North Middlesex University Hospital Research Articles

Health check

Senior health visitor Shirley Adebayo, of North Middlesex University Hospital, sets out how early years settings can help tackle the epidemic of tooth decay among young children

Health check

In this series by senior health visitors, Shirley Adebayo, a senior health visitor at North Middlesex University Hospital, London, talks about stages of speech and language development following a case of pre-verbal three-year-old boys

Inflammatory Bowel Disease in Turkish Populations Served by English NHS Trusts

It is estimated that there are about 500,000 Turkish people living in the UK, of whom about 300,000 are of Cypriot origin. A Freedom of Information request was sent to the four NHS Trusts in London which served areas with significant Turkish communities. The request sought information on the total number of patients admitted between 2016 and 2020 with inflammatory bowel disease. Between 2016 and 2020, 1936 patients with inflammatory bowel disease were admitted to North Middlesex University Hospital NHS Trust. Some of these patients will have been readmitted in different years, leading to an inflation of the overall number. The average number of cases admitted each year was approximately 387. The proportion of White British patients with ulcerative colitis was 0.4; for Turkish Cypriots, it was 0.43 and for Turkish patients, 0.45. A z test comparison of these proportions showed that there was no difference between the Turkish communities (z = 0.52 ns) and no overall difference between White British and all Turkish patients (z = −1.5, ns). Between 2016 and 2020, the Homerton Healthcare Foundation Trust admitted 215 English patients with inflammatory bowel disease, of whom 113 had ulcerative colitis. Of the 26 Turkish patients, 4 had ulcerative colitis. The proportion of Turkish patients with Crohn’s disease was significantly greater than that amongst English patients (z = 3.58, p < 0.0003). In the context of the relatively large number of Turkish people with inflammatory bowel disease in both trusts, the absence of published work on the impact of these chronic diseases is of concern. The results from this investigation should prompt specific qualitative research into the Turkish experience in the UK following a diagnosis of inflammatory bowel disease with the intention of developing better patient-centred care.

Experience of a District General Hospital With a Diverse Community in Operated Colorectal Cancers According to Ethnic Background.

Background This study aimed to investigate disparities in colorectal cancer (CRC) patients' demographics according to the five major ethnicities of patients living in the catchment area of North Middlesex Hospital. Methodology This retrospective study included CRC patients operated on between January 1, 2010, and December 31, 2014. Records dating to the end of the five-year follow-up were extracted anonymously from a database of CRC outcomes at the North Middlesex University Hospital NHS Trust. Comparisons were made according to ethnicity, patient demographics, type of presentation, cancer location, stage at diagnosis, recurrence, and mortality. Results A total of 176 adult patients were operated on for CRC between January 1, 2010, and December 31, 2014. The majority of the patients were referred as two-week wait target referrals. Emergency presentation of CRC was the highest in White non-UK patients. The White British Irish patients had their tumors mostly in the cecum, followed by the sigmoid colon, while the rectum followed by the sigmoid colon were the most common sites in the Black population. All study populations mainly presented with stage I disease, and the next highest incidence of cancers according to stage and ethnicity was stage IIIb in the Black population. Conclusions Differences in the ethnic background are important factors, especially in a diverse community, which can impact the age and mode of presentation of the disease, as well as the stage it starts to present. The location of the primary tumor, metastases, and recurrence sites are all affected by the ethnic background, which, subsequently, affect the survival of the patient.

Outcome of Operated Colorectal Cancers in Relation to the Type of Initial Referral.

Aim Since the introduction of the target referral system, there has been controversy about its value and whether it affected the short- and long-term outcomes of colorectal cancer surgeries. With contradicting results, this study highlights differences in personal and tumour characteristics, management differences, and outcomes in each referral pathway, including target pathway referrals for suspected cancers, emergency presentations, routine referrals, and incidentally discovered cancers during screening. Methods A retrospective study of colorectal cancer (CRC) patients operated on between January 1, 2010, and December 31, 2014, with records dating to the end of the five-year follow-up, was extracted anonymously from the database of CRC outcomes at the North Middlesex University Hospital NHS Trust, London. The total number of patients operated on through the four pathways was 176, with full records and competent follow-ups. Patients were classified according to the mode of referral: two-week wait (2WW or target), routine, emergency, and incidental discovery referrals. Comparisons were made between these groups with regard to personal and tumour characteristics, management, and outcome. Results It has been demonstrated by this study that targetreferrals present mainly with stage I cancers as compared to emergency referrals that present with more stage II (IIa+ IIb+ IIc). The highest percentage of cancer locations within the large bowel was rectal, followed by sigmoid in both target and emergency groups; 8.8% of target patients needed neoadjuvant chemoradiotherapy in the form of FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) chemotherapy protocol with the addition of radiotherapy in patients with advanced rectal cancers, compared to 13.3% of emergency patients. Conclusion The colorectal 2WW system was the main pathway supplying colorectal cancer operations; it mostly showed earlier cancers than the other referral groups; its cancers were mostly rectosigmoid with less need for adjuvant chemotherapy; fewer recurrences; and it also showed a lower five-year mortality rate than the emergency group.

VNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery?

The Obstetrician & GynaecologistEarly View Commentary vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? Wai Yoong MD FRCOG, Corresponding Author Wai Yoong MD FRCOG [email protected] orcid.org/0000-0001-7286-5968 Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKCorrespondence: Wai Yoong. Email: [email protected]Search for more papers by this authorVictoria Sampson MRCOG, Victoria Sampson MRCOG Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKSearch for more papers by this authorLusekelo Mwenechanya MBBS, Lusekelo Mwenechanya MBBS Specialist Trainee, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKSearch for more papers by this authorJan Baekelandt MD PhD, Jan Baekelandt MD PhD orcid.org/0000-0002-8344-8622 Gynaecological Oncologist, Department of Gynaecology, Imelda Hospital, Bonheiden, BelgiumSearch for more papers by this author Wai Yoong MD FRCOG, Corresponding Author Wai Yoong MD FRCOG [email protected] orcid.org/0000-0001-7286-5968 Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKCorrespondence: Wai Yoong. Email: [email protected]Search for more papers by this authorVictoria Sampson MRCOG, Victoria Sampson MRCOG Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKSearch for more papers by this authorLusekelo Mwenechanya MBBS, Lusekelo Mwenechanya MBBS Specialist Trainee, Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UKSearch for more papers by this authorJan Baekelandt MD PhD, Jan Baekelandt MD PhD orcid.org/0000-0002-8344-8622 Gynaecological Oncologist, Department of Gynaecology, Imelda Hospital, Bonheiden, BelgiumSearch for more papers by this author First published: 20 February 2023 https://doi.org/10.1111/tog.12860Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Overview of Obstructive Hypertrophic Cardiomyopathy

Antonis Pantazis, Consultant Cardiologist at the Royal Brompton and Harefield Hospitals and North Middlesex University Hospital in London, UK, and Chairperson of the European Society of Cardiology (ESC) Working Group on Myocardial and Pericardial Diseases, provided an expert insight into the various aspects of obstructive hypertonic cardiomyopathy (HCM) during an EMJ- conducted podcast. Pantazis opened the podcast by providing a definition of HCM and describing this clinical condition, discussing the typical symptoms and diagnostic tests that can be performed. Pantazis then explained the demographics of those diagnosed with HCM, followed by the treatment options currently available, with the aims and limitations of these being described. Pantazis presented a case study of a female patient who was diagnosed with HCM following their sister’s diagnosis. They were initially reluctant to have surgery but changed their mindset as the symptoms of HCM progressed and became increasingly life-limiting. The podcast concluded with lifestyle recommendations for patients with HCM, including type and intensity of exercise prescription.

An Emerging Pattern? A Further Case of Anticipated Capacity Loss in Pregnancy: North Middlesex University Hospital NHS Trust V SR [2021] EWCOP 58.

In 2021, the Court of Protection made a third anticipatory declaration that it was lawful for a capacitous pregnant woman to be subject to possible forcible treatment contingent on her losing capacity before or during birth. North Middlesex University Hospital v SR raises three interesting questions for discussion which this commentary will explore. First, it is submitted that there is a growing, yet alarming, trend in the use of anticipatory or contingent declarations to manage such challenging cases of future loss of, or fluctuating, capacity in pregnant women. This trend now seems to have been widened by SR and could potentially capture any pregnant woman, rather than those in narrower, exceptional circumstances. Secondly, this commentary discusses the judge's justification of basing the issuing of anticipatory or contingent declarations on a 'real risk' P will lose capacity in the future, highlighting the potential problems with framing such controversial powers on 'risk'. Finally, it provides an exploration of the alternative option of utilising advance care plans to better deal with these types of matters, in the name of giving back the power to pregnant women to decide on what should happen to them in labour in the event that they do lose capacity before or during delivery.

