Queen Elizabeth University Hospital Research Articles

Views of emergency care providers in providing healthcare for asylum seekers and refugees

BackgroundThe number of asylum seekers awaiting decisions on their claims in the UK has more than tripled since 2014. How we meet international obligations to provide appropriate healthcare to asylum...

Machine Learning in Clinical Diagnosis of Head and NeckCancer.

Machine learning has been effective in other areas of medicine, this study aims to investigate this with regards to HNC and identify which algorithm works best to classify malignant patients. An observational cohort study. Queen Elizabeth University Hospital. Patients who were referred via the USOC pathway between January 2019 and May 2021. Predicting the diagnosis of patients from three categories, benign, potential malignant and malignant, using demographics and symptoms data. The classic statistical method of ordinal logistic regression worked best on the data, achieving an AUC of 0.6697 and balanced accuracy of 0.641. The demographic features describing recreational drug use history and living situation were the most important variables alongside the red flag symptom of a neck lump. Further studies should aim to collect larger samples of malignant and pre-malignant patients to improve the class imbalance and increase the performance of the machine learning models.

Improving the 'Golden Patient' Initiative at a British Major Trauma Centre: A Single-Centre Study.

Introduction Delays in theatre start times are expensive and associated with poor outcomes. To reduce these delays, a Golden Patient (GP) protocol was used at one of Britain's major trauma centres, the Queen Elizabeth University Hospital, Glasgow. We sought to clarify how often Golden Patients (GPs) were stepped down from being first on the day's trauma list and to identify significant contributing factors. Methods We collected data over an eight-week period, with 80 GPs collated in total. If stepped down, we recorded their age, gender, injury, location, and day of planned surgery. Univariate analyses were then performed to test for statistical significance. We also followed stepped-down patients, noting how long until they received their operation. Results The incidence of GPs stepped down from being first on the list was 11.25%. This did not vary with age, gender, or type of injury, but was significantly associated with patients being at home the night before their planned operation (p=0.0114) and cases occurring on Fridays (p=0.0139). Of those stepped-down GPs who remained for operative management, all received their operation within one day. Conclusion This study, the first of its kind since the COVID-19 pandemic, shows low rates of GP step down, comparable to previous audits of GP initiatives in similar centres. When delays did occur, GPs received timely operative management once underlying issues were resolved. This study suggests that planned GPs should be admitted the night before their operation. Whilst the GP system serves trauma patients well, we identified areas for improvement in the efficiency of our own service applicable to other busy major trauma centres.

470 Survival Stratification After Proximal Femoral Fracture Surgery Using the Modified Glasgow Prognostic Score

Abstract Aim Proximal femoral fracture (PFF) after blunt trauma is common and significantly associated with mortality. A simple scoring system based on systemic inflammation, the modified Glasgow Prognostic Score (mGPS), has been shown to stratify survival in patients with malignant disease and we wished to assess its usefulness in the trauma cohort. Method Patient demographics, albumin, C-reactive protein (CRP), and survival data were retrospectively obtained from a previous local hip fracture audit of 278 adult (>18 years) patients whose PFFs were repaired between October 2012 and April 2014 at the Queen Elizabeth University Hospital, Glasgow. Follow-up was for 18 months allowing the generation of survival curves and univariate analysis using Kaplan-Meier and Log Rank analyses. Multivariate survival analysis and hazard ratios were calculated using Cox Regression. Results The median survival was 26.5 months with a 41.4% 1-year mortality. On univariate analysis, one year mortality was associated with advanced age (>80 years, p<0.0001), American Society of Anaesthesiology (ASA) score(p<0.0001), CRP (>10mg/L, p=0.027), Albumin (<35g/L, p=0.007), type of surgery (p=0.005) and mGPS (p=0.016). On multivariate analysis advanced age (p<0.001), male gender (p=0.016), ASA score (p<0.001) and mGPS (p=0.027) retained significance as predictive factors for 1-year mortality. A higher mGPS was associated with a shorter median survival (37.4, 27.6 and 24.0 months for mGPS 0, 1 and 2 respectively (p=0.048)). Conclusions This study demonstrated a statistically significant survival association with advanced age, ASA score, male gender and mGPS. This is the first study looking at mGPS as a predictive factor for one year mortality following PFF.

