North West London Research Articles

North West London New Model of Care Project (NMOC) – improving inpatient mental health care for children and young people

AimsSpecialised inpatient mental health services for children and young people are commissioned and managed by NHS England (NHSE) and provided by NHS as well as independent sector. The access to beds has been managed nationally with young people admitted far from home. There were capacity issues identified in London. To address these concerns, NHSE invited organisations to work in partnership to co-design and establish new models of care. This is one of the first of such projects, set up to manage the budget for children and young people's beds on behalf of NHSE and change the way of managing and monitoring admissions.Our aims:To reduce length of inpatient stayTo enable admission of young people as close to home as possibleTo improve resource efficiency, capacity and capability of managing young people in crisis in the community.MethodA number of changes were introduced, including engagement of community and inpatient clinical staff, repatriation to units closer to home and introduction of CRAFT meetings (early review meetings in inpatient units to enable timely and effective discharge planning and support back to local services). The implementation has been closely monitored by the project manager and clinical group, which included representatives from all organisations involved.ResultAfter four years, young people are admitted to hospitals closer to home and the length of inpatient stay has decreased by 18%. The number of admissions has decreased by 28%. Out of area occupied beds days have been decreased by 66%.Significant recurrent budget savings have been achieved. Over the past three years, these savings have been reinvested in developing crisis community support and more specialist community services within CNWL and West London Trust.ConclusionThere have been considerable benefits of multiple organisations working in partnership to improve patients care. The success of the project has created further opportunities for the development of services which provide safe and effective alternatives to admission (such as crisis services, home treatment teams and specialized community services). In summary, this collaborative model has improved the quality of care and experience for young people and reduced the need for psychiatric admission.

Improving patient waiting times and quality of care by arranging access to notes from a neighbouring trust

AimsWe aim to improve waiting times in the Emergency Department and improve the overall quality of care of out-of-area patients by arranging for the liaison team to have access to the electronic notes system of a neighbouring trust.MethodSt Thomas’ Hospital is located in south London, right opposite the City of Westminster. As a result, approximately 20% of patients we see in mental health liaison are from that locality. Given that they belong to a different trust, we do not have access to their notes, which leads to a delay in trying to establish whether they are known to local mental health services. Often, staff are reluctant to divulge information. When information is shared, it is often late and/or incomplete. We approached the Chief Clinical Information Officer and Head of Information Governance from Central and North West London (CNWL) NHS Foundation Trust. We held weekly meetings which included both IT departments. Our IT had to install the electronic notes application (SystmOne) on our computers and open relevant firewall ports. The information is access through an NHS Smartcard, therefore CNWL had to authorise read-only Smartcard profiles for every member of the liaison team. A quick reference guide was created for all staff that would be using the new application. The system went live on 21 January 2021.ResultWe audited patient outcomes in December 2020 and February 2021 for initial comparison. In December 2020, the median time from referral to discharge was 6 hours 35 minutes. 25% of patients were admitted and 17% discharged with HTT. In February 2021, the median time from referral to discharge was 3 hours 19 minutes. 16% of patients were admitted and 5% discharged with HTT.ConclusionIt is likely that by reducing the time required for collateral information, overall waiting times in the emergency department will be reduced. Clinicians are likely to feel more confident in their discharge planning if they have access to all clinical notes and previous risk assessments, which might in turn reduce referrals to HTT or admission. There should be further attempts by neighbouring NHS trusts, especially in London, to ensure access to their electronic notes system in order to reduce waiting times and improve the quality of patient care. We have already been approached for more information by a trust in North London who are interested in establishing access to a neighbouring trust's notes.

