London Hospital Research Articles

Well-being in newly qualified doctors: exploring the value of peer-led reflective sessions

IntroductionFollowing the COVID-19 pandemic and ongoing pressures within the National Health Service, there has been an increasing concern about the well-being of junior doctors in the UK. Newly qualified doctors...

Audit of clinical outcomes from our nurse-led adrenal nodule clinic in a London hospital

Audit of clinical outcomes from our nurse-led adrenal nodule clinic in a London hospital

P145 Single-centre experience of managing patients with anti-HMGCR antibody immune-mediated necrotizing myopathy

Abstract Background/Aims Anti-HMGCR antibodies are associated with a rare form of immune mediated necrotizing myopathy. Statin exposure is common, but statin-naïve presentations can occur. Given its rarity, optimal treatment regimes, alternative cholesterol lowering therapy, and implications of monitoring antibody titre have yet to be established. Methods A retrospective single-centre study was carried out at our tertiary neuromuscular clinic. All patients with a positive anti-HMGCR antibody presenting with a myopathy from 2010-2023, seen in the neuromuscular clinic at the Royal London Hospital, were included. Data on demographics, investigations, and treatments were recorded. Results In total, 39 patients were included in the analysis. Within the anti-HMGCR cohort, ethnically the largest proportion were white (27/39), followed by Asian (n = 7), and four patients black/black-African. 61% of patients were female. The commonest comorbidities were type 2 diabetes mellitus (67%), and hypertension (59%). Median age of onset was 66 (IQR 11). Three patients had no known statin exposure prior to disease onset, of which one had a limb-girdle muscular dystrophy distribution of muscle involvement. Median creatinine kinase (CK) at presentation was 8122 units/L (IQR 5338-14000). Alternative cholesterol lowering therapy was successfully commenced with ezetimibe (n = 18), or PCSK9 inhibitors (n = 3), with no progression of disease. Five malignancies were reported: one breast Ca, one tubo-ovarian, two thyroid, and one low grade NHL. None of the patients had cardiac involvement. 79% of patients were treated with prednisolone. Induction triple therapy of a steroid, IVIg and DMARD was used in 36% of patients. Methotrexate and IVIg were the commonest DMARDs used (59% and 54% respectively), often used in combination with prednisolone. Only four patients had a flare in disease requiring treatment re-escalation, nine patients are in remission off immunosuppression (Table 1). 21% were treated with rituximab, and two patients with abatacept. Where antibody titres were available, anti-HMGCR correlated significantly with CK levels (r = 0.689, p < 0.001). Of the patients with more than one HMGCR titre recorded, 8/14 reduced over time, and of those, 5/8 corresponded to a meaningful improvement in CK, while two patients had an improving CK, with a stable HMGCR titre. 4/14 patients are in remission off all immunosuppression, of which two of these had HMGCR titres below the threshold of positivity, and two had falling titres. Conclusion Anti-HMGCR IMNM remains rare. We demonstrate that remission off immunosuppression is achievable, and that anti-HMGCR titres may be of use to support immunosuppression withdrawal. We also show that, in this cohort of patients, alternative cholesterol lowering therapy is safe, and not associated with worsening disease. Disclosure K.E. Clark: None. R. Thomas: None. S. Kelly: None. L. Walker: None. A. Herrey: None. A. Dougan: None. R. Patel: None. S. Fhadil: None. A. Radunovic: None.

P004 Empowering the reproductive choices of patients with rheumatic disease: using the BSR 2022 pregnancy guidelines audit tool to evaluate pre-conception medication advice