Synergistic working: dental core trainees and foundation doctors in OMFS

We describe our experience of multidisciplinary teamworking in the oral and maxillofacial surgery (OMFS) department at the Queen Elizabeth University Hospital in Glasgow, which has a unique setup including both foundation doctors and dental core trainees (DCTs). Very few other units in the UK utilise DCTs and foundation doctors working together at a junior level in OMFS. This article explores the advantages and disadvantages of this interdisciplinary approach, and why we believe that other departments should also adopt this strategy

OPTIMA-BP: empOwering PaTients in MAnaging Blood Pressure – protocol for a randomised parallel group study comparing use of Kvatchii web-based patient education portal as an addition to home blood pressure monitoring

IntroductionHypertension is the leading modifiable risk factor for cardiovascular disease and is implicated in half of all strokes and myocardial infarctions. One-third of the adults in Scotland have hypertension yet...

The West of Scotland Cohort of Mitochondrial Individuals with the m.3243A>G Variant: Variations in Phenotypes and Predictors of Disease Severity.

The m.3243A>G variant is the commonest mitochondrial (mt) DNA pathogenic variant and a frequent cause of mitochondrial disease. Individuals present with a variety of clinical manifestations from diabetes to neurological events resembling strokes. Due to this, patients are commonly cared for by a multidisciplinary team. This project aimed to identify patients with confirmed mt.3243A>G-related mitochondrial disease attending the Muscle Clinic at Queen Elizabeth University Hospital in Glasgow. We explored potential correlates between clinical phenotypes and mtDNA heteroplasmy levels, HbA1c levels, body mass index, and specific clinical manifestations. We investigated if there were discrepancies between non-neurological speciality labelling in clinical records and individuals' phenotypes. Data were gathered from the West of Scotland electronic records. Phenotypes were ascertained by a clinician with expertise in mitochondrial disorders. Statistical analyses were applied to study relationships between tissue heteroplasmy, HbA1c and clinical phenotypes including body mass index (BMI). Forty-six individuals were identified from 31 unrelated pedigrees. Maternally inherited diabetes and deafness was the prominent syndromic phenotype (48%). A significant association was found between overall number of symptoms and bowel dysmotility (p < 0.01). HbA1c was investigated as a predictor of severity with potential association seen. Although used widely as a prognosticator, neither corrected blood nor urine mtDNA heteroplasmy levels were associated with increased number of symptoms. In 74.1% of records, syndromic phenotypes were incorrectly used by non-neurological specialities. This m.3243 A > G patient cohort present with marked clinical heterogeneity. Urine and blood heteroplasmy levels are not reliable predictors of disease severity. HbA1c may be a novel predictor of disease severity with further research required to investigate this association. We infer that prognosis may be worse in patients with low BMIs and in those with bowel dysmotility. These results underscore a multidisciplinary approach and highlight a problem with inaccurate use of the existing nomenclature.

P57 A review of change of Remifentanil PCA protocol at Queen Elizabeth University Hospital Maternity Unit

P57 A review of change of Remifentanil PCA protocol at Queen Elizabeth University Hospital Maternity Unit

P116 A review of the use of cell salvage in Queen Elizabeth University Hospital Maternity Unit, Glasgow

P116 A review of the use of cell salvage in Queen Elizabeth University Hospital Maternity Unit, Glasgow