GMC training survey and missing trainees in psychiatry

AimsTo investigate the extent of misattributed responses in the General Medical Council (GMC) National Training Surveys (NTS).BackgroundAs part of its role in quality assurance of medical training, the GMC conducts an annual survey of trainers and trainees. Benchmarking of trusts’ performance is indicated by red flags denoting outlying poor performance. The validity of this depends on the correct attribution of responses to trusts. We have previously found that responses for Foundation Year One (FY1) trainees undertaking psychiatry placements were misattributed to trainees’ affiliated acute trusts (AT), even though the mental health trusts (MHT) were providing the training placements.MethodData from the online reporting tool were used to calculate the numbers of FY1, Foundation Year Two (FY2), and General Practice Speciality trainees (GPST) on psychiatry placements attributed to ATs and MHTs in 2019. A range is provided for the data, as results for trusts with one or two trainees are not reported. The data were analysed by training level and the 13 Health Education England (HEE) regions to give a proportion of trainees missing from the MHT data (% missing), an indication of response misattribution.Result296-302 FY1s were attributed to MHTs and 114-148 to ATs, giving a % missing of 27.4-33.3%. 261-275 FY2s were attributed to MHTs and 89-125 to ATs, giving a % missing of 24.4-30.0%. 507-511 GPSTs were attributed to MHTs and 49-73 to ATs, giving a % missing of 8.8-12.6%.Across the three training levels, all HEE regions were affected by data misattribution. The regions most affected were South London, Kent Surrey Sussex, and North West London, with missing % of 51.6-54.3%, 33.9-40.7% and 29.9-32.5% respectively. The HEE regions least affected were East Midlands, North Central and East London, and East of England, with missing % of 4.3-6.0%, 5.6-8.1% and 5.5-10.4% respectively.ConclusionResponse misattribution for psychiatry placements in the NTS is rife, with the greatest impact on FY1s. While this issue affects all HEE regions, wide variation exists. Response misattribution means that the calculation of outliers is based on incomplete data, threatening the validity of the results. By liaising with our local HEE office to ensure correct attribution of our trainees, Surrey and Borders Partnership NHS Foundation Trust reduced our % missing from 50.0-56.8% in 2018 to 5.4-10.1% in 2019, thus proving that it is possible to remedy the situation on a local level.

881-P: Improving Diabetes Inpatient Safety by Implementing a Concise Diabetes Training Programme for All Staff

Improving safety by training frontline staff The National Diabetes Inpatient Audit (NaDIA) makes grim reading with errors, harm, increased stay and mortality. Complex diabetes care is often delivered by staff with little diabetes training. The Diabetes 10 Point Training which was developed around common errors, is concise and relevant taking 30-60 minutes. Training empowers staff to deliver safe care by knowing when and how to escalate concerns. Training takes place in the clinical area with content adapted to unique departmental challenges. Delivered via digital platforms since March 2020, training will soon be available via e-learning. In 2015 640 staff in Poole Hospital were trained. NaDIA data saw the hospital move from the highest to the lowest quartile for insulin errors. In North West London in 2018 3000 staff received training. NaDIA results for a major inner London Hospital indicated significant improvements. Medication errors from 38.3% to 7.3% Prescription errors from 16.0% to 2.7% Glucose management errors from 24.7% to 5.3% Insulin errors from 24.7% to 4.7% Severe hypoglycaemia from 10.4% to 4.2% The Diabetes 10 Point Training programme is translatable across healthcare systems because it focuses on issues which are universally applicable. With ability to reach staff at scale. Disclosure R. L. Miller: None.

From the public sector to the gig economy

From the public sector to the gig economy

Improving training and support by improving our out of hours handover, Central and North West London NHS Foundation Trust

AimsDuring out of hour handovers at St Charles Hospital – the two duty SHO (senior house officers) cover on site, whereas the on-call registrar and consultant are available to contact by phone. Some trainees may experience difficulties in contacting their seniors for support, or may not feel comfortable doing so. Trainees may also feel like they would benefit from being more informed of the hospital situation, or added learning and educational opportunities from the shift. The aim of this project was to improve the out of hours support for the on-call SHOs – which we hope to have positive short (such as improving confidence and performance) - and longer-term impacts (improving retention in the deanery and specialty).MethodThe project proposed instating a 15-minute Zoom call at the start of each night shift (9:30pm) which involved the on-call team (SHOs, registrar, consultants and ideally bed managers). Firstly – a survey monkey questionnaire was sent to trainees to gain a baseline on how supported/informed/ease and learning opportunities for that shift. The project then piloted three separate Plan Do Study Act cycles of change and collected feedback from trainees after each cycle. Both qualitative feedback and quantitative feedback from trainees were collected in the Likert scale format after each PDSA cycle.ResultResults showed that a key benefit of this call is that any pressing issues can be brought up and addressed. Furthermore, for the benefit of the trainees, generally trainees felt more supported whilst they are on call, and got to know the fellow on call team. In addition, trainees reported feeling more at ease when calling their senior colleagues.ConclusionIt is particularly important for doctors to feel supported and informed during their on call shift, especially in the current climate, where there are fast changes and adaptations taking place due to the pandemic. By adding a short meeting at the beginning of each night shift, doctors in the hospital demonstrated an increase in feeling supported, informed and having educational opportunities during their on call shifts. In the long term, by addressing on call issues and making trainees feel more confident and supported during their shift, is likely to benefit and improve recruitment and retention.

