surgical treatment. Median follow-up was 67.2 months (range 3.1-310.4); overall survival at 5 and 10 years was 91.0% (95% CI: 84.9-94.7%) and 82.5% (95% CI: 72.9-88.9%), respectively. Imaging-based median progression-free survival was 42.7 months (95% CI: 24.7 to 72.4); 5-year progression-free survival was 63.4% (95% CI: 55.0-70.6%); 10-year progression-free survival was 18.7% (95% CI: 12.4-26.1). Nineteen patients (12.3%) reached 10 years follow-up without disease recurrence and therefore were considered cured. Most patients with SB NET present in a metastasised stage. Multimodal treatment concepts may be associated with excellent clinical outcomes. Future work should explore optimal approaches to treatment sequencing and patient selection.

1120 Time to Revascularisation for Chronic Limb Threatening Ischaemia – Audit of a Major UK Vascular Service

Abstract Aim Chronic Limb Threatening Ischaemia (CLTI) is severe peripheral arterial disease where arterial supply is sufficiently compromised to threaten tissue viability. CLTI has a prevalence of 1-2% and carries significant morbidity and mortality. Early revascularisation is essential for tissue preservation. Recent guidance from CQUIN 2022/23 set national targets for time to revascularisation based on VSGBI guidelines. This audit assessed one major vascular centre’s compliance. Method Audit standards were taken from VSGBI Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF 2019). Data from Imperial College Healthcare NHS Trust was collected from February-April 2022 for inpatients and outpatients presenting with new CLTI. The primary outcome was time to revascularisation from referral. Secondary inpatient outcomes included time to referral, specialist reviews, imaging and discussion at MDT. Results 59 inpatients and 33 outpatients were included. 54% of inpatients and 83% of outpatients who were candidates for revascularisation breached targets: 5 days and 14 days respectively. Of those breaching most inpatients were re-vascularised within 6-10 days; whilst for outpatients the majority were re-vascularised within 46-75 days. At the time of data collection 7 outpatients were awaiting revascularisation, all >5 months since CLTI onset. Conclusions A significant portion of patients are breaching revascularisation targets, increasing risk of poor outcomes. In both pathways delays are multi-factorial. Contributing factors for inpatients include delays in pre-surgery optimisation and bed/theatre slot pressures. For outpatients’ pre-assessment, surgical optimisation, MDT discussion and/or investigations all contribute to delays. Implementation of early anaesthetic optimisation or outpatient one-stop clinics could be considered.

Editorial Comment.

No AccessJournal of UrologyAdult Urology21 Jun 2023Editorial CommentThis article comments on the following:Biopsy Assessment of Oncologic Control 3 Years Following Primary Partial Gland Cryoablation: A Prospective Cohort Study of Men With Intermediate-risk Prostate Cancer Taimur T. Shah Taimur T. ShahTaimur T. Shah Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003569.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. REFERENCES 1. . Biopsy assessment of oncologic control three years following primary partial gland cryoablation: a prospective cohort study of men with intermediate risk prostate cancer. J Urol. 2023; 210(3):000-000. Google Scholar 2. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2023; 388(17):1547-1558. Crossref, Medline, Google Scholar 3. PACE-A: an international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—primary endpoint analysis. J Clin Oncol. 2023; 41(6_suppl):298. Crossref, Google Scholar 4. . MP80-16 Black patients have worse continence outcomes at 12 months following robotic-assisted radical prostatectomy. J Urol. 2023; 209(suppl 4):e1159. Abstract, Google Scholar 5. Early-medium-term outcomes of primary focal cryotherapy to treat nonmetastatic clinically significant prostate cancer from a prospective multicentre registry. Eur Urol. 2019; 76(1):98-105. Crossref, Medline, Google Scholar 6. Focal therapy compared to radical prostatectomy for non-metastatic prostate cancer: a propensity score-matched study. Prostate Cancer Prostatic Dis. 2021; 24(2):567-574. Crossref, Medline, Google Scholar © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology7 Jun 2023Biopsy Assessment of Oncologic Control 3 Years Following Primary Partial Gland Cryoablation: A Prospective Cohort Study of Men With Intermediate-risk Prostate Cancer Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Taimur T. Shah Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom More articles by this author Expand All Advertisement PDF downloadLoading ...

