NICE Guidelines Research Articles

P110 Characteristics of Difficult to treat Rheumatoid Arthritis patients in a large District Hospital in the UK

Abstract Background/Aims Difficult-to-treat rheumatoid arthritis (D2T RA) has a notably higher impact on a patient’s quality of life and is a significant cost and service pressure to the health care provision in comparison to non-D2T RA. The primary aim of this study is to delineate the major contributing factors and characteristics of patients leading to a diagnosis of D2T RA, using the criteria established by the European League Against Rheumatism (EULAR). Methods A retrospective study was conducted within the Rheumatology department in a large district general hospital, with a catchment population of over 700,000 people. A cohort of 722 patients, all of which were on biologic Disease Modifying Anti-Rheumatic Medications (DMARDs) was selected. In this study, we present our findings for the first 95 consecutive patients. Results Of the selected 95 patients, 13% met the EULAR criteria for D2T RA. The key characteristics within this subset include 75% being sero-positive (both Rheumatoid factor and anti-cyclic citrullinated peptide), 66% being categorized as obese, and 42% having concurrent fibromyalgia and osteoarthritis. Among these 13% D2T RA patients, 25% demonstrated a high disease activity index and 75% showed moderate severity. All these patients had been started on at least two conventional DMARDs including methotrexate before escalating to more advanced treatments in line with NICE guidelines. From the subgroup of high disease activity D2T RA patients, 67% had tried at least three types of biologic or targeted synthetic DMARDs (b/ts DMARDs), and 33% had been trialled on four different types of b/ts DMARDs. Similarly, out of the medium severity D2T RA subgroup, 45% had tried three and four DMARDs respectively and 10% had been given five biologic or synthetic DMARDs. Conclusion The major contributing factors leading to D2T RA within this study population appear to be seropositivity for both RF and anti-CCP, obesity, and the presence of comorbidities like fibromyalgia and osteoarthritis. The intertwined relationship between these factors emphasizes the need for a comprehensive and individualized approach to managing patients with D2T RA. Although this cohort is larger than the previous studies, the sample size is relatively small. We aim to look at the remaining 627 patients to identify trends and modifiable risk factors that could help prevent the future development of D2T RA. Disclosure K. Oo: None. M. Memon: None. P. Sharma: None. S. Dahiya: None.

E022 Audit on the baricitinib dose in elderly and patients with chronic kidney disease among a cohort of rheumatoid arthritis patients

Abstract Background/Aims Baricitinib use among elderly patients and in patients with chronic kidney disease needs modification of the dose. Baricitinib dose should be reduced to 2mg daily in patients who are 75 years or older given the associated increased risks in this age group. Additionally, baricitinib should be avoided in patients with creatinine clearance of less than 30 ml/min and dose needs to be reduced in patients with a creatinine clearance between 30-60 ml/min because it is primarily renally excreted drug. Methods All the blueteq requests for baricitinib at University Hospitals Coventry and Warwickshire, from 05/07/2021 to 05/07/2023 were evaluated. There were 128 patients who have been on baricitinib during this period. Twenty patients out of this, were 75 years or above. The baricitinib dose in patients above the age of 75 and in patients with chronic kidney disease was assessed by using NICE guidance on the use of baricitinib in patients with rheumatoid arthritis and the BNF as the audit standards respectively. Results Of the 20 patients who were 75 years and above, 13 patients were still on baricitinib. Ten patients were on a dose of 2mg daily which is in keeping with NICE guidance while 3 patients were still receiving a dose of 4mg daily. Seven patients were started on baricitinib after 75 years and 4 of them were started on 4mg daily which is not keeping with NICE guidance. Of the 128 patients, none of them had a creatinine clearance less than <30 ml/min while there were 16 patients who had received baricitinib (at some point) with a creatinine clearance of 30-60 ml/min. Of them, 14 patients were at some point on 4mg daily dose of Baricitinib which is not in keeping with guidance. Of those 14 patients, 6 patients were still receiving a dose of 4mg daily. Conclusion In conclusion, it appears that we have not completely adhered to standard criteria laid down by NICE guidelines and in the BNF. This presentation aims to raise awareness among rheumatologists regarding these guidelines. Also, changing the format of the prescription to include the age and renal functions would prompt the prescriber to amend the dose accordingly. The use of baricitinib may reduce in the future due to concerns of increased cardiovascular disease. However, there is a group of patients who are already on baricitinib and will want to continue, despite these concerns, given the significant improvements in disease control. Disclosure C. Rosa: None. J. Joseph: None. G. Kasavkar: None.