‘SHOULD WE SEND THE HEAD?’ INCIDENCE OF PATHOLOGICAL NECK OF FEMUR FRACTURES: A ONE-YEAR RETROSPECTIVE OVERVIEW

Neck of femur fracture (NOF#) is the commonest reason for admission to an orthopaedic ward with 70-75,000 cases each year in the UK1. The femoral head is often sent to pathology if there is clinical suspicion of a malignant cause. There is limited evidence in the literature to support the efficacy of this2. The purpose of this project was to study the incidence of femoral head pathology analysis in NOF # patients with a background of malignancy and evaluate the impact this investigation has on guiding future management.Retrospective analysis of all neck of femur fractures admitted to the Queen Elizabeth University Hospital between 01/01/2021 and 31/12/2021. The electronic notes were accessed and for patients with past medical history of malignancy, it was confirmed whether femoral head or bone reamings were sent to pathology, resultant findings and the impact on subsequent management.In 2021, 784 patients were admitted to the QEUH with a NOF#. Of these, 770 (98.2%) underwent operative management, 138 (17.3%) of whom had a past medical history (PMH) of malignancy. Intra-operative pathology was sent from 19 (13.7%) of these 138 patients. No malignant cells were found in 13 (69%) samples, and in 6 (31%), the known active malignancy was confirmed. In all cases where samples were sent for pathology, none caused any change in management.In this retrospective study, pathological investigations in NOF# patients with a PMH of malignancy had no impact on further management. The authors would not advocate for sending pathology results in this cohort group.

NECK OF FEMUR FRACTURES AND THE INCIDENCE OF METASTASIS ON LONG LEG FEMUR VIEWS

Neck of femur fractures are a common trauma presentation and patients with a history of malignancy are sent for long leg femur views (LLF), to exclude a distal lesion which would alter the management plan (Intra-medullary nail/Long stem Hemiarthroplasty). The aim of this is to identify incidence of malignancy on LLF views, the length of time in between each xray (XR) and to identify demographics.Data was retrospectively collected from 01/01/2021 to 31/01/2021 from a single centre. All patients admitted to the Queen Elizabeth University Hospital had their electronic records (Bluespier, PACS, Clinical Portal) accessed. These confirmed if patients had a past medical history of malignancy, if they had LLF view and the time differences between diagnostic pelvis XR and LLF XR.A total of 784 patients were identified in the specified time period. Of these, 138 were identified with a malignancy and there were 85 LLF views completed. LLF views diagnosed 1 patient with known prostate cancer that had a new distal femoral metastasis (Incidence = 1.28 cases per 1000). This patient underwent further imaging (MRI Femur) and received a long stem hip hemiarthroplasty. The average length of wait between the images was 9 hours 27 minutes.LLF views can alter management of patients with malignancy and are therefore useful to perform. There can be a long delay between each image. Therefore we recommend imaging tumour with common bony metastasis (Renal, Thyroid, Breast, Prostrate, Lung) and other remaining tumours with known secondary metastasis. Imaging primary low risk (eg basal cell carcinoma) can lead to long delays in a frail patient cohort and consideration should be given to rationalise appropriate use of resources.

The impact of inconsistent human annotations on AI driven clinical decision making

In supervised learning model development, domain experts are often used to provide the class labels (annotations). Annotation inconsistencies commonly occur when even highly experienced clinical experts annotate the same phenomenon (e.g., medical image, diagnostics, or prognostic status), due to inherent expert bias, judgments, and slips, among other factors. While their existence is relatively well-known, the implications of such inconsistencies are largely understudied in real-world settings, when supervised learning is applied on such ‘noisy’ labelled data. To shed light on these issues, we conducted extensive experiments and analyses on three real-world Intensive Care Unit (ICU) datasets. Specifically, individual models were built from a common dataset, annotated independently by 11 Glasgow Queen Elizabeth University Hospital ICU consultants, and model performance estimates were compared through internal validation (Fleiss’ κ = 0.383 i.e., fair agreement). Further, broad external validation (on both static and time series datasets) of these 11 classifiers was carried out on a HiRID external dataset, where the models’ classifications were found to have low pairwise agreements (average Cohen’s κ = 0.255 i.e., minimal agreement). Moreover, they tend to disagree more on making discharge decisions (Fleiss’ κ = 0.174) than predicting mortality (Fleiss’ κ = 0.267). Given these inconsistencies, further analyses were conducted to evaluate the current best practices in obtaining gold-standard models and determining consensus. The results suggest that: (a) there may not always be a “super expert” in acute clinical settings (using internal and external validation model performances as a proxy); and (b) standard consensus seeking (such as majority vote) consistently leads to suboptimal models. Further analysis, however, suggests that assessing annotation learnability and using only ‘learnable’ annotated datasets for determining consensus achieves optimal models in most cases.

60. To Swab or not to swab? A review of the value of pus swabs in the management of cervico-facial infections

At present, the majority of inpatients who undergo incision and drainage of cervico-facial infections at the Queen Elizabeth university Hospital have pus swabs sent routinely for culture and sensitivity tests. We aim to explore if there is evidence to support this practice, and whether pus swabs had any influence on the patient’s definitive antibiotic regimen.

189. 18 months of Quality and Outcomes in Oral and Maxillofacial Surgery data for Trauma in Glasgow- lessons learnt and the future: is this our CSAG moment?

We present our OMFS trauma activity from August 2020- February 2022 from the Queen Elizabeth University Hospital, and our Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) data from the same period, for mandible and orbit fractures, comparing our outcomes with that of similar UK units.

118. Antibiotic Stewardship in a Major Trauma Tertiary Maxillofacial Department

The aim of this investigation is to evaluate the clinical equipoise in antibiotic stewardship in a major trauma tertiary Maxillofacial department at the Queen Elizabeth University Hospital, Glasgow. For the purpose of this study, focus has been placed on patients undergoing fixation of zygomatic arch, zygomatico-maxillary complex or orbital fractures.

Incidence of cerebrovascular accident following head and neck free tissue transfer surgery

The aim of this study was to determine the incidence of postoperative cerebrovascular accident (CVA) following head and neck free tissue transfer and to identify predictive risk factors. A retrospective audit was performed of patients who underwent head and neck reconstructive surgery at Queen Elizabeth University Hospital between 2009 and 2020. The patient records were analysed to identify those who developed CVA within 30 days after surgery. A total of 1109 patients underwent head and neck free tissue transfer surgery, including 1048 neck dissection procedures. Of these, 78.6% had one or more identified risk factors for perioperative stroke. Five patients (0.45%) developed postoperative CVA. The results showed that CVA correlated to patients with hypercholesterolemia (P = 0.007). This study demonstrates the safety of free tissue transfer. Despite underlying co-morbidities and risk factors, the incidence of CVA is low following surgery and manipulation of the major vasculature of the neck.

Rationale and Design for the LOnger-term effects of SARS-CoV-2 INfection on blood Vessels And blood pRessure (LOCHINVAR): an observational phenotyping study

IntroductionCOVID-19 may lead to long-term endothelial consequences including hypertension, stroke and myocardial infarction. A pilot study ‘COVID-19 blood pressure endothelium interaction study’, which found that patients with normal blood pressure...

P086 Patient perceptions of musculoskeletal ultrasound as an educational tool in a rheumatology podiatry clinic

Abstract Background/Aims Emerging evidence suggests musculoskeletal ultrasound (MSUS) may benefit patient understanding of their inflammatory arthritis and medication adherence. The overall objective was to explore patient perceptions of MSUS when used as a patient education tool in relation to foot problems in people with rheumatic and musculoskeletal diseases (RMD). Methods Consecutive patients attending a rheumatology podiatry clinic at the Queen Elizabeth University Hospital Podiatry Department, Glasgow, were invited to participate. To gather information on how useful MSUS was for patient understanding of their foot problems, participants completed a brief questionnaire before and after their MSUS scan. MSUS assessment of affected foot structures was conducted by a single podiatrist with MSUS training (LN) using an Esaote MyLabAlpha portable US machine. Participants were shown both grayscale and power Doppler MSUS still images with/without video clips and caliper measurements depending on the presenting complaint. Anatomical foot models were used to orientate patients to foot anatomy and corresponding MSUS images. Results A total of 43 (12 male: 31 female) participants were recruited with a mean (SD) age of 50 (12) years and median disease duration (IQR) of 6 (1,10) years. The most common RMD was spondylarthopathy (30%) followed by RA (23%). In this group, the rearfoot region (35%) was most frequently involved. The most frequently affected structure was tendons (30%) with multiple structures affected in 19%. A range of mechanical and inflammatory MSUS diagnoses were made. 56% of participants had not previously seen MSUS of the joints or tendons, with the remaining 44% unsure. 93% reported the MSUS scan improved understanding of their foot pain and 98% reported it will make them more likely to adhere to podiatry treatments and advice [Table 1]. 98% also reported that MSUS was more useful than other educational resources for understanding their foot pain. Still images were selected most frequently as the method that made the most sense to participants. Conclusion This study provides preliminary evidence of the potential value of MSUS as an educational tool in podiatry, with potential to enhance adherence with podiatry interventions and rehabilitation programmes. Further work using a follow up design is required. Disclosure L. Newcombe: None. J. Tougher: None. N. Kelleher: None. J. Woodburn: None. R. Barn: None.