Abstract Background/Aims For ideal pregnancy outcomes, patients with inflammatory rheumatic disease require targeted disease control with pregnancy compatible medications. A proactive approach is required given that people often won’t disclose plans for a pregnancy with healthcare professionals unless directly asked, and 45% of UK pregnancies are unplanned. The BSR 2022 guidelines on prescribing drugs in pregnancy and breastfeeding makes various recommendations on pre-pregnancy counselling for people with rheumatic disease with referral to specialists with relevant expertise as appropriate. Therefore, we used the linked BSR audit tool to evaluate documentation of pre-pregnancy counselling in rheumatology clinics lacking obstetric input at our hospital. Methods Inclusion criteria were all females, aged 15-45 years, attending a doctor-led Rheumatology clinic without obstetric input between 24/4/23 - 30/4/23 at University College London Hospital. Exclusion criteria were infertility and those seen as one-off clinic appointments and not commenced on medications. Clinic notes from all Rheumatology reviews over the preceding one year were assessed using the audit tool in the 2022 BSR pregnancy guidelines. People currently pregnant were audited for the year prior to the date of conception of their pregnancy. Results Among 50 clinics reviewed, 42 female subjects were eligible across 19 clinics, 64% of whom were aged 36-45 years and 36% were aged 21-35 years. Six subjects were pregnant. Diagnoses included: 24% systemic lupus erythematosus; 19.5% rheumatoid arthritis; 17% seronegative axial spondyloarthropathy; and the remaining 39% consisted of fibromyalgia, hypermobility, and other inflammatory arthritidies. 70% of people were screened for antibodies that could adversely impact pregnancy (i.e. anti-Ro or anti-phospholipid). Only 26% of subjects had documentation of being asked if they wished to conceive. In subjects who did not express a wish to conceive, only 21% were asked if they were using contraception. A total of 17% of the 42 subjects were referred to a specialist Obstetric-Rheumatology clinic for pre-pregnancy counselling during the study period. Of 35 subjects taking medications, only 22.8% had documentation of appropriate pre-pregnancy drug counselling within the last year. Of patients without documented pre-pregnancy advice, 46% were taking medications considered unsafe in pregnancy. Furthermore, no patients were signposted to sources of further information on drug therapy and/or rheumatic disease in pregnancy. Conclusion This audit highlights a lack of regular documented discussions around family planning and medication counselling in female subjects of childbearing age attending rheumatology clinics lacking obstetric input. Regular discussions are important for those who do and don’t wish to conceive, to appropriately counsel regarding pre-pregnancy measures or contraception. This audit using the BSR audit tool will be used as the baseline for a quality improvement project to support colleagues in providing regular, accurate reproductive health advice, supported by trusted online resources and referral to a specialist obstetric-rheumatology service as required. Disclosure A. Shirazi: None. B. Goulden: Grants/research support; Undertaking a PhD supported by Versus Arthritis (ref. 22975). I. Giles: Grants/research support; IG has received an unrestricted research grant, travel and speaker fees from UCB Pharma.

P095 Association between autism and chronic musculoskeletal pain; a single tertiary adolescent rheumatology centre experience

Abstract Background/Aims Autism is a common neurodevelopmental disorder and can present with atypical sensorimotor function and altered pain response. Evidence suggests that patients with autism have a different processing mechanism which can alter pain perception. Pain evaluation and management is often insufficient in patients with autism. Chronic musculoskeletal pain in adolescents is common and is frequently associated with other co-morbidities. The adolescent musculoskeletal pain service at University College London Hospital uses a multidisciplinary approach to provide treatment and ongoing support for young people with chronic musculoskeletal pain up to the age of 19 years, bridging significant and often stressful life events such as exams and moving away from home. Methods A retrospective review of patient records was conducted between October 2021 and October 2023. New patients attending the adolescent chronic musculoskeletal pain clinic at University College London Hospital were identified and the prevalence of autism was noted. The presence of other co-morbidities and symptoms was also recorded. Statistical analysis was undertaken using GraphPad Prism (Fisher’s exact test) to determine any differences between patients with and without a diagnosis of autism. Results Retrospective data was obtained on 82 new patients aged between 13 and 18 years seen in the adolescent chronic musculoskeletal pain clinic. 28 patients (34%) had a diagnosis of autism. A higher proportion of autistic patients with chronic musculoskeletal pain were male compared to those without autism (36% vs 11%, p = 0.016). More patients with autism reported co-existing mental health difficulties, especially anxiety and depression (68% vs 37%, p = 0.011). Conversely, patients without autism reported a higher incidence of postural orthostatic tachycardia symptoms (POTS) or symptoms of postural dizziness (57% vs 25%, p = 0.009). Other co-morbidities and symptoms were found to be similar between patients with and without autism (headaches 18% vs 39%, abdominal pain 36% vs 54%, fatigue 61% vs 46%, sleep difficulties 68% vs 54%, attention deficit hyperactivity disorder 18% vs 9%). Conclusion This small retrospective study demonstrates that over a third of new patients seen in the adolescent chronic musculoskeletal pain service are autistic. This suggests a possible link between autism and chronic pain but more research is needed to evaluate this and larger studies are required. Patients with chronic musculoskeletal pain and autism were more likely to be male and have mental health difficulties compared to those without autism. The high incidence of mental health difficulties highlights the need for multidisciplinary team working, in particular psychological support. The results of this study have important implications for training and suggest that novel treatment strategies are needed to help advance therapies for chronic musculoskeletal pain in young people with autism. Disclosure E. Williams: None. S. Mavrommatis: None. J. Glanville: None. M. Leandro: None. D. Sen: None. C. Fisher: None.