P009 Improving axial spondyloarthritis time to diagnosis: a quality improvement project

Abstract Background/Aims The average UK time to diagnosis for axial spondyloarthritis (axSpA) remains unacceptably long, i.e., 8.3 years, with high economic costs and impact on patients' outcomes. Until October 2021, the Rheumatology department at Ipswich Hospital did not have an axSpA service, no specific referral pathways, no dedicated clinics, and no standardized patient journey. The main objective was to develop an axSpA service from scratch and to raise awareness on axSpA amongst health professionals. A more specific quantifiable objective was to reduce the time from patient presentation in primary and secondary care to axSpA diagnosis in rheumatology. Methods For the first year since service inception (November 2021 to February 2022), we have set up the ambitious aim of developing an axSpA service, focusing on designing a referral pathway, on establishing connections with primary and secondary care, and on providing education on axSpA. To evaluate improvement in time from patient presentation in primary/ secondary care to axSpA diagnosis, we have audited all new suspected axSpA cases in the first three months of service inception (November 2021 - February 2022) and compared data from the same period of time, a year later (October 2022 - February 2023). The Plan-Do-Study-Act (PDSA) methodology was used. The quality improvement project is part of Aspiring to Excellence programme (endorsed by National Axial Spondyloarthritis Society/NASS). Results Our axSpA service was established in November 2021. We initially established connections with primary and secondary care. Within a year, we have developed an axSpA referral pathway for primary care which was designed to reflect NICE guidelines. All suspected axSpA referrals were triaged in rheumatology as urgent rather than routine and booked into a dedicated axSpA clinic running once weekly. All patients benefited from a specialized physiotherapy review. Formal and informal referral patwhays were also developed with secondary care. Additionally, we have established monthly multidisciplinary team meetings with dermatology, ophthalmology, spinal team, as well as community physiotherapy. Regular education sessions were delivered to primary care. A specific radiology- MRI pathway was also established. The audit on time until diagnosis included a total of 94 patients with suspected axSpA. The waiting time from initial presentation in primary/ secondary care to rheumatology first appointment decreased from a median of 17 weeks to 5 weeks; the time from first rheumatology appointment to diagnosis decreased from 17 weeks to 7 weeks. Overall, patients with axSpA had to wait a median of 13 weeks from initial presentation to diagnosis in rheumatology versus 29 weeks at service inception. Conclusion In only a year, we have established an axSpA service de novo with clear and standardized pathways. There was a significant improvement in waiting times for patients waiting to be referred and diagnosed with axSpA. Disclosure S. Voules: None. C. Kelly: None. M. Alcala: None. S. Premraj: None. T. Gudu: None.

P014 Treatment response in psoriatic arthritis: a comparison between the disease activity scores psoriatic arthritis response criteria and disease activity score-28

Abstract Background/Aims Despite NICE guidelines recommending the use of the PsA response criteria (PsARC), to assess response to biologic therapies in patients with psoriatic arthritis (PsA), some clinicians use the Disease Activity Score (DAS-28) criteria, developed for rheumatoid arthritis. However, whether the two scores are interchangeable and/or capture similar information has not yet been explored. Here, we investigate the differences and overlap between these two disease activity scores, in identifying good/poor responders, in PsA. Methods Utilising treatment response data from the OUTPASS cohort; a UK based multi-centre observational study, PsA patients assessed with PsARC and DAS-28 scores were calculated at baseline (pre-treatment), 3-months and 6-months (3M),(6M), following treatment, where available. EULAR good/moderate response was combined and compared with PsARC responder status. Subgroup analysis of patients with both PsARC and DAS-28 scores at either 3M or 6M, were tested for agreement using the Cohen’s Kappa test. Statistical tests were also used, as appropriate, to investigate differences between the baseline subcomponents, in the observed concordant and discordant data. Results Response data from 418 patients was available. An average of 76% were classified as responders according to PsARC, and 80% according to the EULAR response criteria, for both 3M and 6M, with 12% discordance. A subgroup analysis of 218 patients assessed with both scores, (up to 6M), revealed 17.9% responder discordance between PSARC and DAS-28, and 82.1% concordance. The Cohen’s Kappa test defined the assessment of responder/non-responder outcome, as an ‘almost perfect agreement’ (0.82) between the two criteria. Further statistical analyses, of baseline subcomponents, of both response criteria, between these discordant/concordant subsets, showed no significant difference, except for PsARC Physician’s and Patient’s Global Assessments (PhGA), (PGA), (P = 0.01, P = 0.02, Table 1). Conclusion PsARC and EULAR response criteria show ‘almost perfect agreement’, strongly supporting clinical use for either score. PhGA, (not a subcomponent of DAS-28) and PsARC PGA were the only significantly different (P < 0.05) components between the discordant and concordant groups, highlighting the importance of considering psychosocial factors which may affect pain tolerance and treatment response. Comparative analyses with other widely used scores, such as DAPSA, would also be informative for future work. Disclosure K. Patel: Grants/research support; This project has received support from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 101007757 (HIPPOCRATES), the JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA, the results reflect only the author's view and the JU are not responsible for any use that may be made of the information it contains.. N. Nair: None. M. Jani: None. H. Chinoy: Consultancies; H.C. has received Consulting for PTC Therapeutics. Member of speakers’ bureau; H.C. has received fees as a speaker for GSK, UCB. Other; H.C. for Advisory Board member for Astra Zeneca, Pfizer, Argenx, Galapagos; Data and Science Monitoring Board chair for Horizon Therapeutics. J. Bluett: Grants/research support; J.B. has received a research grant award from Pfizer and travel/conference fees from UCB, Fresenius Kabi, Pfizer and Eli Lilly. (Pfizer: WI239449). A. Barton: Grants/research support; A.B. has received research grants from Bristol Myers Squibb and Pfizer and speaker fees from Galapagos.. P. Curry: None.

Support for primary care prescribing for adult ADHD in England: national survey.

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support. This study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement. Cross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care. Three interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software. Data from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region - for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%). Elements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps.

Adherence to timeline for decision to delivery interval in accordance with NICE guidelines and its impact on neonatal outcomes in a rural tertiary health care centre of Central India

Adherence to timeline for decision to delivery interval in accordance with NICE guidelines and its impact on neonatal outcomes in a rural tertiary health care centre of Central India

Mindfulness possibilities in the treatment of chronic headaches

IntroductionHeadache is a very common health problem worldwide and in our country due to the increasing environmental damage and daily stress. The proportion of patients with headache in general practice is 4-5%, in neurology up to 30%. Chronic headache as a persistent stressor exhausts the body through central sensitisation, which can lead to the consolidation of maladaptive coping strategies such as avoidance, feelings of loss of control, catastrophising pain. This can lead to a deterioration in quality of life and depression also. The effectiveness of pharmacotherapy in coping with chronic pain is limited, so attention should be paid to modifying maladaptive pain behaviour, as recommended by the NICE guidelines. The international literature shows that mindfulness-based cognitive therapy (MBCT) has been shown to be effective in the management of chronic headache, primarily in improving quality of life, increasing self-efficacy and reducing pain catastrophisation and depression (Hunt et al., 2022).ObjectivesOur first objective was to introduce mindfulness-based cognitive therapy in Hungary to patients suffering from chronic headache. Secondly, we wanted to measure the impact of the method on quality of life, coping with pain and depression.MethodsN=28 patients, suffering from chronic headaches (tension headache and migraine) participated in the study at the Department of Clinical Psychology, Semmelweis University (BNO: G430, G431, G442). Selection criteria were: referral from a neurologist, age 18-65. The intervention was an 8-session mindfulness-based cognitive therapy for pain (Day, 2017) led by an MBCT teacher and a clinical psychology resident. Before the intervention, all patients had an individual first interview and filled in the questonnaires. Measures: Beck Depression Questionnaire, Pain Catastrophizing Scale, Comprehensive Headache-related Quality of life Questionnaire, Five Facet Mindfulness Questionnaire, Cognitive Emotion Regulation Questionnaire.ResultsAfter the intervention, there was a significant reduction in the negative impact of pain on quality of life (p<0.05, Cohen’s d=0.6), pain catastrophization (p<0.01, Cohen’s d=0.74), and depression (p<0.001, Cohen’s d=0.84). In addition, several sub-factors of mindfulness increased, including non-reactivity and being non-judgemental (p<0.05, Cohen’s d=0.57), as well as adaptive cognitive emotion regulation strategies (p<0.05, Cohen’s d=0.49).ConclusionsWe can conclude, that in line with international findings, MBCT has been shown to be effective in reducing the negative impact of depressive symptoms, pain catastrophisation and headache on quality of life, and in helping people to cope with pain more adaptively, primarily through the acquisition of mindfulness skills.Disclosure of InterestNone Declared

The difficulties of Adult ADHD management within a Community Mental Health Team

IntroductionADHD is a neurodevelopmental disorder characterised by: inattention, hyperactivity and impulsivity.Diagnosis of ADHD in adults is complex, owing to the need for retrospective evidence that symptoms began in childhood as well as the high rates of comorbid mental health conditions. There are no public specialized clinics for adults with ADHD in Ireland. In their absence, referrals are sent to general adult psychiatry.ObjectivesAn audit of standards of care received by patients with ADHD against those set by the NICE guidelines.MethodsCare received pre and 8 weeks post MDT (multi-disciplinary team) educational session. Inclusion criteria: existing adult community mental health team (CMHT) patients with a diagnosis of ADHD. Recommendations as per NICE guideline used for assessment: Specialist MDT team input, OT/ Psychology input, MDT review of reports, Specialist consultant with training in diagnosis and treatment, Diagnosis based on structured assessment e.g. DIVA, Detailed psychiatric assessment, Physical health monitoring before commencing treatment (e.g. ECG), Ongoing physical health monitoring (BP, HR, weight), Patient regularly attending follow upResultsThere were 7 patients with diagnosed ADHD attending the CMHT, 4 male, 3 female aged 19-42yo. 4 patients were diagnosed privately (average age at diagnosis 31yrs). 2 were diagnosed by CAMHS. And 1 was diagnosed by primary care psychology (age 27). 8 weeks following MDT meeting; 2 patients had been commenced on ADHD medication. Those on the wait list for OT/psychology remained on the wait list.ConclusionsADHD is a specialised area which requires a specialist MDT led by a consultant with expertise in diagnosis and treatment. As evidenced by this audit, despite the best efforts of adult psychiatric services, teams are not sufficiently resourced to meet the needs of adults with ADHD and fall short of the expected standards of care.Disclosure of InterestNone Declared

Non‐pharmacological interventions in ID patients with challenging behaviours

The STOMP (stopping over‐medication of people with a learning disability, autism or both with psychotropic medicines) initiative and NICE guidelines regarding the management of challenging behaviour in adults with intellectual disability (ID) promote the use of non‐pharmacological approaches ahead of medication, with an emphasis also on reducing dosage or stopping medication where appropriate. Here the authors report on the findings of a service evaluation looking at how often a community intellectual disability psychiatry clinic initiates non‐pharmacological approaches in cases referred for challenging behaviour, and importantly whether this impacts the dosages of medication subsequently prescribed.

Prescription practices for antipsychotic medication in an acute inpatient ward: Risks / benefits discussions with patients and performance of baseline investigations as per NICE guidelines

IntroductionAntipsychotic medications are essential for managing psychiatric disorders, offering symptom relief and improved functioning. However, their use carries potential risks. Vigilant monitoring and patient engagement are crucial when initiating antipsychotics.ObjectivesTo explore whether comprehensive discussions with patients concerning the benefits and risks of antipsychotics are taking place, and whether baseline investigations are performed before initiation of antipsychotics as per NICE guidelines.MethodsThis retrospective study focused on admissions to a male acute ward between March 1 and May 31, 2023. Data from electronic patient records included demographics, Mental Health Act (MHA) status, psychiatric diagnoses, medical co-morbidities, documentation of medication benefits / side effects discussions with patients, medication information provision, as well as baseline investigations involving weight, height, waist/hip circumference, pulse, blood pressure, blood glucose, HbA1c, lipid profile, prolactin levels, movement disorder assessment, nutritional status, diet, physical activity, and ECG.ResultsAmong 23 admitted patients, 15 were newly initiated or reintroduced to antipsychotics, with 14(93.3%) admitted under the MHA. Primary diagnoses included Paranoid Schizophrenia (33.33%), Unspecified Non-Organic Psychosis (20%), Bipolar Affective Disorder (20%), and others. Medical comorbidities were observed in 10(66.7%), notably type 2 diabetes (40%). Among initiates, 6(40%) were new to treatment, while in 9(60%) it was re-initiated.Within the 15-patient group, discussions on treatment benefits engaged 11(73.3%), while 4(26.7%) lacked complete documentation. Only 6(40%) had discussions about side effects. Metabolic side effects were discussed with 3(20%), extrapyramidal effects with 2(13.33%), while 4(26.7%) had general side effect talks. Patient information leaflets were given to 5(33.3%) patients. Baseline measurements: 12(80%) had weight/height, 4(26.7%) waist/hip, and 14(93.3%) pulse/blood pressure assessed. Blood tests were declined by 4(26.7%). Baseline glucose, HbA1c, lipids, and prolactin were assessed in 8(53.3%), 10(66.7%), 9(60%), and 8(53.3%) patients respectively. Nutritional status was assessed in 13(86.7%), movement disorders in 1(6.7%), and physical activity in 1(6.7%). All 15(100%) patients were offered ECGs, although 5(33.3%) declined.ConclusionsAdherence to NICE guidelines for baseline investigations and risk/benefit discussions prior to antipsychotic initiation was low, apart from ECGs, weight/height, pulse/blood pressure, assessment of nutritional status, and discussions about antipsychotics’ benefits. Implementing effective monitoring and patient engagement to mitigate potential side effects, is crucial to facilitating the safe and efficient utilisation of antipsychotics.Disclosure of InterestNone Declared

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.

Assessment of the impact of a personalised nutrition intervention in impaired glucose regulation over 26 weeks: a randomised controlled trial

Dietary interventions can reduce progression to type 2 diabetes mellitus (T2DM) in people with non-diabetic hyperglycaemia. In this study we aimed to determine the impact of a DNA-personalised nutrition intervention in people with non-diabetic hyperglycaemia over 26 weeks. ASPIRE-DNA was a pilot study. Participants were randomised into three arms to receive either (i) Control arm: standard care (NICE guidelines) (n = 51), (ii) Intervention arm: DNA-personalised dietary advice (n = 50), or (iii) Exploratory arm: DNA-personalised dietary advice via a self-guided app and wearable device (n = 46). The primary outcome was the difference in fasting plasma glucose (FPG) between the Control and Intervention arms after 6 weeks. 180 people were recruited, of whom 148 people were randomised, mean age of 59 years (SD = 11), 69% of whom were female. There was no significant difference in the FPG change between the Control and Intervention arms at 6 weeks (− 0.13 mmol/L (95% CI [− 0.37, 0.11]), p = 0.29), however, we found that a DNA-personalised dietary intervention led to a significant reduction of FPG at 26 weeks in the Intervention arm when compared to standard care (− 0.019 (SD = 0.008), p = 0.01), as did the Exploratory arm (− 0.021 (SD = 0.008), p = 0.006). HbA1c at 26 weeks was significantly reduced in the Intervention arm when compared to standard care (− 0.038 (SD = 0.018), p = 0.04). There was some evidence suggesting prevention of progression to T2DM across the groups that received a DNA-based intervention (p = 0.06). Personalisation of dietary advice based on DNA did not result in glucose changes within the first 6 weeks but was associated with significant reduction of FPG and HbA1c at 26 weeks when compared to standard care. The DNA-based diet was effective regardless of intervention type, though results should be interpreted with caution due to the low sample size. These findings suggest that DNA-based dietary guidance is an effective intervention compared to standard care, but there is still a minimum timeframe of adherence to the intervention before changes in clinical outcomes become apparent.Trial Registration:www.clinicaltrials.gov.uk Ref: NCT03702465.

A rapid improvement event: progesterone prescribing in prevention of miscarriage

A rapid improvement event (RIE) is a standard operational excellence technique that uses team-based problem solving to improve processes. In this study, a RIE was undertaken to improve progesterone prescribing...

Identification of people with Lynch syndrome from those presenting with colorectal cancer in England: baseline analysis of the diagnostic pathway

It is believed that >95% of people with Lynch syndrome (LS) remain undiagnosed. Within the National Health Service (NHS) in England, formal guidelines issued in 2017 state that all colorectal cancers (CRC) should be tested for DNA Mismatch Repair deficiency (dMMR). We used a comprehensive population-level national dataset to analyse implementation of the agreed diagnostic pathway at a baseline point 2 years post-publication of official guidelines. Using real-world data collected and curated by the National Cancer Registration and Analysis Service (NCRAS), we retrospectively followed up all people diagnosed with CRC in England in 2019. Nationwide laboratory diagnostic data incorporated somatic (tumour) testing for dMMR (via immunohistochemistry or microsatellite instability), somatic testing for MLH1 promoter methylation and BRAF status, and constitutional (germline) testing of MMR genes. Only 44% of CRCs were screened for dMMR; these figures varied over four-fold with respect to geography. Of those CRCs identified as dMMR, only 51% underwent subsequent diagnostic testing. Overall, only 1.3% of patients with colorectal cancer had a germline MMR genetic test performed; up to 37% of these tests occurred outside of NICE guidelines. The low rates of molecular diagnostic testing in CRC support the premise that Lynch syndrome is underdiagnosed, with significant attrition at all stages of the testing pathway. Applying our methodology to subsequent years’ data will allow ongoing monitoring and analysis of the impact of recent investment. If the diagnostic guidelines were fully implemented, we estimate that up to 700 additional people with LS could be identified each year.

Association between energy delivery from parenteral nutrition and refeeding syndrome in hospitalized adults: A retrospective cohort study.

Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adultson PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation wasassociated with RFS development. We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors. A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8 ). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04-1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04-2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25-2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19-2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04-2.51). RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy.

TOTAL HIP ARTHROPLASTY OR HIP HEMIARTHROPLASTY: WHAT IS THE CORRECT CHOICE IN ALCOHOLICS AGED 40 TO 65 YEARS?

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively).This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts.Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%).In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results.

'I Can't Get No Satisfaction'… Experience in the treatment, satisfaction, and professional support of young depressed people using SPARX.

Depression in young people is common and can lead to poor long-term outcomes. Digital therapies are a promising means of promoting access to care. Currently, among the digital treatments for depression in adolescents recognized by the NICE guidelines, there is SPARX (Smart, Positive, Active, Realistic, X-factor), based on Cognitive Behavioral Therapy, CBT. This narrative review aimed to evaluate: 1) Who were the depressed young people who used SPARX and what was their experience with the treatment? 2) Were users satisfied with the SPARX treatment? Did the youth's perceived level of satisfaction with using SPARX impact completion rates? 3) What was the role of professionals (researchers, consultants, teachers) in the SPARX studies? Has their support in running SPARX affected completion rates? A narrative review of the English literature was performed. The articles were searched in Pubmed, SCOPUS, and Web of Science databases (from 2012 to 2023) with keywords such as 'SPARX,' depression' and 'young adult'. Of 557 papers, 18 were included in our review. The young people who used SPARX were students or adolescents from special help-seeker populations at risk or with mild to moderate depression. The highest satisfaction levels were present in users of primary health services, such as general practice and counseling services. The support of the school counselor and experts in mental health clinicians was instrumental in impacting user satisfaction and completion rates. The personalization of the game in terms of user culture - symbols, language, norms, values, and artifacts; the customization of the avatar, the gender identity; the narrative structure; the presence of a guide character (virtual therapist); the CBT homework seemed to represent crucial SPARX characteristics related to satisfaction and completion rates. Our narrative review provides an overview of the main results of using SPARX with interesting considerations that may suggest improvements for broader use and diffusion of this digital treatment.

Evaluating pharmacological THRomboprophylaxis in Individuals undergoing superficial endoVEnous treatment across NHS and private clinics in the UK: a multi-centre, assessor-blind, randomised controlled trial—THRIVE trial

IntroductionEndovenous therapy is the first choice management for symptomatic varicose veins in NICE guidelines, with 56–70 000 procedures performed annually in the UK. Venous thromboembolism (VTE), including deep vein thrombosis...

2048 Antipsychotic medication prescription in elderly patients in Royal Gwent Hospital, Wales

Abstract Introduction he use of anti-psychotics is higher in older people than their younger adult counterparts due to high prevalence of dementia/delirium. Anti-psychotic drugs cause side effects which include cardiovascular, metabolic, extra pyramidal and risk of falls. So, we set out to do a QIP on antipsychotic medication prescription on our Geriatric wards comparing it with NICE guidelines. Method We had 2 approaches to use. Firstly, we prepared a check list for anti-psychotic medication monitoring according to NICE guidelines 2021 and we applied this retrospectively to our patients who had been initiated on anti-psychotics within the last year, the aim being to compare our practice with best practice. Secondly, we prepared a questionnaire for doctors to assess their knowledge about anti-psychotic NICE guidelines and distributed this to our junior doctors in RGH. Results • Main Indication for prescription was Behavioural and psychological symptoms of dementia (BPSD) - 94% of the time • Risperidone was the most commonly prescribed (64%) antipsychotic. • 83% of them had non-pharmacological methods tried before considering antipsychotic medications. • 82% had their baseline ECGs checked and falls risk assessments done • 35% had their lipids checked and 47% had their HbA1c checked • 52% of the doctors were aware about NICE guidelines on prescribing anti-psychotic medications • 70% of the doctors had knowledge about the side effects. Conclusions Our study showed the most commonly used antipsychotic drug was risperidone. We were good at documenting the indication, trying non-pharmacological methods and discussing side effects with patients/family. Hba1c, lipids and prolactin were not often checked, showing room to develop best practice. We are in the process of finalising stickers as a checklist when starting antipsychotics. To improve knowledge, we have presented the findings and aim to put up posters on wards and to do regular teachings.

1956 Audit on the prompt mobilisation of patients following hip arthroplasty

Abstract Background Hip fractures are fractures involving the femoral head, neck or proximal shaft. They most often occur in frail, osteoporotic elderly patients following falls. Hip fractures are associated with a 30-day mortality rate of 10% and a 1-year mortality rate of approximately 30%. NICE and NHFD advise prompt mobilisation post-surgery - with patients being mobilised by the day after surgery at the latest: 1. Nice Guidelines Hip Fracture in Adults; Quality statement 6: Rehabilitation after surgery 2. NHFD KPI 4 – prompt mobilisation after surgery Method We carried out two audit cycles assessing the mobilisation rate of patients by the day after hip arthroplasty, at Bradford Royal Infirmary. In the first cycle, from 23 eligible patients, we found only 15 (65%) were mobilised within a day of surgery. Results These patients had a reduced length of stay compared to the patients not mobilised by the day after surgery (15.1 vs 18.1 days). As per our data, the reasons for delayed mobilisation included 1. pain (suggest early and regular analgesia), and 2. system miss (discussed with local physiotherapy team). After four months we reaudited. Of 23 eligible patients we found an improvement in patients being mobilised - 17 patients (74%) were mobilised within a day of surgery. Once again length of stay was less in the patients who had been mobilised (21.2 vs 29.7 days). Similar reasons for delayed mobilisation remained. Conclusion Our interventions improved the promptness of mobilisation in patients who had undergone hip arthroplasty. This led to a reduced duration of inpatient stay and better patient outcomes. Audit limitations included population size.