Aula Abbara—advocating social justice for refugees

Speaking to Aula Abbara at a coffee shop in the leafy area of St James Park, London, it is clear a passion for social justice is the theme that has connected all the dots in her life. So it was no surprise she became a doctor, or that she would eventually find herself working with refugees and other vulnerable populations in various parts of the world or that she would choose to specialise in infectious diseases. Today, Abbara is a consultant clinician in infectious diseases at Imperial College Healthcare NHS Trust, London, UK where she is an Honorary Senior Clinical Lecturer and teaches Global and Public Health at the University. She has also worked with multiple aid agencies delivering humanitarian relief and now works part time for Médecins Sans Frontières as an infectious diseases and malaria advisor.

Increase in hypoglycaemia and hyperglycaemia in people with diabetes admitted to hospital during COVID-19 pandemic

BackgroundWe used detailed information on patients with diabetes admitted to hospital to determine differences in clinical outcomes before and during the COVID-19 pandemic in the UK. MethodsThe study used electronic patient record data from Imperial College Healthcare NHS Trust. Hospital admission data for patients coded for diabetes was analysed over three time periods: pre-pandemic (31st January 2019–31st January 2020), Wave 1 (1st February 2020–30th June 2020), and Wave 2 (1st September 2020–30th April 2021). We compared clinical outcomes including glycaemia and length of stay. ResultsWe analysed data obtained from 12,878, 4008 and 7189 hospital admissions during the three pre-specified time periods. The incidence of Level 1 and Level 2 hypoglycaemia was significantly higher during Waves 1 and 2 compared to the pre-pandemic period (25 % and 25.1 % vs. 22.9 % for Level 1 and 11.7 % and 11.5 % vs. 10.3 % for Level 2). The incidence of hyperglycaemia was also significantly higher during the two waves. The median hospital length of stay increased significantly (4.1[1.6, 9.8] and 4.0[1.4, 9.4] vs. 3.5[1.2, 9.2] days). ConclusionsDuring the COVID-19 pandemic in the UK, hospital in-patients with diabetes had a greater number of hypoglycaemic/hyperglycaemic episodes and an increased length of stay when compared to the pre-pandemic period. This highlights the necessity for a focus on improved diabetes care during further significant disruptions to healthcare systems and ensuring minimisation of the impact on in-patient diabetes services. SummaryDiabetes is associated with poorer outcomes from COVID-19. However the glycaemic control of inpatients before and during the COVID-19 pandemic is unknown. We found the incidence of hypoglycaemia and hyperglycaemia was significantly higher during the pandemic highlighting the necessity for a focus on improved diabetes care during further pandemics.

What constitutes a 'skin expert' in the social media era?

Journal Article Accepted manuscript What constitutes a ‘skin expert’ in the social media era? Get access Laksha Bala, Laksha Bala Department of Dermatology, Charing Cross Hospital, Imperial College Healthcare NHS Trust https://orcid.org/0000-0002-8242-379X Search for other works by this author on: Oxford Academic Google Scholar Nada Khalil, Nada Khalil Department of Dermatology, Charing Cross Hospital, Imperial College Healthcare NHS Trust Search for other works by this author on: Oxford Academic Google Scholar Neil P Patel, Neil P Patel Department of Dermatology, Charing Cross Hospital, Imperial College Healthcare NHS Trust https://orcid.org/0000-0003-2613-6056 Search for other works by this author on: Oxford Academic Google Scholar Khawar Hussain Khawar Hussain Department of Dermatology, Charing Cross Hospital, Imperial College Healthcare NHS Trust Corresponding author: Dr Khawar Hussain. Email: Khawar.Hussain1@nhs.net Search for other works by this author on: Oxford Academic Google Scholar Clinical and Experimental Dermatology, llad125, https://doi.org/10.1093/ced/llad125 Published: 30 March 2023 Article history Received: 22 March 2023 Revision received: 26 March 2023 Accepted: 28 March 2023 Published: 30 March 2023

Commentary on "The road to reliable peptide assays is paved with good guidelines".

Commentary on "The road to reliable peptide assays is paved with good guidelines".