The Impact of Slice Interval and Equation on the Accuracy of Magnetic Resonance Image Estimation of Quadriceps Muscle Volume in End Stage Liver Disease.

IntroductionEnd stage liver disease (ESLD) is associated with loss of muscle mass and function, known as sarcopenia, which can increase the risk of complications of ESLD, hospitalization and mortality. Therefore, the accurate assessment of muscle mass is essential to evaluate sarcopenia in ESLD. However, manual segmentation of muscle volume (MV) can be laborious on cross-sectional imaging, due to the number of slices that require analysis. This study aimed to investigate the impact of reducing the number of slices required for MV estimation. Further, we aimed to compare two equations utilized in estimating MV (cylindrical and truncated cone).MethodsThirty eight ESLD patients (23 males; 54.8 ± 10.7 years) were recruited from the Queen Elizabeth University Hospital Birmingham. A 3T MRI scan was completed of the lower limbs. Quadriceps MV was estimated utilizing 1-, 2-, 3-, and 4 cm slice intervals with both cylindrical and truncated cone equations. Absolute and relative error (compared to 1 cm slice interval) was generated for 2-, 3-, and 4 cm slice intervals. L3 skeletal muscle index (SMI) was also calculated in 30 patients.ResultsRelative error increased with slice interval using the cylindrical (0.45 vs. 1.06 vs. 1.72%) and truncated cone equation (0.27 vs. 0.58 vs. 0.74%) for 2, 3, and 4 cm, respectively. Significantly, the cylindrical equation produced approximately twice the error compared to truncated cone, with 3 cm (0.58 vs. 1.06%, P < 0.01) and 4 cm intervals (0.74 vs. 1.72%, P < 0.001). Finally, quadriceps MV was significantly correlated to L3 SMI (r2 = 0.44, P < 0.0001).ConclusionThe use of the truncated equation with a 4 cm slice interval on MRI offers an efficient but accurate estimation of quadricep muscle volume in ESLD patients.

Usability of novel major TraumaApp for digital data collection

BackgroundDelivery of major trauma care is complex and often fast paced. Clear and comprehensive documentation is paramount to support effective communication during complex clinical care episodes, and to allow collection of data for audit, research and continuous improvement. Clinical events are typically recorded on paper-based records that are developed for individual centres or systems. As one of the priorities laid out by the Scottish Trauma Network project was to develop an electronic data collection system, the TraumaApp was created as a data collection tool for major trauma that could be adopted worldwide.MethodsThe study was performed as a service evaluation based at the Queen Elizabeth University Hospital Emergency Department. Fifty staff members were recruited in pairs and listened to five paired major trauma standby and handover recordings. Participants were randomised to input data to the TraumaApp and one into the existing paper proforma. The time taken to input data add into was measured, along with time for clarifications and any errors made. Those using the app completed a System Usability Score.ResultsNo statistically significant difference was demonstrated between times taken for data entry for the digital and paper documentation, apart from the Case 5 Handover (p < 0.05). Case 1 showed a significantly higher time for clarifications and number of errors with digital data collection (p = 0.01 and p = 1.79E-05 respectively). There were no other differences between data for the app and the proforma. The mean System Usability score for this cohort was 75 out of 100, with a standard deviation of 17 (rounded to nearest integer).ConclusionDigital real-time recording of clinical events using a tool such as the TraumaApp is comparable to completion of paper proforma. The System Usability Score for the TraumaApp was above the internationally validated standard of acceptable usability. There was no evidence of improvement in use over time or familiarity, most likely due to the brevity of the assessments and the refined user interface. This would benefit from further research, exploring data completeness and a potential mixed methods approach to explore training requirements for use of the TraumaApp.