OA24 Age-associated T-bet+ B cells in healthy and autoimmune pregnancy

Abstract Background/Aims Inflammatory rheumatic diseases (IRD), including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), affect females of reproductive age and are characterised by loss of immune tolerance and an increased burden of adverse pregnancy outcomes (APO). Mechanisms by which IRD may affect immune adaptations of healthy pregnancy to maintain host and fetal defence whilst tolerating male fetal antigens are poorly characterised. This study aimed to investigate B cell subpopulations in healthy and IRD in pregnancy, with a focus on IgD-CD27- (double negative, DN) T-bet+ B cells, considered pathogenic in IRD. Given disparate relationships between disease activity and risk of APO in SLE and RA pregnancy, the objective of this pilot study was to determine if pregnancy alters the frequency and/or the phenotype of DN T-bet+ B cells in IRD compared with healthy control pregnancies. Methods Peripheral blood mononuclear cells were obtained from IRD pregnancy (SLE n = 5; RA n = 8), IRD non-pregnancy (SLE n = 12; RA n = 10), and healthy pregnant (n = 8) people at University College London Hospital by informed consent. Cells were analysed by flow cytometry to identify B cell subpopulations and their expression of multiple markers including T-bet, IFN-γR, TLR7, TLR9, Ki67, CD38 and CD19 was assessed. Results There were no significant differences in B cell subpopulations, categorised based on the expression of IgD and CD27, between the cohorts. In healthy pregnancy, the median frequency (%) of CD19+T-bet+, IgD-CD27+T-bet+, DNT-bet+ cells was 5, 1.3 and 2, respectively. In contrast, the median frequency of CD19+T-bet+ cells was significantly elevated in SLE pregnancy at 13% compared with 5% (p < 0.05) in healthy pregnancy[GI3] [RV4] . Similarly, the median frequency of DNT-bet+ B cells was elevated in SLE pregnancy at 6% compared with 2% (p = 0.009) in healthy pregnancy. RA pregnancy, but not SLE pregnancy, had significantly lower frequency of Ki67+ DN T-bet+ cells compared to non-pregnant RA (p=0.04) and SLE (p=0.07). ROC analysis demonstrated that for both RA (p = 0.016, AUC = 0.84, 95% CI [0.65, 1.00]) and SLE (p = 0.015, AUC=0.88) the frequency of DN T-bet+ Ki67+ B cells can discriminate between pregnancy and non-pregnancy samples. In pooled analysis (n = 43), but not in single cohorts, DN T-bet+ cells had significantly high TLR7 and TLR9 expression. High frequencies of CD19hi DN T-bet+ cells were found but were unaffected by pregnancy. Clustering revealed canonical DN T-bet+ clusters and CD38hi T-bet+ clusters enriched in SLE and pregnancy-altered. Conclusion We have immunophenotyped B cell populations in healthy pregnancy and identified different patterns of alteration in frequency and proliferation of DNTbet+ cells in IRD compared with healthy pregnancy that are disease specific. This pilot study reveals previously unrecognized immunological changes in disease pregnancy warranting further larger studies of their mechanistic basis and clinical relevance. Disclosure S. Benton: None. C. Raine: None. K. Shah: None. S. Luong: None. A. Venkatkrishnan: None. M. Leandro: None. M. Castelino: None. D. Sen: None. D.A. Isenberg: None. A. Akbar: None. I. Giles: Grants/research support; IG has received an unrestricted research grant, travel and speaker fees from UCB Pharma. V.R. Reddy: None.