116 COVID-19: What do pregnant women know now? A cross sectional study

Introduction/Aims: Pregnancy predisposes women to increased risk of severe COVID-19. The UKOSS has shown pregnant women with BAME background, age >35 years and pre-existing medical conditions may be at even further risk. The aim of this study was to assess if months into the pandemic we are mitigating risk appropriately by ensuring our varied population is informed. The objective was to ascertain levels of COVID-19 knowledge among pregnant patients. Methods: We conducted a survey between October-December 2020 of women attending antenatal clinics at North Middlesex University Hospital, London.

708 Examining the Management of Acute Lower GI Bleeds in Order to Improve Policies and Reflect Safe and Updated Guidance

Abstract Introduction Acute lower gastrointestinal bleeding (LGIB) tends to occur in elderly patients with complex comorbidities. At North Middlesex University Hospital (NMUH), LGIB patients are primarily managed by the surgical department. We amended local policies by integrating aspects of new guidelines published by the British Society of Gastroenterology (BSG). Method Handover documentation between November 2019 and January 2020 established patients admitted with LGIB (n = 45). Further data regarding the management of these patients was collated from clinical software and compared to standards set from BSG guidelines. Results We found NMUH to be efficient in ruling out upper GI bleeds via 24-hour OGDs and had low surgical intervention rates (0.02%). 40% of patients were transfused with an admission haemoglobin above suggested NICE thresholds, accounting for cardiovascular comorbidities. 56% of patients were discharged without a documented anticoagulation plan. Over 50% of patients did not have BSG recommended inpatient investigations. Conclusions Updated Trust guidelines aim to uphold areas that NMUH were shown to excel in, while reiterating NICE transfusion thresholds and include guidance regarding anticoagulant and antiplatelet medications. The Oakland score and shock index have been integrated into local protocols and will aid clinicians in making safe decisions in the management of LGIB patients.

100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance

Abstract Introduction Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge. Method 4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services. Results From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers. Conclusions Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

Eddie Josse: forensic and educational polymath

Credit: Craig Hibbert/ Daily Mail/Solopix Edouard “Eddie” Josse was Britain’s longest serving police surgeon until his retirement, five years ago at the age of 82. Also a one time BMA...

177 - Introduction of Lung Cancer Patient Navigator at North Middlesex University Hospital (NMUH): how does it influence performance in meeting National Optimal Lung Cancer Pathway Times?

177 - Introduction of Lung Cancer Patient Navigator at North Middlesex University Hospital (NMUH): how does it influence performance in meeting National Optimal Lung Cancer Pathway Times?

The associations between social factors and suboptimal use of paediatric dental services (Tiny Teeth): a mixed method study

BackgroundDental decay is the leading reason for hospital admission of children aged 5–9 years. Prevalence of dental decay is strongly associated with deprivation, decreased maternal education, and ethnicity. This study aimed to investigate social and parental factors that prevent timely and regular use of dental services in Haringey and Enfield (London, UK), and to address the suitability of the emergency department (ED) as a site of opportunistic oral health education, using a dental intervention (DI). MethodsThe study was undertaken at the North Middlesex University Hospital's paediatric ED in North London, UK. It was a mixed method study with cross-sectional surveys, a brief DI, and qualitative interviews. Parents of children aged 10 years and younger in the ED were invited to participate in the study. Informed written consent was obtained from 101 participants. Data collection was from Jan 31, 2019, to March 13, 2019. Questionnaires collected background social and medical data, and assessed each caregiver's oral health literacy. The Big Bites and Pearly Whites DI provided parents with up-to-date information about teeth cleaning practices, dentistry, and diet. A post-intervention questionnaire assessed changes in parental knowledge. Adjusted logistic regressions explored associations between social factors and child dental registration. Seven semistructured interviews were conducted, collecting data on barriers faced to the use of paediatric dental services. FindingsBlack British, Caribbean, and African children had an odds ratio of 0·158 (95% CI 0·037–0·679) for dental registration compared with their white counterparts, after adjusting for age of child and sibling number. The DI led to a significant difference between pre and post intervention median knowledge scores (Wilcoxon signed rank test; p=0·009) with a small effect size (r=0·2). Qualitative interviews exposed that current oral health advice, from dentists alone, is inconsistent and not universally delivered, resulting in late, suboptimal, and problem-based attendance. InterpretationTo maximise and reinforce early and universal parental receipt of oral health messages, collaboration and coordination is needed between educational, dental, and general health providers. Disparities in health-seeking behaviour due to ethnicity and knowledge should be accounted for when planning service engagement programmes. The study supports the ED as a site to opportunistically make every contact count by reinforcing preventive oral health messages. The major limitations of the study are its size and cross-sectional design. FundingNone.

1510P - Delayed onset immune related adverse effects (IRAEs) of pembrolizumab in non-small cell lung cancer

BackgroundThe humanised PD1 antibody, Pembrolizumab, is used as monotherapy in the 1st and 2nd line setting for patients with advanced non-small cell lung cancer (NSCLC). There is a lack of data about the delayed onset of IRAEs which is important as patients can be on prolonged treatment. MethodsThis is a retrospective study of NSCLC patients treated with pembrolizumab across 4 institutions in London (North Middlesex University Hospital, Princess Alexandra Hospital, St. Bartholomew’s Hospital and University College London Hospital). IRAEs recorded on clinic letters from start of treatment until March 2019 were categorised as early (<180 days from first dose) or delayed (>180 days). Results139 patients (60% male) with advanced NSCLC were treated with pembrolizumab. Median age was 67 years and 75% (104/139) were adenocarcinoma. Median follow up was 191 days with 3 patients completing 2 years of treatment. IRAEs were reported in 53% (73/139) with patients experiencing up to five different IRAEs. 34% (40/116) of all IRAEs were delayed and colitis was the most common (54%) late IRAE, followed by skin & mucosal toxicities (Table). There were no differences in the grade of severity (P=0.37) or number of toxicities requiring permanent discontinuation of pembrolizumab between early and delayed IRAEs (P=0.31). All patients with pneumonitis, 88% with hepatitis and 87% with colitis were treated with steroids. In 88% (35/40) of patients with delayed IRAEs, toxicities resolved or became asymptomatic. All but 2 cases of endocrinopathy required chronic hormone replacement therapy. 19 cases of treating through toxicity with maintenance low dose corticosteroid were identified. Of these, only one developed progressive disease with the remainder continuing to receive pembrolizumab.Table1510PTableIRAEsEarlyDelayedGeneral e.g. Fatigue172Rash/Pruritis2311Colitis1112Hypo/Hyperthyroidism73Hepatitis53Pneumonitis53Hypophysitis22Arthritis13Blepharitis/Conjunctivitis31Polymyalgia/Myositis21Nephritis01TOTAL76 (66%)40 (34%) ConclusionsDelayed onset IRAEs are common and exhibit a different profile of toxicities compared to early onset. They are no more severe than early IRAEs and can be effectively managed to allow patients to continue their treatment. Legal entity responsible for the studyNorth Middlesex University Hospital, Princess Alexandra Hospital, St. Bartholomew’s Hospital and University College London Hospital. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Adoption of a single-page best practice algorithm improves outcomes in patients with acute atrial fibrillation: a multi-disciplinary quality improvement project

Introduction: In response to a serious incident involving an atrial fibrillation (AF) associated stroke, a quality improvement project was established to examine and improve all aspects of patient care for individuals presenting with acute AF to London’s North Middlesex University Hospital (NMUH).Materials and Methods: The presenting complaint was examined for 2,105 consecutive medical admissions to identify 100 patients (4.7%) with acute AF. For each patient, 36 indices and performance indicators were collected and analysed against international standards. Deficiencies were identified in documentation, risk stratification, anticoagulation and arrhythmia management decisions. With cross-specialty collaboration, a single-page AF management algorithm was established using sequential PDSA methodology, and a further 100 consecutive patients with acute AF were analysed prospectively. A composite end-point of adverse outcomes (AF-associated readmission, stroke, cardiac death or major bleeding) was examined.Results: Algorithm implementation significantly reduced the proportion of patients exposed to unnecessary stroke risk (30% vs 4%, p<0.0001); improved identification and documentation of thromboembolic potential (50% vs 88%, p<0.0001), reduced incorrect drug decisions (12% vs 2%, p=0.01), reduced contraindicated rhythm control (8% vs 0%, p=0.007), and increased direct oral anticoagulant (DOAC) prescribing (38% vs 86%, p<0.0001) over warfarin. After a mean follow-up of 248 +/- 91 days, there was a significant reduction in composite adverse outcomes (22% vs 6%, p=0.0018).Conclusion: Using established quality improvement methodology and cost-neutral multi-disciplinary expertise, this novel management algorithm has significantly improved the quality and safety of care for patients with acute AF at NMUH.

Incorporating motivational interviewing into rheumatology care.

Deborah Palmer, Advanced Nurse Practitioner, North Middlesex University Hospital, and Yasser El Miedany, Consultant Rheumatologist, discuss ways to close the gap between disease control and patient empowerment.

Abstract 267: A Single-page Best Practice Algorithm Reduces Stroke Risk and Improves Arrhythmia Management Decisions in Patients With Acute Atrial Fibrillation: A Quality Improvement Project

Objectives: In response to a serious incident involving an atrial fibrillation (AF) associated stroke, a quality improvement project was established to examine and abrogate unnecessary thromboembolic risk in patients presenting with acute AF to London’s North Middlesex University Hospital (NMUH). Methods: The presenting complaint was examined for 2,105 consecutive medical admissions to identify 100 patients (4.7%) with acute AF. For each patient, 36 indices and performance indicators were collected and analysed against international standards and the collective best practice of the local Cardiology team. Deficiencies were identified throughout the inpatient experience, including documentation, risk stratification, anticoagulation and arrhythmia management decisions. With cross-specialty collaboration, a single-page AF management algorithm was subsequently established using sequential PDSA methodology, and following its introduction a further 100 consecutive patients with acute AF were analysed prospectively. Results: Algorithm implementation significantly reduced the proportion of patients exposed to unnecessary stroke risk (30% -&gt; 4%, p&lt;0.0001); improved identification and documentation of thromboembolic potential (50% -&gt; 88%, p&lt;0.0001), reduced incorrect drug decisions (12% -&gt; 2%, p=0.01), reduced contraindicated rhythm control (8% -&gt; 0%, p=0.007), and increased direct oral anticoagulant (DOAC) prescribing (38% -&gt; 86%, p&lt;0.0001) over warfarin. There was a trend towards reduced mean inpatient stay (4.7 -&gt; 3.5 days, p=0.11). Conclusions: Using established quality improvement methodology and cost-neutral multi-disciplinary expertise, this novel management algorithm has significantly improved the quality and safety of care for patients with acute AF at NMUH. Prospective analysis of long-term adverse outcomes is now required to establish morbidity or mortality benefit.

An audit into granulocyte-colony stimulating factor (G-CSF) primary prophylaxis for early breast cancer chemotherapy at the North Middlesex University Hospital (NMUH)

Background to the audit: The London cancer network guidelines for breast cancer recommend that for patients receiving adjuvant/neoadjuvant regimes such as FEC100-T or EC90-T, five days G-CSF primary prophylaxis D2-6 be given.1

Palliative radiotherapy for Merkel cell carcinoma: single-centre experience and review of the literature

AbstractBackground and purposeMerkel cell carcinoma is a rare and aggressive primary cutaneous neuroendocrine carcinoma with a high risk of loco-regional and distant metastasis. It is predominantly seen in the elderly, on the head and neck or extremities. Although treated primarily with surgery, some patients are too frail. A World Health Organization performance status of two or more with co-existing medical co-morbidities, or the site of the disease adjacent to a critical structure, can prevent surgical management. In this cohort of patients, primary palliative radiotherapy has been found to achieve excellent tumour regression and improve quality of life. A new palliative split-course hypofractionated regime has been used in North Middlesex University Hospital in this cohort of patients. The purpose of this case series was to provide supporting evidence on the efficacy of this dose and fractionation regime and review the literature for the palliative management of Merkel cell carcinoma.Materials and methodsIn total, four patients were treated with the palliative split-course hypofractionated regime. The regime consisted of an initial 20 Gray in 5 fractions over 1 week, a 2-week gap and then a further 20 Gray in 5 fractions over 1 week. Tolerability and response to treatment were evaluated by history and clinical examination.Results and conclusionThe split-course hypofractionated regime was well tolerated, achieved excellent tumour regression and improved quality of life in all four patients. Since then, a further three patients have been successfully treated with the above regime. This case series demonstrates the efficacy of this dose and fractionation in a select group of patients too frail for radical management and adds to the evidence base for the optimal palliative management of Merkel cell carcinoma.