Days and weeks do matter: a call for testing infants at risk of HIV acquisition at birth.

aDepartment of Paediatrics, Imperial College Healthcare NHS Trust, London, UK bDepartment of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC, Canada cDepartment of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA. Correspondence to Patricia M. Flynn, St. Jude Children's Research Hospital, Memphis, TN 38105, USA. E-mail: [email protected] Received 5 December, 2022 Accepted 14 December, 2022

The gut microbiota and metabolome are associated with diminished COVID-19 vaccine-induced antibody responses in immunosuppressed inflammatory bowel disease patients.

Patients with inflammatory bowel disease (IBD) treated with anti-TNF therapy exhibit attenuated humoral immune responses to vaccination against SARS-CoV-2. The gut microbiota and its functional metabolic output, which are perturbed in IBD, play an important role in shaping host immune responses. We explored whether the gut microbiota and metabolome could explain variation in anti-SARS-CoV-2 vaccination responses in immunosuppressed IBD patients. Faecal and serum samples were prospectively collected from infliximab-treated patients with IBD in the CLARITY-IBD study undergoing vaccination against SARS-CoV-2. Antibody responses were measured following two doses of either ChAdOx1 nCoV-19 or BNT162b2 vaccine. Patients were classified as having responses above or below the geometric mean of the wider CLARITY-IBD cohort. 16S rRNA gene amplicon sequencing, nuclear magnetic resonance (NMR) spectroscopy and bile acid profiling with ultra-high-performance liquid chromatography mass spectrometry (UHPLC-MS) were performed on faecal samples. Univariate, multivariable and correlation analyses were performed to determine gut microbial and metabolomic predictors of response to vaccination. Forty-three infliximab-treated patients with IBD were recruited (30 Crohn's disease, 12 ulcerative colitis, 1IBD-unclassified; 26 with concomitant thiopurine therapy). Eight patients had evidence of prior SARS-CoV-2 infection. Seventeen patients (39.5%) had a serological response below the geometric mean. Gut microbiota diversity was lower in below average responders (p=0.037). Bilophila abundance was associated with better serological response, while Streptococcus was associated with poorer response. The faecal metabolome was distinct between above and below average responders (OPLS-DA R2X 0.25, R2Y 0.26, Q2 0.15; CV-ANOVA p=0.038). Trimethylamine, isobutyrate and omega-muricholic acid were associated with better response, while succinate, phenylalanine, taurolithocholate and taurodeoxycholate were associated with poorer response. Our data suggest that there is an association between the gut microbiota and variable serological response to vaccination against SARS-CoV-2 in immunocompromised patients. Microbial metabolites including trimethylamine may be important in mitigating anti-TNF-induced attenuation of the immune response. JLA is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-502), funded by Imperial College London and The Joyce and Norman Freed Charitable Trust. BHM is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-002). The Division of Digestive Diseases at Imperial College London receives financial and infrastructure support from the NIHR Imperial Biomedical Research Centre (BRC) based at Imperial College Healthcare NHS Trust and Imperial College London. Metabolomics studies were performed at the MRC-NIHR National Phenome Centre at Imperial College London; this work was supported by the Medical Research Council (MRC), the National Institute of Health Research (NIHR) (grant number MC_PC_12025) and infrastructure support was provided by the NIHR Imperial Biomedical Research Centre (BRC). The NIHR Exeter Clinical Research Facility is a partnership between the University of Exeter Medical School College of Medicine and Health, and Royal Devon and Exeter NHS Foundation Trust. This project is supported by the National Institute for Health Research (NIHR) Exeter Clinical Research Facility. The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care.

The impact of the COVID-19 pandemic on perinatal services and maternal mental health in the UK.

COVID-19 has created many challenges for women in the perinatal phase. This stems from prolonged periods of lockdowns, restricted support networks and media panic, alongside altered healthcare provision. We aimed to review the evidence regarding the psychological impact on new and expecting mothers following changes to antenatal and postnatal service provision within the UK throughout the pandemic. We conducted a narrative literature search of major databases (PubMed, Medline, Google Scholar). The literature was critically reviewed by experts within the field of antenatal and perinatal mental health. Changes to service provision, including the introduction of telemedicine services, attendance of antenatal appointments without partners or loved ones, and lack of support during the intrapartum period, are associated with increased stress, depression and anxiety. Encouraging women and their partners to engage with aspects of positive psychology through newly introduced digital platforms and virtual service provision has the potential to improve access to holistic care and increase mental well-being. An online course, designed by Imperial College Healthcare NHS Trust in response to changes to service provision, focuses on postnatal recovery inspiration and support for motherhood (PRISM) through a 5-week programme. So far, the course has received positive feedback. The pandemic has contributed to increased rates of mental illness among pregnant and new mothers in the UK. Although the long-term implications are largely unpredictable, it is important to anticipate increased prevalence and complexity of symptoms, which could be hugely detrimental to an already overburdened National Health Service.