P061 A comparative analysis of Systemic Lupus Erythematosus, Rheumatoid arthritis and Juvenile Idiopathic Arthritis pregnancy outcomes: Results from a three-year prospective, case-controlled, single centre study of 183 patients

Abstract Background/Aims Patients with inflammatory rheumatic diseases (IRD) have an increased risk of adverse pregnancy outcomes (APO), although the comparative risk of APO in rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (SLE) pregnancies has not been directly compared. Therefore, this study examined pregnancy outcomes (PO) of subjects with RA, JIA, and SLE, who had all received pre-pregnancy counselling to ensure disease control, to identify whether there are any differences in APO between each individual IRD group. Pregnancy outcomes were compared with healthy pregnant subjects lacking IRD, to determine the comparative risk of APO in RA, JIA and SLE pregnancies. Methods A prospective case-controlled study was conducted at University College London Hospital from February 2018 to February 2021. A total of 183 patients were enrolled into the study, consisting of 120 pregnant patients including 60 patients with an IRD (n = 29 RA, n = 12 JIA and n = 19 SLE), 60 pregnant patients without any IRD and 63 non-pregnant patients with IRD (n = 30 RA, n = 12 JIA, n = 21 SLE). Pregnancy outcome data was obtained from all pregnant patients and the individual IRD groups’ outcomes were compared to each other and against outcomes from pregnancies without an IRD. Results Patients were predominantly Caucasian, ranging from 17-45 years of age. Of 111 reported PO, 99.09% (n = 110) resulted in a live birth (n = 27 (100.00%) RA, n = 11 (100.00%) JIA, n = 18 (94.74%) SLE versus n = 54 (100.00%) pregnancies without IRD). Overall, 5.56% (n = 1 SLE pregnancy) resulted in a spontaneous early trimester miscarriage, 6.36% (n = 7) were pre-term births (n = 3 (11.11%) RA, n = 1 (9.09%) JIA, n = 2 (11.11) SLE pregnancies versus n = 1 (1.85%) pregnancy without IRD). No stillbirths/foetal deaths were reported. Only two maternal complications were reported (n = 1 Group B strep infection, n = 1 gestational diabetes in RA pregnancies). In total six foetal complications were observed in four RA (n = 1 each for enlarged kidney, tongue tied, neonatal jaundice and Group B strep infection), n = 1 JIA (tongue tied) and n = 1 SLE (prolapsed cord) pregnancies. In relation to disease activity statuses in pregnancy, the majority of IRD pregnant patients were in remission (n = 42 (73.68%), n = 18 RA, n = 6 JIA and n = 18 SLE), 28 (49.12%) IRD patients had low disease activity (n = 8 RA, n = 2 JIA and n = 18 SLE) and nine (15.79%) had moderate/high disease activity (n = 6 RA, n = 2 JIA and n = 1 SLE). Only two (3.51%) RA patients reported disease flares during pregnancy, whereas no JIA/SLE patients experienced any flares. Conclusion This first prospective case-controlled study of RA, JIA, SLE and healthy pregnancies has identified favourable and comparable PO between IRD pregnancies with good disease control. This study highlights the importance and need for IRD pregnant women to undergo pre-pregnancy counselling and maintenance of disease control during pregnancy to enhance the chances of successful pregnancy outcomes. Disclosure H. Nguyen: None. D.A. Isenberg: Consultancies; AstraZeneca, Merck Serono, Eli Lilly, Servier, Genentech. D.J. Williams: Grants/research support; National Institute for Health Research University College London Hospitals Biomedical Research Centre. I. Giles: Grants/research support; UCB Pharma.

Laparoscopic totally extraperitoneal hernia repair in patients with a history of previous abdominopelvic surgery.

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30days. There was one conversion to open and one death within 60days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.

Advising the immunocompromised traveller: a review of immunocompromise at The London Hospital for Tropical Diseases Travel Clinic between 1st April 2019 and 30th April 2020.

Immunocompromised travellers (ICTs) face greater infectious and non-infectious travel-associated risks than their immunocompetent counterparts. Increasing travel and emergence of novel immunosuppressants poses great challenges for travel medicine practitioners to confidently provide up-to-date evidence-based risk management advice and pre-travel care for ICTs. We reviewed the records of ICTs attending the London Hospital for Tropical Diseases (HTD) Travel Clinic between 1st April 2019 and 30th April 2020 with the aim to describe demographic and travel characteristics, type, and severity of immunocompromise, the degree of risk associated with intended travel and evaluate travel advice. Of the 193 ICTs identified, immunocompromise was due to physiological reasons (42%), chronic infection (17.1%) and immunosuppressive therapy (16.6%). Median age was 38 (range 9 months to 84 years) and male to female ratio 0.75 (83:110). Travel was intended to 80 countries for a median of 16 days (range 2 to 3167), predominantly for leisure (53%), non-medical work (17%) and visiting friends and relatives (12%). Live vaccine safety dominated discussion in the pre-travel consultation. Existing guidelines arguably fell short in dealing with travel risks associated with hyper-specific conditions, targeted immunosuppressants and non-vaccine preventable infections. Our cohort represents a wide spectrum of immunocompromise, for whom we arguably need more measurable ways to approach travel-associated risks. We propose prospective qualitative participatory research to inform our unit of the priorities of ICTs in the pre-travel consultation. We further recommend the formation of a repository of specialists and formulary of complex cases to direct subsequent informative systematic review and prospective risk studies.

Facilitators and Barriers to Weight Loss Among Patients With Idiopathic Intracranial Hypertension.

Little is known about motivation for weight loss and barriers to weight loss among patients with idiopathic intracranial hypertension (IIH). Such information is crucial for developing tailored weight management recommendations and novel interventions. We administered a survey to patients with IIH presenting to neuro-ophthalmology clinics at The University of Michigan Kellogg Eye Center (Michigan, USA) and St. Thomas' Hospital (London, England). Participants rated importance and motivation to lose weight (1-10 scale; 10 = extremely important/motivated). Facilitators and barriers to weight loss were assessed using open-ended survey questions informed by motivational interviewing methodology. Open-ended responses were coded by 2 team members independently using a modified grounded theory approach. Demographic data were extracted from medical records. Descriptive statistics were used to analyze quantitative responses. Of the 221 (43 Michigan and 178 London) patients with IIH (Table 1), most were female (n = 40 [93.0%] Michigan and n = 167 [94.9%] London). The majority of patients in the United States were White (n = 35 [81.4%] Michigan), and the plurality were Black in the United Kingdom (n = 67 [37.6%] London]) with a mean (SD) BMI of 38.9 kg/m2 (10.6 kg/m2) Michigan and 37.5 kg/m2 (7.7 kg/m2) London. Participants' mean (SD) level of importance to lose weight was 8.5 (2.2) (8.1 [2.3] Michigan and 8.8 [2.1] London), but their mean (SD) level of motivation to lose weight was 7.2 (2.2) (6.8 [2.4] Michigan and 7.4 [2.1] London). Nine themes emerged from the 992 open-ended coded survey responses grouped into 3 actionable categories: self-efficacy, professional resources (weight loss tools, diet, physical activity level, mental health, and physical health), and external factors (physical/environmental conditions, social influences, and time constraints). Most responses (55.6%; n = 551) were about barriers to weight loss. Lack of self-efficacy was the most discussed single barrier (N = 126; 22.9% total, 28.9% Michigan, and 20.4% London) and facilitator (N = 77; 17.5% total, 15.9% Michigan, and 18.7% London) to weight loss. Other common barriers were related to physical activity level (N = 79; 14.3% total, 13.2% Michigan, and 14.8% London) and diet (N = 79; 14.3% total, 9.4% Michigan, and 16.3% London). Commonly reported facilitators included improvements in physical activity level (N = 73; 16.6% total, 18.5% Michigan, and 15.1% London) and dietary changes (N = 76; 17.2% total, 16.4% Michigan, and 17.9% London). Patients with IIH believe weight loss is important. Self-efficacy was the single most mentioned important patient-identified barrier or facilitator of weight loss, but professional resource needs and external factors vary widely at the individual level. These factors should be assessed to guide selection of weight loss interventions that are tailored to individual patients with IIH.

Art, pharmacy and history of skin marking and surgical inks in plastic surgery

Plastic surgeons can be distinguished in pre-planning much of their surgery by drawing on the skin. The history of marking the body with ink in plastic surgery goes back to the 1400s. The Sommerlad pen was originally developed at the London Hospital in the 1970s. Sommerlad pens and Bonney’s blue ink allow for a consistent weight of the pen in hand, a reliable source of ink, and an ability to vary the thickness of the line drawn. There has been a suspicion that gentian violet, a component of Bonney’s blue ink, is a carcinogen, resulting in supply problems. Animal models have demonstrated the carcinogenic properties of gentian violet, but evidence to support the carcinogenic potential of gentian violet in humans is sparse. In the surgical setting, we must adhere to using published and described ink formulas. Proprietary formulations lack standardisation, and the compounds used are not always disclosed. The concerning findings of in-vitro and animal models are a valuable addition to our knowledge about these compounds; however, to over-extrapolate and restrict its use on humans as a topical skin marker takes away an important component of a plastic surgeon’s armamentarium.

Shaping alcohol services to meet patients' needs

This article examines the joint working of nurse practitioners with healthcare assistants (HCAs), and how this can shape services to be patient-centred and relevant to effective care. Nurses and healthcare staff are at the centre of patient care and often are best placed to set up clinics to address emerging patient need. This article examines the nursing and healthcare staff from the alcohol and drug liaison team of an inner London hospital, and how they responded to an emerging need from the patients they were treating. Often, patients who have had an alcohol detoxification in hospital are normally signposted to their local alcohol service. These signposted patients often do not engage with their local alcohol service and come back to hospital with more severe complications of alcohol use. This article shows how this team of HCAs and nurses have re-designed their outpatients clinic to enable these patients to be treated. This has been achieved with largely positive outcomes. The mix of the practitioners has been important to enable this model to work. In summary, nurse practitioners with HCAs can respond and shape services to be efficient for patients. With their shared skills, they can produce a patient-centred interface. This can also bring huge fiscal cost savings. This article is encouraging this approach to be more uniform in the NHS and encourage professionals to consider joint working.

Observational cohort study of 100 patients presenting with functional visual loss: clinical characteristics and comparison with other functional neurologic disorders

ObjectiveRecent research has helped to develop a more detailed understanding of many functional neurologic disorders. The aim of this study was to increase our knowledge of functional visual loss and to compare the findings with those of other functional syndromes. DesignProspective and retrospective observational cohort study. MethodsThis study took place at neuro-ophthalmology clinics at 3 major hospitals in London, United Kingdom, over a 12-month period. The study population consisted of 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. All participants had their diagnosis confirmed with a full neuro-ophthalmic examination, neuroimaging, and visual electrophysiology. A full assessment of all participants’ medical history was obtained from their general practitioner, and all participants completed a series of questionnaires assessing relevant associations. ResultsData were obtained on 157 participants, 100 with functional visual loss, 21 pathologic control subjects with organic visual loss, and 36 healthy nonpathologic control subjects. Participants with functional visual loss were typically female (74%) with a mean age at vision loss of 40.0 ± 16 years. Sixty-four percent of participants had bilateral vision loss; the remainder, unilateral loss. Twenty-six percent of the total cohort had organic visual loss with functional overlay. Fifty percent of participants with functional visual loss had a preexisting psychiatric diagnosis, the most common being a depressive disorder. Sixty-two percent of participants had an ocular history, and 87% had a previously diagnosed medical illness, most commonly neurologic (45%). Thirty-five percent of participants self-reported at least 1 additional functional symptom. ConclusionsOur population of functional visual loss subjects shares many similarities with the majority of patients with other functional neurologic disorders. They are generally young and female and have a greater than expected rate of psychiatric, medical, and coexisting ocular conditions. We found increased rates of precipitating stressors, clinical depression, and organic eye problems in subjects with functional visual loss.

Augmented reality: a new perspective in dental education

INTRODUCTION The Microsoft HoloLens is a mixed reality device with the capability to provide a real-time 3D platform using multiple sensors and holographic processing to display information, and even to simulate a virtual world. With rapidly evolving technology and virtual learning on the increase, the HoloLens can be used as a vital tool for education and surgical planning. The aim of this pilot study was to ascertain its benefit in dental education and in the surgical planning of complex oral surgery procedures. METHODS A cohort of postgraduate dentists working at the Eastman Dental Hospital in London were shown two holographic videos. Participation was voluntary and an email invitation was sent to all non-consultant grade dental staff across multiple dental specialties. The cases demonstrated were a mandibular third molar in close association with the inferior alveolar nerve and an impacted tooth. Each video had a narration and explanation by a consultant oral surgeon. After having watched the videos, participants were asked to rate seven statements using a Likert scale. RESULTS Eighty-two per cent of participants reported improved comprehension of orientating anatomical structures. All participants (100%) noted improved confidence in surgical planning. Ninety-four per cent believed that the technology was an invaluable surgical tool in postgraduate training. CONCLUSIONS Augmented reality has the potential to change the face of surgery in the 21st century. This technology can be used to improve surgical training, especially in an environment where hands-on training is limited and virtual learning is promoted.

Post-operative hypotension after cardiac surgery is associated with acute kidney injury.

ObjectivesTo describe the incidence of post-operative hypotension in patients undergoing cardiac surgery during the first 12 hours in ICU and any relationship between hypotension and the development of acute kidney injury (AKI). DesignRetrospective, observational cohort study. SettingSingle centre tertiary teaching hospital in London, UK. Participants100 adult patients who underwent elective cardiac surgery requiring intra-operative cardiopulmonary bypass between May 2021 and November 2021. InterventionsNone. Measurements and Main ResultsA hypotensive event was defined as mean arterial pressure < 65 mmHg of at least 1 minute in duration. Invasive blood pressure data was analysed for the first 12 hours after the surgery and any association between post-operative hypotension and AKI was assessed. 91% of patients experienced hypotension in the first 12 hours post-procedure. On average, a patient would experience 9 hypotensive events, with an event lasting for an average of 5 minutes. 16 patients (16%) developed at least stage 1 AKI. The average duration of hypotension was significantly higher in the AKI group (4.6 min [3.3, 8.0] vs 8.1 min [5.2, 14.2], p=0.029). Those suffering an AKI had a longer ICU and hospital length of stay. ConclusionsThis study has demonstrated that hypotension in the first 12 hours after cardiac surgery is common and that prolonged hypotensive events are associated with developing an acute kidney injury. This emphasises the importance of treating hypotension aggressively and highlights a target for further research and intervention.

Evaluation of a hospital-initiated tobacco dependence treatment service: uptake, smoking cessation, readmission and mortality

BackgroundThe National Health Service in England aims to implement tobacco dependency treatment services in all hospitals by 2024. We aimed to assess the uptake of a new service, adapted from the Ottawa Model of Smoking Cessation, and its impact on 6-month quit rates and readmission or death at 1-year follow-up.MethodsWe conducted a pragmatic service evaluation of a tobacco dependency service implemented among 2067 patients who smoked who were admitted to 2 acute hospitals in London, England, over a 12-month period from July 2020. The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence specialists, provision of pharmacotherapy and behavioural support throughout the hospital stay, and telephone support for 6 months after discharge. The outcomes were (i) patient acceptance of the intervention during admission, (ii) quit success at 6 months after discharge, (iii) death, or (iv) readmission up to 1 year following discharge. Multivariable logistic regression was used to estimate the impact of a range of clinical and demographic variables on these outcomes.ResultsThe majority (79.4%) of patients accepted support at the first assessment. Six months after discharge, 35.1% of successfully contacted patients reported having quit smoking. After adjustment, odds of accepting support were 51–61% higher among patients of all non-White ethnicity groups, relative to White patients, but patients of Mixed, Asian, or Other ethnicities had decreased odds of quit success (adjusted odds ratio (AOR) = 0.32, 95%CI = 0.15–0.66). Decreased odds of accepting support were associated with a diagnosis of cardiovascular disease or diabetes; however, diabetes was associated with increased odds of quit success (AOR = 1.88, 95%CI = 1.17–3.04). Intention to make a quit attempt was associated with a threefold increase in odds of quit success, and 60% lower odds of death, compared to patients who did not intend to quit. A mental health diagnosis was associated with an 84% increase in the odds of dying within 12 months.ConclusionsThe overall quit rates were similar to results from Ottawa models implemented elsewhere, although outcomes varied by site. Outcomes also varied according to patient demographics and diagnoses, suggesting personalised and culturally tailored interventions may be needed to optimise quit success.

Investigating the cause of increased tetracycline-resistant Neisseria gonorrhoeae in England, 2016-20.

Antimicrobial resistance in Neisseria gonorrhoeae is a global public health concern. Tetracycline resistance (TetR) increased from 39.4% to 75.2% between 2016 and 2021 in N. gonorrhoeae isolates collected through national surveillance in England, despite the absence of use of tetracyclines for the treatment of gonorrhoea. We investigated whether there was correlation between bacterial sexually transmitted infection (STI) tests performed and treatment with antimicrobials, with increased TetR in N. gonorrhoeae. We examined correlations between bacterial STI tests, antimicrobial treatment and TetR in N. gonorrhoeae, using national surveillance data from three large sexual health services (SHS) in London during 2016-20. Doxycycline prescribing data and antibiograms of a non-STI pathogen from distinct patient groups (sexual health, obstetric and paediatric), at a large London hospital, were analysed to identify if doxycycline use in SHS was associated with resistance in a non-STI organism. A substantial increase in TetR was observed, particularly in isolates from gay, bisexual and other MSM (GBMSM). Strong positive correlations were observed exclusively in GBMSM between N. gonorrhoeae TetR and both bacterial STI tests (r = 0.97, P = 0.01) and antimicrobial treatment (r = 0.87, P = 0.05). Doxycycline prescribing increased dramatically during the study period in SHS. Prevalence of TetR in Staphylococcus aureus was higher in isolates sourced from SHS attendees than those from other settings. Frequent screening of GBMSM at higher risk of STIs, such as those on pre-exposure prophylaxis (PrEP) leading to/and increased use of doxycycline for the treatment of diagnosed infections, may account for the increase in TetR in N. gonorrhoeae.

A retrospective audit of general practitioner's referrals to Guys and St Thomas' specialist menopause clinic between 2021 and 2022.

Purpose: We performed a retrospective audit of General Practitioners' (GPs) referrals to the specialist Menopause Clinic at Guys and St Thomas's (GSTT) between 2021 and 2022. We aim to establish the indication for the referrals and whether they were compliant with the National Institute for Health and Care Excellence Guidance NICE.Background: GSTT is a teaching hospital in central London that educates gynaecologists in training as well as (GP) for specialist certification in Menopause. The menopause clinic receives approximately 580 GP referrals per month from South East London practices. The current waiting time for an initial appointment is up to 1year. This delay reflects an increase in demand for menopause care and a deficit in service provision in many areas of the UK.NICE has recommended that GPs refer complicated cases to menopause specialists, with 11 specific criteria.Study Sample and Data Collection: We randomly selected 50 patients referred to the GSTT clinic by a GP between 2021 and 2022. Patient data were collected, including patient demographics, date of referral, indication for referral, date of consultation, waiting time, past medical history, investigations, and treatment instigated during the appointment.Results: The majority of referrals to the GSTT menopause Specialist clinic met the NICE guidelines (76%). One-sixth of the referrals could have been prevented or managed through alternative routes. Finally, although this is a small study, some patient unmet needs (PUNS) and GPs' educational needs have been identified.

Reflections on wellbeing and what it looks like in our practice.

BVA held its inaugural Wellbeing Awards at the end of last year and, here, members of one of the winning teams, Blue Cross Merton animal hospital in London, share their experiences of wellbeing initiatives that have had a positive impact.

Are we gaining valid consent for dental extractions? A retrospective audit on restorability assessment at one dental institution.

Introduction This paper explores the widely relevant topic of obtaining valid consent in dental practice, focusing on assessing restorability of teeth planned for extraction. The General Dental Council stresses discussing treatment options, benefits and risks for informed decision-making. The study evaluates if pertinent factors, including tooth structure, endodontic status, periodontal health and patient considerations, are considered before consent.Aim To ensure restorability has been assessed and all options communicated with patients for completeness of the consent process before tooth extraction.Objective To assist clinicians in their systematic assessment of a tooth's restorability and provide a framework for contemporaneous documentation.Materials and methods A two-week retrospective audit of oral surgery outpatients at a dental hospital in London was conducted, analysing the frequency of restorability discussions and patient involvement in decision-making. A simplified restorability guide and educational interventions were introduced to target the set standard of 100% of consenting clinicians to discuss restorability with patients.Results Results from two audit cycles show a significant increase in documented restorability discussions and consideration of patient factors.Discussion The study recognised restorability assessment subjectivity, thus creating a simplified tool for clinicians. Patients may lack awareness of restorability options, consequences of edentulism, future costs and tooth replacement considerations, emphasising the importance of documented discussions.Conclusion Educational interventions and a simplified restorability guide proved beneficial and showed significant improvement in communication with patients regarding restorability and gaining valid consent. Further consideration should be given to barriers patients face when opting for tooth extraction of their restorable teeth, including discussions regarding long-term consequences.