Evaluation of an attention deficit hyperactivity disorder (ADHD) assessment & treatment service

AimsThe Central and North West London NHS Foundation Trust ADHD clinic offers diagnosis and medication stabilisation for adults with ADHD, in preparation for discharge back to GP for continued prescribing and monitoring. Referral waiting time is shortened by efficiently managing the service and soon transfer of care to GP whilst referrals have been increasingly accepted years on years. A snap shot service evaluation was made to understand characteristics of service exploring its strength and areas to improve.MethodAll 115 patients offered in March and April 2019 for an ADHD specialist assessment were sampled from the new electronic patient record SystmOne in use since 1st March 2019.Data were collected forMale & Female ratioAge range distributionClinical Commissioning Group referral sourceClinic attendance characteristicsADHD diagnosis, sub-types and psychiatric comorbidityADHD Medication prescribedFP10 Prescription duration by prescribersPatient data were anonymously encoded into Microsoft Excel Sheet for sorting, counting, summating and illustrating into tables and pie charts.ResultThe male & female ratio of the sample was 6:5 and nearly half were in age range 20-29 years. Majority were referred from Westminster and West London Clinical Commissioning Groups.107 patients completed the assessment, of which 106 were diagnosed as having an adult ADHD.22% of follow-up clinics were cancelled or not attended (DNA) by patients. The majority of the patients (62%) required 1-2 follow-ups before transfer to GP, whilst 8% did not require or want follow-ups either already being on ADHD medication, not wanting medication or having lost to reviews. Only 3% require six or more follow-ups.Majority were reviewed after two- to five-week prescription, the peak being four-weekly.91% of completion to GP were discharged on ADHD medication, majority being singly on Elvanse (48%) and Concerta XL (25%). Discharge without ADHD medication was due to concerns for its addiction, preference on non-medication treatment, intolerance of medication adverse effect or mental health priority treatment.ConclusionCollaboration with GPs for their pre-treatment physical health screening facilitated prompt prescribing initiation on assessment with most discharges taken place after 1-2 follow-ups, enabling service turn-over with short waiting time (6-9 months in 2018/2019). Service expansion for increasing referral uptake is probably feasible from this baseline by appointing additional sessional clinicians and further efficiency management on clinic scheduling & DNA with a target majority likely requiring 1-2 follow-ups with average four-weekly prescribing.

Identification of palliative care needs among people with dementia and its association with acute hospital care and community service use at the end-of-life: A retrospective cohort study using linked primary, community and secondary care data

Background: Hospital admissions among people dying with dementia are common. It is not known whether identification of palliative care needs could help prevent unnecessary admissions. Aim: To examine the proportion of people with dementia identified as having palliative care needs in their last year of life, and the association between identification of needs and primary, community and hospital services in the last 90 days. Design: Retrospective cohort study using Discover, an administrative and clinical dataset from 365 primary care practices in London with deterministic individual-level data linkage to community and hospital records. Setting/participants: People diagnosed with dementia and registered with a general practitioner in North West London (UK) who died between 2016 and 2019. The primary outcome was multiple non-elective hospital admissions in the last 90 days of life. Secondary outcomes included contacts with primary and community care providers. We examined the association between identification of palliative care needs with outcomes. Results: Among 5804 decedents with dementia, 1953 (33.6%) were identified as having palliative care needs, including 1141 (19.7%) identified before the last 90 days of life. Identification of palliative care needs before the last 90 days was associated with a lower risk of multiple hospital admissions (Relative Risk 0.70, 95% CI 0.58–0.85) and more contacts with the primary care practice, community nurses and palliative care teams in the last 90 days. Conclusions: Further investigation of the mechanisms underlying the association between identification of palliative care needs and reduced hospital admissions could help reduce reliance on acute care for this population.

Predicting Risk of Hospital Admission in Patients With Suspected COVID-19 in a Community Setting: Protocol for Development and Validation of a Multivariate Risk Prediction Tool.