Do Children with Immune Thrombocytopenia Have Cerebral Microbleeds?

Background Children with immune thrombocytopenia (ITP) have a low platelet count due to autoimmune destruction and reduced platelet production. ITP increases bleeding risk, with potentially devastating consequences. However, most children have mild disease that resolves spontaneously (Cooper 2014). For this reason, international guidelines recommend observation unless there is overt bleeding (Neunert et al. 2019; Provan et al. 2019). This has resulted in fewer patients exposed to treatment, but there are few data evaluating the safety and impact of this approach. Patients with ITP often have petechiae associated with thrombocytopenia. We hypothesised that a similar process may be occurring in the brain parenchyma. Using susceptibility weighted magnetic resonance imaging (SW-MRI-a technique that is particularly sensitive to haemosiderin deposition), we have previously identified occult cerebral microbleeds (CMBs) in 43% of thrombocytopenic adults with ITP (Cooper et al. 2020). Studies in other disorders have associated CMBs with impaired cognitive function (Morrison et al. 2017). This method has not previously been used to evaluate thrombocytopenic children. Methods 38 children aged 8-17 years old with a diagnosis of ITP and a platelet count under 30 x109/L at any time during their disease course, underwent SW-MRI. Recruitment was from the paediatric immune haematology clinic at Imperial College Healthcare NHS Trust specialist ITP centre. SW-MRI were assessed by two neuroradiologists blinded to clinical details. Number, size and location of CMBs were correlated with clinical metadata including paediatric bleeding questionnaire (PBQ) score, validated cognitive testing (Cogstate), health-related quality of life (HRQoL) scores and fatigue scores. We compared imaging data to 20 age-matched healthy controls (siblings from another SW-MRI Imperial College study using the same imaging protocol). Results The study cohort was 55% male with median age of 12.4 years (range 8-18 years). 66% had chronic ITP (lasting over 12 months) and 76% had active disease (platelet count below 100 x109/L or were on treatment) at the time of MRI. Median disease duration was 33 months (range 1-129 months). Of the cohort, 73% had received treatment including: tranexamic acid, steroids, thrombopoietin-receptor agonists-TPO-RA, intravenous immunoglobulins (IVIg), rituximab and others, with a median treatment episodes of 3 and 68% are currently on TPO-RA treatment. Of 38 patients, 5 (13%) had a detectable CMB (median 3 CMBs, range 1-10); no CMBs were detected in controls. All patients with CMBs had chronic ITP. The patient with the highest CMB burden had 10 CMBs in total (Figure 1). He had multi-refractory disease, 3002 days with a platelet count under 10 x 109/L, a paediatric bleeding score of 14 and minimal responses to IVIg, prednisone, dexamethasone, rituximab, eltrombopag, romiplostim, sirolimus and mycophenolate mofetil. There was a statistically significant correlation with higher PBQ score and the presence of CMBs (p=0.047 using the Mann-Whitney U test); no participants with a bleeding score under 4 had a CMB (PBQ median score 5, range 1-19); conversely many patients with a higher bleeding score did not have a CMB either (Figure 2). There was no correlation with disease duration and CMBs. Cognitive impairment, fatigue and reduced HRQoL were not associated with CMBs. Discussion Although there is heterogeneity in this cohort, the high proportion of chronic ITP and treated patients reflects referrals to an ITP specialist centre. The proportion of children with a CMB is lower than in adults, however disease duration is shorter in this cohort. As none of the children with acute ITP or a bleeding score less than 4 had CMBs, this may support the practice of observing asymptomatic patients whilst awaiting spontaneous remission, although confirmation from a larger cohort is needed. SW-MRI may also be valuable in stratifying patients with intermediate bleeding scores for therapy. In this study, CMBs were not associated with poor HRQoL, fatigue or cognitive impairment. A national study with differing centres is required to better understand the significance of this novel finding of CMBs in childhood ITP. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal