NHS Setting Research Articles

The use of Facebook in a community pharmacist-led weight management programme – a London-based proof of concept study

IntroductionIn the United Kingdom (UK), 63% of adults are overweight,(1) costing the NHS £6.1 billion/year. With the public using digital technology over healthcare professionals (HCPs) for health advice, this warrants an investigation of technology use in community pharmacy, given its previous successful use.(2)AimTo determine the feasibility and perceptions of a community pharmacist (CP)-led weight management programme (WMP), enhanced by a Facebook support group (FSG).MethodsA proof of concept study was conducted between January-March 2020. Recruitment was via a pharmacy, the university and a community Facebook group. Inclusion criteria: over 18 years; overweight; no medical conditions. Participants attended face-to-face meetings (ftf) with a CP and final year pharmacy student (PS) on two occasions (0 (baseline) and 4 weeks). At baseline, participants were given the NHS weight loss programme and set weight loss goals. During ftf, participants had height, weight, and waist circumference (WC) measurements by a CP/PS and discussed eating habits, exercise and alcohol. In between ftf, participants accessed the FSG (created (December 2019) and moderated by a CP). Here, they received posts about diet, exercise and motivation. Participants were to have their measurements taken ftf at 8-weeks, however, COVID-19 meant participants had to self-declare these via video call. Following the 8-week programme, participants completed a 4-section survey about their experience (signing up to the service; comparison to previous weight loss attempts; the FSG and overall perceptions). Question types included multiple choice, Likert scale and free text comments. Data were analysed in Excel (Microsoft Corporation 2016) with changes in height, weight, waist circumference, alcohol and exercise being calculated.ResultsFifty-five participants were recruited. 18 were lost to follow-up, most (n=12/18) citing COVID-19. Of the 37 participants remaining (70.3% female, mean age=37 years), 22 were obese, the rest overweight. Mean weight loss, mean percentage weight loss and mean WC reduction at 4-weeks was 1.6 kg (SD+/- 1.7 kg), 1.8% (SD+/- 1.9%) and 2 cm (SD+/- 1.96 cm) respectively. At week 8 measurements were self-declared. Mean weight loss at 8-weeks from baseline was 2.7 kg (SD +/- 2.6 kg) and mean percentage weight loss was 3% (SD+/- 3%). Only five participants’ self-declared WC measurements at 8-weeks with mean reduction being 3.6 cm. Five participants moved to healthier BMI classifications by week 8. All participants accessed the FSG at least weekly with 13 accessing it daily. Diet posts were the most popular (n=20/37). Participants learned about portion control and increasing fruits/vegetables intake. All participants would recommend the programme to their friends/family.ConclusionAn 8-week CPWMP, enhanced with FSG, supported participants to lose a mean of 3% body weight. Participants accessed the page regularly and were positive about its usefulness. One limitation was that the COVID-19 lockdown prevented the 8-week ftf, therefore, self-declared measurements were used. The pandemic has highlighted the importance of pharmacy embracing technology for service delivery, particularly when in-person contact is limited. The implication of this study is that it provides proof that the concept of digital service delivery could work in practice.

Comprehend, Cope and Connect (CCC) – Getting to the simple heart of the complex problem

This paper provides a brief introduction to the CCC therapy approach while demonstrating how it is embedded in a transpersonal world view. Its origins, starting from inner experience and meeting specific service challenges within various NHS setting are discussed. The theoretical basis for CCC in Interacting Cognitive Subsystems is introduced, providing a non-medical explanation for psychotic and other so-called ‘symptoms’. The three components of the approach are explained. ‘Comprehend’ covers an emotion-focused, trauma-informed, co-produced formulation. ‘Cope’ is about finding other ways to manage, and ‘Connect’ is reflected in the central place given to relationship, both with the self, within the self, with other people, and reaching out to wider, spiritual connectedness beyond the human world. The paper concludes by summarising publications, research and deployment of the approach.

COVID-19 and dental nursing

2020 will be a memorable year for all of us. The COVID-19 pandemic has had huge impacts on our personal and social lives but as dental professionals we have also seen substantial changes to our working lives. Dental nurses in both NHS and private settings have contributed to the pandemic response in many ways including, but not limited to, being redeployed to other NHS services, working in Urgent Dental Care Centres, and getting dental practices reorganised and ready to restart non-urgent care. The importance of good quality dental research has been highlighted by the pandemic and this article interviews two dental nurses contributing to different parts of the research pathway during the pandemic.

Heat stress and PPE during COVID-19: impact on healthcare workers' performance, safety and well-being in NHS settings

Personal protective equipment (PPE) can potentiate heat stress, which may have a negative impact on the wearer's performance, safety and well-being. In view of this, a survey was distributed to healthcare workers (HCWs) required to wear PPE during the coronavirus disease 2019 pandemic in the UK to evaluate perceived levels of heat stress and its consequences. Respondents reported experiencing several heat-related illness symptoms, and heat stress impaired both cognitive and physical performance. The majority of respondents stated that wearing PPE made their job more difficult. These, and additional, responses suggest that modification to current working practices is required urgently to improve the resilience of HCWs to wearing PPE during pandemics.

An intervention to improve the quality of life in children of parents with serious mental illness: the Young SMILES feasibility RCT.

An intervention to improve the quality of life in children of parents with serious mental illness: the Young SMILES feasibility RCT.

52P The complexities of the delivery of an RNA sequencing service for FFPE solid tumour samples within an NHS setting

52P The complexities of the delivery of an RNA sequencing service for FFPE solid tumour samples within an NHS setting

Secondary non-invasive prenatal screening for fetal trisomy: an effectiveness study in a public health setting.

To evaluate the effectiveness of secondary screening using non-invasive prenatal testing (NIPT) in a routine NHS setting including test performance, turn-around times (TATs) and no-call (failure to obtain result) rates. To examine the influence of maternal and fetal characteristics on test performance. Retrospective cohort. London teaching hospital. A total of 8651 pregnancies undergoing screening for fetal trisomy using NIPT provided by an NHS cell-free DNA screening laboratory-the SAFE laboratory. Screening test evaluation and TATs. Univariate and multivariate logistic regression analysis to identify significant predictors of no-call results and reported by low fetal fraction (<2%), very high fetal fraction (>40%) and processing failure. Test performance, TATs and no-call rates, factors affecting no-call results. Average TAT was 4.0days (95% CI 4.0-4.2days). Test sensitivities for trisomies 21 and 13/18 were 98.9% (95% CI 95.9-99.9%) and 90.4% (95% CI 80.0-96.8%), respectively. The overall no-call rate was 32/8651 (0.37%, 95% CI 0.26-0.52%). The overall risk of a no-call result was influenced by gestational age, dichorionic twin pregnancy, history of malignancy and pregnancies affected by trisomy 13/18, but not by maternal weight or use of low-molecular-weight heparin. High-throughput NIPT can be effectively embedded into a public health NHS setting. TATs of 4days and no-calls of <0.5% were well within clinically desirable tolerances. Gestational age, maternal weight, assisted reproductive techniques, use of low-molecular-weight heparin and past history of malignancy did not have major impacts on test no-call rates and should not constitute reasons for withholding the option of NIPT from women. Turn-around times of 4days, no-call (test failure) rates of 0.37% and highly accurate NIPT can be successfully embedded in the NHS.

UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS framework

Background Studies indicate there is a need to improve the delivery of unexpected news via obstetric ultrasound, but there have been few advances in this area. One factor preventing improvement has been a lack of consensus regarding the appropriate phrases and behaviours which sonographers and ultrasound practitioners should use in these situations. Aims To develop consensus guidelines for unexpected news delivery in Early Pregnancy Unit and Fetal Anomaly Screening Programme NHS settings. Methods A workshop was conducted to identify priorities and reach consensus on areas of contention. Contributors included interdisciplinary healthcare professionals, policy experts, representatives from third-sector organisations, lay experts and academic researchers ( n = 28). Written and verbal feedback was used to draft initial guidance which was then circulated amongst the wider writing group ( n = 39). Revisions were undertaken until consensus was reached. Results Consensus guidelines were developed outlining the behaviours and phrases which should be used during scans where unexpected findings are identified. Specific recommendations included that: honest and clear communication should be prioritised, even with uncertain findings; technical terms should be used, but these should be written down together with their lay interpretations; unless expectant parents use other terminology (e.g. ‘foetus’), the term ‘baby’ should be used as a default, even in early pregnancy; at the initial news disclosure, communication should focus on information provision. Expectant parents should not be asked to make decisions during the scan. Conclusions These recommendations can be used to develop and improve news delivery interventions in obstetric ultrasound settings. The full guidelines can be accessed online as supplemental material and at https://doi.org/10.5518/100/24 .

"Who to Tell, How and When?": Development and Preliminary Feasibility of an Empowerment Intervention for People Living with Dementia Who are Fearful of Disclosing Their Diagnosis.

ObjectiveThis study describes the adaptation of Honest, Open, Proud (HOP), to develop an empowerment intervention supporting disclosure decision-making for dyads of people living with dementia and their chosen supporter.MethodsMedical Research Council guidelines for developing complex interventions informed intervention development and feasibility testing. This included identifying the evidence base and theory (establishing HOP theory of change, a systematic review on decision-making in dementia, a stakeholder consultation), modelling the intervention materials with research experts (creation of version 1.0) and experts by experience (creation of version 2.0), and pilot testing the intervention recording participant observations and facilitator reflections. The final version of the intervention materials was developed with experts by experience of dementia where the accessibility of language and appropriate styles of facilitation were the focus.ResultsThe concept of the intervention was strongly endorsed by respondents of the stakeholder consultation (209/226). Stakeholder preferences included face-to-face delivery, a manualized workbook approach and the inclusion of the primary carer during intervention delivery. Recruitment for intervention groups took place in non-NHS settings (2 small groups recruited) and NHS settings (no groups recruited). In non-NHS settings, 7 dyads agreed to take part in one of two intervention groups. Both intervention groups had over 70% attendance by participants (group 1: 72.2% group 2: 87.5%).ConclusionThe concept of an intervention to support diagnostic disclosure was endorsed by stakeholders; however, recruitment was challenging; the “who to tell, how and when?” intervention has the potential to fill a gap in the post-diagnostic pathway.

Effectiveness of nurse-led group CBT for hot flushes and night sweats in women with breast cancer: Results of the MENOS4 randomised controlled trial.

ObjectiveTroublesome hot flushes and night sweats (HFNS) are experienced by many women after treatment for breast cancer, impacting significantly on sleep and quality of life. Cognitive behavioural therapy (CBT) is known to be effective for the alleviation of HFNS. However, it is not known if it can effectively be delivered by specialist nurses. We investigated whether group CBT, delivered by breast care nurses (BCNs), can reduce the impact of HFNS.MethodsWe recruited women with primary breast cancer following primary treatment with seven or more HFNS/week (including 4/10 or above on the HFNS problem rating scale), from six UK hospitals to an open, randomised, phase 3 effectiveness trial. Participants were randomised to Group CBT or usual care (UC). The primary endpoint was HFNS problem rating at 26 weeks after randomisation. Secondary outcomes included sleep, depression, anxiety and quality of life.ResultsBetween 2017 and 2018, 130 participants were recruited (CBT:63, control:67). We found a 46% (6.9‐3.7) reduction in the mean HFNS problem rating score from randomisation to 26 weeks in the CBT arm and a 15% (6.5‐5.5) reduction in the UC arm (adjusted mean difference −1.96, CI −3.68 to −0.23, P = .039). Secondary outcomes, including frequency of HFNS, sleep, anxiety and depression all improved significantly.ConclusionOur results suggest that specialist nurses can be trained to deliver CBT effectively to alleviate troublesome menopausal hot flushes in women following breast cancer in the NHS setting.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data.

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths)groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data

Background: International and UK data suggest that Black, Asian and Minority Ethnic (BAME) groups are at increased risk of infection and death from COVID-19. We aimed to explore the risk of death in minority ethnic groups in England using data reported by NHS England. Methods: We used NHS data on patients with a positive COVID-19 test who died in hospitals in England published on 28th April, with deaths by ethnicity available from 1st March 2020 up to 5pm on 21 April 2020. We undertook indirect standardisation of these data (using the whole population of England as the reference) to produce ethnic specific standardised mortality ratios (SMRs) adjusted for age and geographical region. Results: The largest total number of deaths in minority ethnic groups were Indian (492 deaths) and Black Caribbean (460 deaths) groups. Adjusting for region we found a lower risk of death for White Irish (SMR 0.52; 95%CIs 0.45-0.60) and White British ethnic groups (0.88; 95%CIs 0.86-0.0.89), but increased risk of death for Black African (3.24; 95%CIs 2.90-3.62), Black Caribbean (2.21; 95%CIs 2.02-2.41), Pakistani (3.29; 95%CIs 2.96-3.64), Bangladeshi (2.41; 95%CIs 1.98-2.91) and Indian (1.70; 95%CIs 1.56-1.85) minority ethnic groups. Conclusion: Our analysis adds to the evidence that BAME people are at increased risk of death from COVID-19 even after adjusting for geographical region, but was limited by the lack of data on deaths outside of NHS settings and ethnicity denominator data being based on the 2011 census. Despite these limitations, we believe there is an urgent need to take action to reduce the risk of death for BAME groups and better understand why some ethnic groups experience greater risk. Actions that are likely to reduce these inequities include ensuring adequate income protection, reducing occupational risks, reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications.

Innovative recruitment and clinical orientation programme to manage NHS junior doctor shortfall: A district hospital experience

International medical graduates (IMGs) contribute significantly towards the NHS care provision. No standardised clinical orientation programme (COP) for IMGs new to the NHS exists. Our objective was to describe recruitment and retention strategies for junior doctors (JDs) in general medicine and develop a framework to anticipate outcomes of these interventions using the realist evaluation methodology. We performed quality improvement interventions of recruitment and COP for new entrant IMGs in our organisation employed between December 2017 and April 2019. Twenty-three IMGs were recruited, 96% successfully completed the COP with a mean contract duration of 13±5 months. From the academic year 2017/18 to 2018/19, mean JD post occupancy increased from 54±3 to 73±4 JDs (p<0.001) and JD locum spend fell by £1.9 million. Our structured COP provides a stable, trained and financially sustainable JD workforce. Application in broader NHS settings is recommended.

P013: MENOS4 trial: Nurses can be trained to effectively deliver CBT for menopausal hot flushes in women with breast cancer to reduce hot flush bother and improve quality of life

Introduction: Hot flushes and night sweats (HFNS) are a common problem in women after breast cancer, often with a significant impact on daily life. Cognitive Behavioural Therapy (CBT) is effective for the alleviation of HFNS, but not widely available. This study assessed whether breast care nurses can be trained to effectively deliver a CBT intervention to alleviate hot flushes in women with breast cancer in the NHS setting.

Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation

Background and aim The NHS collects a large number of data on patient experience, but there are concerns that it does not use this information to improve care. This study explored whether or not and how front-line staff use patient experience data for service improvement. Methods Phase 1 – secondary analysis of existing national survey data, and a new survey of NHS trust patient experience leads. Phase 2 – case studies in six medical wards using ethnographic observations and interviews. A baseline and a follow-up patient experience survey were conducted on each ward, supplemented by in-depth interviews. Following an initial learning community to discuss approaches to learning from and improving patient experience, teams developed and implemented their own interventions. Emerging findings from the ethnographic research were shared formatively. Phase 3 – dissemination, including an online guide for NHS staff. Key findings Phase 1 – an analysis of staff and inpatient survey results for all 153 acute trusts in England was undertaken, and 57 completed surveys were obtained from patient experience leads. The most commonly cited barrier to using patient experience data was a lack of staff time to examine the data (75%), followed by cost (35%), lack of staff interest/support (21%) and too many data (21%). Trusts were grouped in a matrix of high, medium and low performance across several indices to inform case study selection. Phase 2 – in every site, staff undertook quality improvement projects using a range of data sources. The number and scale of these varied, as did the extent to which they drew directly on patient experience data, and the extent of involvement of patients. Before-and-after surveys of patient experience showed little statistically significant change. Making sense of patient experience ‘data’ Staff were engaged in a process of sense-making from a range of formal and informal sources of intelligence. Survey data remain the most commonly recognised and used form of data. ‘Soft’ intelligence, such as patient stories, informal comments and daily ward experiences of staff, patients and family, also fed into staff’s improvement plans, but they and the wider organisation may not recognise these as ‘data’. Staff may lack confidence in using them for improvement. Staff could not always point to a specific source of patient experience ‘data’ that led to a particular project, and sometimes reported acting on what they felt they already knew needed changing. Staff experience as a route to improving patient experience Some sites focused on staff motivation and experience on the assumption that this would improve patient experience through indirect cultural and attitudinal change, and by making staff feel empowered and supported. Staff participants identified several potential interlinked mechanisms: (1) motivated staff provide better care, (2) staff who feel taken seriously are more likely to be motivated, (3) involvement in quality improvement is itself motivating and (4) improving patient experience can directly improve staff experience. ‘Team-based capital’ in NHS settings We propose ‘team-based capital’ in NHS settings as a key mechanism between the contexts in our case studies and observed outcomes. ‘Capital’ is the extent to which staff command varied practical, organisational and social resources that enable them to set agendas, drive process and implement change. These include not just material or economic resources, but also status, time, space, relational networks and influence. Teams involving a range of clinical and non-clinical staff from multiple disciplines and levels of seniority could assemble a greater range of capital; progress was generally greater when the team included individuals from the patient experience office. Phase 3 – an online guide for NHS staff was produced in collaboration with The Point of Care Foundation. Limitations This was an ethnographic study of how and why NHS front-line staff do or do not use patient experience data for quality improvement. It was not designed to demonstrate whether particular types of patient experience data or quality improvement approaches are more effective than others. Future research Developing and testing interventions focused specifically on staff but with patient experience as the outcome, with a health economics component. Studies focusing on the effect of team composition and diversity on the impact and scope of patient-centred quality improvement. Research into using unstructured feedback and soft intelligence. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Voice hearers’ experiences of the Making Sense of Voices approach in an NHS setting

ABSTRACT The ‘Making Sense of Voices’ (MsV), or ‘Maastricht’ approach has become established within large sections of the voice hearing community, as well as being adopted by some professional mental health workers. However, there has been limited research to assess this intervention. A recent case series using the MsV approach reported promising results across a number of standardised outcome measures. The current study reports on the voice hearers’ experience of having received the MsV intervention, through the use of “exit interviews” conducted as part of the case series. Individual participants’ experiences indicated a range of reactions to the intervention. Positive outcomes appeared to relate to a better understanding of voice hearing experiences and a greater sense of control over voices. Not all participants reported a positive experience of communicating with their voices. Outcomes are discussed within the context of potential common and distinct “ingredients” of the MsV approach, compared to other approaches to working with distressing voices.

Validation and implementation of a bespoke pan-cancer NGS panel for FFPE solid tumour analysis within an NHS setting

Abstract Background The All Wales Medical Genomics Service (AWMGS) receives around 90 FFPE solid tumour samples per week for genetic analysis. Streamlining of testing is required in order to ensure the laboratory has the capacity and capability to meet the growing needs of the precision medicine era. With this in mind, AWMGS aimed to validate and incorporate a single NGS panel into service for the detection of, in the first instance, single nucleotide variations in a range of tumour types using a minimum of 10ng FFPE-derived DNA. Methods The validation involved the evaluation of the panel for the detection of single nucleotide variations in FFPE-extracted DNA. The workflow consisted of a SeqCap EZ HyperCap (Roche) protocol, sequencing on the Nextseq 550 (Illumina) and an in-house bioinformatic analysis pipeline. The validation encompassed the determination of assay sensitivity, specificity, accuracy, reproducibility and limit of detection via a series of validation rounds whereby previously tested surplus FFPE-derived DNAs of known genotype along with 2 cell-line reference standards were used as control samples to evaluate the performance of the panel. Results The panel showed a high degree of specificity, sensitivity and reproducibility, and could reliably detect variants in samples with as little as 10ng input DNA. However, despite multiple optimisation attempts, low input samples of Conclusions AWMGS successfully validated and optimised a bespoke NGS pan-cancer panel to provide molecular characterisation of FFPE solid tumour samples, with a minimum requirement of 50ng input DNA. This panel was implemented into the laboratory in a phased approach, initially replacing existing technologies for the delivery of existing NHS services. The panel provides an increased level of genomic information compared to previous testing methods and has greater clinical utility. As the panel has been designed to detect copy number and structural variations, once validated within the laboratory, this will have an even greater impact on the streamlining of testing. Legal entity responsible for the study Cardiff and Vale University Health Board. Funding NHS England’s Estates and Technology Transformation Fund. Disclosure All authors have declared no conflicts of interest.

Development of a GMC aligned curriculum for internal medicine including a qualitative study of the acceptability of ‘capabilities in practice’ as a curriculum model

The Shape of Training review and the General Medical Council (GMC) requirements in demonstrating generic professional capabilities were major drivers for the Joint Royal Colleges of Physicians Training Board (JRCPTB) to develop the new internal medicine curriculum. In particular, the GMC required progression to a more outcomes-based curriculum. The present curricula for physician training are based on demonstrating a large number of individual competencies that are assessed by a variety of different methods. It was felt that current system was overwhelming and had become a 'tick box' exercise. The new curriculum is based on a much smaller number of outcomes, called capabilities in practice, which reflect the key professional work activities of a fully trained physician. The aim is to re-emphasise the role of professional judgement in 'trusting' the work a trainee does and thus make assessment more realistic and meaningful for both trainees and trainers. The proof of concept study explored the feasibility of using this outcomes-based model of assessment in a UK NHS setting. The learning from the study has enabled us to make significant changes to the internal medicine curriculum. The GMC has recently approved the curriculum and the JRCPTB is implementing the programme from August 2019.

P42 Delayed diagnosis in paediatric sarcoidosis: lessons we can learn

Abstract Background Sarcoidosis is a rare autoinflammatory systemic granulomatous disease that can affect any organ in the body. Paediatric literature does not give a prevalence of neurosarcoidosis. Clinical features can be tricky to identify and piece together to suggest the diagnosis and biochemical markers such as serum angiotensin converting enzyme lack sensitivity. Methods This case report of a 13 year-old boy demonstrates his journey to diagnosis as he bounced between multiple private and NHS care teams. Referral was to our paediatric rheumatology department with a single oesophageal granuloma and bilateral uveitis. Symptoms include nausea, vomiting, weight loss which was regained, fatigue, disturbed sleep, chronic dry cough, then worsening headaches. He had been treated privately with steroid eye drops for bilateral uveitis. Histology of the oesophageal granuloma showed no acute inflammation. A private paediatric rheumatologist review concluded idiopathic uveitis with no underlying systemic disease that could be delineated at that time. A private haematologist subsequently diagnosed him with a chronic systemic inflammatory process leading to an iron deficient anaemia. Results He represented to his ophthalmologist with a 3 week history of worsening headaches and was found to have papilloedema. He was urgently jointly reviewed in the NHS setting by a paediatric gastroenterologist, neurologist and rheumatologist. Clinically apart from the bilateral pappiloedema there were no signs of disease. Urgent MRI demonstrated widespread inflammation and oedema in both cerebellar hemispheres and within his white matter bilaterally, as well as some cortical patches. Magnetic resonance arteriogram and magnetic resonance venogram were normal. Tonsillar herniation and ventricular tightness due to raised intracranial pressure was noted. He was admitted urgently. Bloods showed normal inflammatory markers, iron deficient anaemia, ANCA negative, ACE 30 iu/L, Quantiferon negative. CXR was normal as were pulmonary function tests. A raised urinary calcium with raised calcium:creatinine ratio led to a renal tract ultrasound study that showed early nephrocalcinosis bilaterally. Ophthalmology review demonstrated granulomatous pan uveitis with macular oedema. NOD2 genetic testing was negative. Conclusion Neurosarcoidosis was diagnosed. He was treated with 2mg/kg IV Methylprednisolone over 3 consecutive days then a slow prednisolone wean starting at 60mg per day orally and 6 times a day Prednisolone eye drops. Weekly methotrexate 15mg subcutaneously and 5mg folic acid were started followed shortly by subcutaneous Adalimumab 40mg fortnightly. Repeated MRI brain scans after treatment commenced showed resolution of cerebral inflammation. Follow up ophthalmology reviews demonstrate resolution of his uveitis. Bilateral nephrocalcinosis has persisted despite normalised serum and urinary calcium. It was not until he was seen by an ophthalmologist with expertise in both areas that the severity and nature of the uveitis including it being granulomatous was picked up. The diagnosis was delayed due to the lack of joined up working between private and NHS sectors. Conflicts of Interest The authors declare no conflicts of interest.

Neuromuscular Electrical Stimulation Plus Rehabilitative Exercise as a Treatment for Dysphagia in Stroke and Non-Stroke Patients in an NHS Setting: Feasibility and Outcomes.

Dysphagia is a debilitating condition with significant consequences in terms of physical and mental health. This study demonstrates that it is feasible to provide an intensive therapy program combining neuromuscular electrical stimulation (NMES) with exercise against resistance in the treatment of dysphagia in a public healthcare setting. Thirty-one patients (17 stroke, 14 non-stroke) who experienced dysphagia with reduced laryngeal elevation completed the therapy program. After checking the data sets for comparability, it was deemed appropriate for the outcome data from these patients to be combined with that of 12 stroke patients previously reported to enable statistical analysis on a larger data set (n = 43). A repeated-measures ANOVA revealed a statistically significant increase in amount and variety of food a patient was able to take orally (FOIS) following completion of treatment (p < 0.001). There was no significant between-subject effect of stroke status (p = 0.43), or interaction between treatment and stroke status (p = 0.68). There was a significant improvement in secondary outcome measures of swallow safety with fluids (PAS) (p < 0.001) and swallow-related quality of life (Swal-Qol (p < 0.001). These findings indicate that the therapy program may be associated with reduced impairment in a subset of patients with dysphagia resulting from stroke and non-stroke atiologies, and the data will inform the design of future research to address unanswered questions.