BackgroundDuring the pandemic, remote consultations have become the norm for assessing patients with signs and symptoms of COVID-19 to decrease the risk of transmission. This has intensified the clinical uncertainty already experienced by primary care clinicians when assessing patients with suspected COVID-19 and has prompted the use of risk prediction scores, such as the National Early Warning Score (NEWS2), to assess severity and guide treatment. However, the risk prediction tools available have not been validated in a community setting and are not designed to capture the idiosyncrasies of COVID-19 infection.ObjectiveThe objective of this study is to produce a multivariate risk prediction tool, RECAP-V1 (Remote COVID-19 Assessment in Primary Care), to support primary care clinicians in the identification of those patients with COVID-19 that are at higher risk of deterioration and facilitate the early escalation of their treatment with the aim of improving patient outcomes.MethodsThe study follows a prospective cohort observational design, whereby patients presenting in primary care with signs and symptoms suggestive of COVID-19 will be followed and their data linked to hospital outcomes (hospital admission and death). Data collection will be carried out by primary care clinicians in four arms: North West London Clinical Commissioning Groups (NWL CCGs), Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), Covid Clinical Assessment Service (CCAS), and South East London CCGs (Doctaly platform). The study involves the use of an electronic template that incorporates a list of items (known as RECAP-V0) thought to be associated with disease outcome according to previous qualitative work. Data collected will be linked to patient outcomes in highly secure environments. We will then use multivariate logistic regression analyses for model development and validation.ResultsRecruitment of participants started in October 2020. Initially, only the NWL CCGs and RCGP RSC arms were active. As of March 24, 2021, we have recruited a combined sample of 3827 participants in these two arms. CCAS and Doctaly joined the study in February 2021, with CCAS starting the recruitment process on March 15, 2021. The first part of the analysis (RECAP-V1 model development) is planned to start in April 2021 using the first half of the NWL CCGs and RCGP RSC combined data set. Posteriorly, the model will be validated with the rest of the NWL CCGs and RCGP RSC data as well as the CCAS and Doctaly data sets. The study was approved by the Research Ethics Committee on May 27, 2020 (Integrated Research Application System number: 283024, Research Ethics Committee reference number: 20/NW/0266) and badged as National Institute of Health Research Urgent Public Health Study on October 14, 2020.ConclusionsWe believe the validated RECAP-V1 early warning score will be a valuable tool for the assessment of severity in patients with suspected COVID-19 in the community, either in face-to-face or remote consultations, and will facilitate the timely escalation of treatment with the potential to improve patient outcomes.Trial RegistrationISRCTN registry ISRCTN13953727; https://www.isrctn.com/ISRCTN13953727International Registered Report Identifier (IRRID)DERR1-10.2196/29072

A remotely-delivered community action project to promote a diabetes lifestyle intervention programme in northwest London: basis, process and outcomes.

Background : The prevalence of type 2 diabetes mellitus (T2DM) in London is rising, obesity being a major driver. As part of a primary care placement, the authors (two medical students and a lead general practitioner) directly promoted the Reducing Weight with Intensive Dietary Support (REWIND) programme to patients in Northwest London and collected feedback on the promotion. Methods : The team developed and delivered three remote interventions: a redesigned patient-facing information leaflet, phone calls and text messages, and a live, interactive webinar, to directly engage patients and raise awareness about REWIND. Feedback was collected pre and post-webinar using an anonymised, online survey (essentially functioning as a ‘teaching’ evaluation). Results : Mean interest in REWIND had increased from 2.7 (pre-promotion) to 4.7 (post-promotion), knowledge about REWIND had increased from 2.1 to 4, and self-reported likelihood of enrolling had increased from 2.6 to 4.2 (P<0.01 in all cases). The reported usefulness of the leaflet and webinar was scored 3.7 and 4.4 respectively. Within two weeks of the webinar, two of these patients had joined REWIND. Conclusion : Feedback from the patients and GP revealed that the project successfully raised awareness, improved knowledge, and increased the likelihood of enrolment in REWIND. Diabetes programmes and organisations are encouraged to adapt the methods of this project to their own contexts, especially in light of COVID-19 where remote interventions will remain essential.

Factors Influencing Response to Aflibercept in Diabetic Macular Oedema Patients in a Diverse North West London Population: A Real-World Study.

BackgroundDiabetic macular oedema (DMO) is the leading cause of sight impairment in working age populations in developed countries. Current first line treatment for centre-involving DMO involves intravitreal anti-VEGF but treatment response can be variable. In this retrospective, real world, multi-centre cohort study, we aim to identify ocular and systemic characteristics that correlate with anatomical and functional outcomes for treatment-naive DMO patients treated with intravitreal aflibercept.MethodsRetrospective multicentre cohort study of treatment-naive DMO patients initiated on aflibercept at three North West London hospitals between 2016 and 2018. Baseline systemic and ocular factors, best corrected visual acuity (BCVA) and central macular thickness (CMT) at 12 months were determined and statistically analysed.ResultsA total of 270 eyes of 221 DMO patients met inclusion criteria. Mean age was 62.8 ± 12.1, mean baseline HbA1c was 67 ± 20 mmol/mol, and mean eGFR was 72 mL/min/1.7m2. Mean number of aflibercept injections at 12 months was 6.2. Better baseline BCVA, lower baseline CMT, and absence of epiretinal membrane (ERM) were associated with better BCVA at 12 months whilst lower baseline CMT and proliferative retinopathy status were associated with lower CMT at 12 months.ConclusionOur study is the largest real-world dataset examining factors influencing functional and anatomical response to aflibercept in DMO in the UK. Older age, lower baseline BCVA, higher baseline CMT and more severe diabetic retinopathy were associated with poorer visual acuity at 12 months and prioritisation of these patients within a pressured healthcare setting is recommended.

P089 The cost of repeat ANA testing in north west London pathology services

Abstract Background/Aims The anti-nuclear antibody (ANA) test is commonly used to screen for autoimmune connective tissue (CTD) disease. It is a test that should be used judiciously and should only be requested if a patient presents with symptoms suggestive of a CTD and should not be used as a screening test for vague musculoskeletal symptoms. Recent studies have demonstrated that it is often repetitively requested in those patients both with a known positive and known negative ANA with little value in altering a diagnosis. With this information in mind, we sought to examine the frequency and associated cost of repeat ANA testing in hospital trusts served by North West London Pathology Services (NWL). Methods The trusts included in the study were Imperial College Healthcare NHS Trust, Chelsea and Westminster Hospital Foundation Trust and Hillingdon Hospitals NHS Foundation Trust. Data was obtained regarding how many patients had repeat ANA testing in total between these trusts between 2017-2019. The data was obtained via a freedom of information request. Results In total, there were 6,799 instances of repeated ANA testing in the same patient across three trusts over three years. This included one patient who had 16 ANA tests in a single year in 2017. The cost of an ANA test is £12.27. The total cost of repeat ANA testing in the three years across three trusts was £83,423.73 (£27,807.66 per year on average). Data is provided in tabular form and gives a breakdown of the number of repeat ANA tests per year and how many times the test was repeated in the same patient. Conclusion The requesting of unnecessary tests can add to a hospital pathology workload and is associated with significant cost. It has been previously demonstrated in the literature that repeat ANA testing is of little value and rarely alters the diagnosis of a rheumatic disease. There is a large burden of repeated ANA testing in North West London Pathology Services and this is associated with significant expense. More judicious use of ANA testing can result in significant cost saving. This is the first study to specifically examine the cost of repeat ANA testing in the NHS. Disclosure M. Colquhoun: Other; MC has received support to attend conferences from Pfizer. M. Mouyis: None.

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

ObjectivesThe study aims to investigate GPs’ experiences of how UK COVID-19 policies have affected the management and safety of complex elderly patients, who suffer from multimorbidity, at the primary care level in North West London (NWL).DesignThis is a service evaluation adopting a qualitative approach.SettingIndividual semi-structured interviews were conducted between 6 and 22 May 2020, 2 months after the introduction of the UK COVID-19 Action Plan, allowing GPs to adapt to the new changes and reflect on their impact.ParticipantsFourteen GPs working in NWL were interviewed, until data saturation was reached.Outcome measuresThe impact of COVID-19 policies on the management and safety of complex elderly patients in primary care from the GPs’ perspective.ResultsParticipants’ average experience was fourteen years working in primary care for the NHS. They stated that COVID-19 policies have affected primary care at three levels, patients’ behaviour, work conditions, and clinical practice. GPs reflected on the impact through five major themes; four of which have been adapted from the Safety Attitudes Questionnaire (SAQ) framework, changes in primary care (at the three levels mentioned above), involvement of GPs in policy making, communication and coordination (with patients and in between medical teams), stressors and worries; in addition to a fifth theme to conclude the GPs’ suggestions for improvement (either proposed mitigation strategies, or existing actions that showed relative success). A participant used an expression of “infodemic” to describe the GPs’ everyday pressure of receiving new policy updates with their subsequent changes in practice.ConclusionThe COVID-19 pandemic has affected all levels of the health system in the UK, particularly primary care. Based on the GPs’ perspective in NWL, changes to practice have offered opportunities to maintain safe healthcare as well as possible drawbacks that should be of concern.

161 Does the Weather Contribute to Admissions of Neck of Femur Fractures?

Abstract Introduction The effects of weather on overall mortality are well documented. Anecdotally, icy conditions are perceived to result in more falls and admissions for neck of femur (NOF) fractures. The aim of this unfunded pilot study was to determine whether relationships could be extracted or at least not ruled out by analysing a small dataset, and so give impetus to a larger project. Methods Seven trauma units across north west London were identified and NOF fracture data extracted for five years. Visual inspection of the time series, consideration of the weather on specific days and correlation analysis were used to assess causal links between fracture numbers and a variety of weather parameters (temperature, rainfall, wind and ice risk). Results Overall, 10,929 individuals with hip fractures were admitted over the five-year period. The highest number of admissions in a day was 14. No clear association was found between a weather parameter and daily admissions. However, when accumulated to a weekly timescale, a negative relationship with maximum temperature was found. No seasonal cycle was detected. Conclusion The lack of a daily relationship and presence of a weekly relationship points to a possible delayed response to weather or insufficient daily data to extract a signal. The inconclusive results also indicate that more socioeconomic data will need to be used in future studies, requiring a larger data sample. In addition, even in cold weather an urban environment may not create icy conditions, being ameliorated by the heat island effect and gritting.

Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England

BackgroundTo date, research exploring the public’s awareness of bowel cancer has taken place with predominantly white populations. To enhance our understanding of how bowel cancer awareness varies between ethnic groups, and inform the development of targeted interventions, we conducted a questionnaire study across three ethnically diverse regions in Greater London, England.MethodsData were collected using an adapted version of the bowel cancer awareness measure. Eligible adults were individuals, aged 60+ years, who were eligible for screening. Participants were recruited and surveyed, verbally, by staff working at 40 community pharmacies in Northwest London, the Harrow Somali association, and St. Mark’s Bowel Cancer Screening Centre. Associations between risk factor, symptom and screening awareness scores and ethnicity were assessed using multivariate regression.Results1013 adults, aged 60+ years, completed the questionnaire; half were of a Black, Asian or Minority ethnic group background (n = 507; 50.0%). Participants recognised a mean average of 4.27 of 9 symptoms and 3.99 of 10 risk factors. Symptom awareness was significantly lower among all ethnic minority groups (all p’s < 0.05), while risk factor awareness was lower for Afro-Caribbean and Somali adults, specifically (both p’s < 0.05). One in three adults (n = 722; 29.7%) did not know there is a Bowel Cancer Screening Programme. Bowel screening awareness was particularly low among Afro-Caribbean and Somali adults (both p’s < 0.05).ConclusionAwareness of bowel cancer symptoms, risk factors and screening varies by ethnicity. Interventions should be targeted towards specific groups for whom awareness of screening and risk factors is low.

‘Do I, don’t I?’ A qualitative study addressing parental perceptions about seeking healthcare during the COVID-19 pandemic

BackgroundPaediatric emergency departments have seen reduced attendance during the COVID-19 pandemic. Late paediatric presentations may lead to severe illness and even death. Maintaining provision of healthcare through a pandemic is...

Association of Other Autoimmune Diseases With Thyroid Eye Disease.

BackgroundThyroid eye disease (TED) is a potentially disfiguring and sight-threatening autoimmune (AI) orbitopathy, affecting up to 400,000 people in the UK. There are no accurate early predictors of TED severity. Although polyautoimmunity has been shown to affect AI disease severity, its influence on TED severity has never been investigated. The prevalence of polyautoimmunity among TED patients is also unclear, with discordant results reported in the literature. This study evaluates the prevalence of non-thyroid/“other” AI (OAI) conditions in an ethnically diverse TED cohort and assesses how polyautoimmunity affects TED severity and activity.MethodsA retrospective study of patients presenting to multidisciplinary TED clinics across three North-West London hospitals between 2011 and 2019. Data collected included: 1) demographics; 2) OAI conditions and management; 3) endocrine management of thyroid dysfunction; 4) details of TED and clinical activity score at presentation.ResultsTwo hundred and sixty-seven patients with a median age of 46 (35–54) years were included, 79.4% were female and 55% were Black, Asian and minority ethnic (BAME). Thirty-seven patients (13.9%) had OAI conditions, with rheumatoid arthritis (3.7%), vitiligo (3.0%) and psoriasis (3.0%) among the most prevalent. Of patients with OAI conditions, 43.2% (16/37) required immunosuppression prior to TED onset. Non-immunosuppressed patients with OAI conditions had a significantly higher clinical activity score at presentation than TED-only and previously immunosuppressed patients (p=0.02). No significant differences were observed in thyroid receptor antibody titers between these groups.ConclusionsThis study finds a 13.9% prevalence of OAI conditions among TED patients. Patients with OAI conditions overall have a tendency for more severe and significantly more clinically active TED than those without OAI conditions. Larger, prospective studies are warranted to further evaluate polyautoimmunity as an early predictor of TED severity.

Development of a north-west London paracentesis simulation course for core medical trainees

We designed, implemented and evaluated a near-peer simulation training programme teaching diagnostic and therapeutic abdominal paracentesis to core medical trainees (CMTs). We taught diagnostic and therapeutic abdominal paracentesis to 77 north-west London CMTs over 8 training days over 4 years, 2015 to 2019. The programme was optimised by use of plan, do, study, act (PDSA) cycles and the content was evaluated by anonymous pre- and post-course questionnaires. There was a need for this training; 89% of participants reported inadequate training opportunities pre-course and only 28% felt 'confident' or 'very confident' to insert an ascitic drain. Simulation training appears effective when teaching these skills. Having been low in confidence before the course, all participants reported increased confidence after completing the course. Simulation training has been highlighted as a key aspect of the new internal medicine training programme, which replaces CMT. We would recommend using PDSA cycles to implement effective simulation programmes.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PurposeThe aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time.MethodsA study period of twelve weeks following the introduction of the nationwide “lockdown period”, March 23rd – June 14th, 2020 was identified and compared to the same time period in 2019 as a “baseline period”. A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the ‘eTrauma’ management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis.ResultsThe total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001).ConclusionIn conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves

ObjectivesWe investigated the impact of COVID-19 and national pandemic response on primary care antibiotic prescribing in London. MethodsIndividual prescribing records between 2015 and 2020 for 2 million residents in north west London were analysed. Prescribing records were linked to SARS-CoV-2 test results. Prescribing volumes, in total, and stratified by patient characteristics, antibiotic class and AWaRe classification, were investigated. Interrupted time series analysis was performed to detect measurable change in the trend of prescribing volume since the national lockdown in March 2020, immediately before the first COVID-19 peak in London. ResultsRecords covering 366 059 patients, 730 001 antibiotic items and 848 201 SARS-CoV-2 tests between January and November 2020 were analysed. Before March 2020, there was a background downward trend (decreasing by 584 items/month) in primary care antibiotic prescribing. This reduction rate accelerated to 3504 items/month from March 2020. This rate of decrease was sustained beyond the initial peak, continuing into winter and the second peak. Despite an overall reduction in prescribing volume, co-amoxiclav, a broad-spectrum “Access” antibiotic, prescribing rose by 70.1% in patients aged 50 and older from February to April. Commonly prescribed antibiotics within 14 days of a positive SARS-CoV-2 test were amoxicillin (863/2474, 34.9%) and doxycycline (678/2474, 27.4%). This aligned with national guidelines on management of community pneumonia of unclear cause. The proportion of “Watch” antibiotics used decreased during the peak in COVID-19. DiscussionA sustained reduction in community antibiotic prescribing has been observed since the first lockdown. Investigation of community-onset infectious diseases and potential unintended consequences of reduced prescribing is urgently needed.