Retrospective Case Note Review Research Articles

Trainee as trainer in paediatric laparoscopic appendicectomy.

Intraoperative teaching is an essential surgical skill, but there is little literature regarding trainees acting as trainers; we characterised these cases in paediatric laparoscopic appendicectomy. This is a retrospective review of casenotes over two years (2015-2017) in a single tertiary paediatric surgical centre in the UK. Operating were: paediatric surgery Core Trainees (CT) (postgraduate year (PGY)3-4), Junior Registrars (JR) (PGY5-6) and Senior Registrars (SR) (PGY7+); collectively described as trainees. A total of 53 (20.7%) of 256 appendicectomies were trainee as trainer (TT) cases; 22 cases (41.5%) were performed by a CT supervised by a Registrar, and 31 (58.4%) by a JR supervised by a SR. Among the cases, 17 (32.1%) were complex, 47 (88.7%) were in working hours (8am-5pm), and 50 (94.3%) took place Monday to Friday. Median (interquartile range) duration of surgery was 65 (52-77) minutes. In the first year, 60 (47%) appendicectomies were performed by JRs. JR 1 was TT in three cases (8.8%) and JR 2 in five cases (19.2%); in all cases, the learner was a CT. Overall, there were 26 (10.6%) negative appendicectomies, 8 (3%) conversions, 19 (7%) readmissions within 30 days of discharge and 3 (1.1%) required reoperation; there was no statistically significant difference in complications between TT and non-TT cases. Laparoscopic appendicectomy is an excellent model for trainees to act as trainer; case selection included simple cases during daylight hours. Our outcomes are comparable with published literature, suggesting that this teaching method is safe for patients.

Characteristics and outcomes of people in suicidal crisis at two emergency departments: a service evaluation.

Emergency departments (EDs) provide critical opportunities for nurses to support suicide prevention. This article details a service evaluation that was undertaken to explore the characteristics and outcomes of people in suicidal crisis at two EDs in the East of England during June 2023. Data routinely collected by the ED mental health liaison team were combined with a retrospective case note review of the local NHS mental health trust's electronic patient records. Attendees had a mean age of 35 years and seven months, and were often diagnosed with depression or emotionally unstable personality disorder. Most had a history of self-harm and were currently known to mental health services. Suicide-specific interventions were rarely recorded by nurses and relapse behaviours were prevalent after presentation. Local and national suicide prevention strategies should encourage nurses to address gaps in support, thereby improving patients' experiences in and beyond the ED.

Presentation of enthesitis-related arthritis and juvenile-onset spondyloarthritis: a cross-sectional study in a pediatric and adult clinic

BackgroundJuvenile idiopathic arthritis (JIA) comprises a whole spectrum of chronic arthritis starting before 16 years of age. The study aims to explore the clinical and demographic descriptors, treatment, and disease progression of enthesitis-related arthritis (ERA) in comparison with juvenile-onset spondyloarthritis (SpA).MethodsCross-sectional analysis of consecutive patients in two dedicated clinics, with a single visit and retrospective case-notes review. Arthritis, enthesitis and sacroiliitis were evaluated by scoring disease activity and damage. Continuous variables were reported by median, interquartile range; categorical variables were reported by the frequency comparison of the two groups.ResultsThirty-three cases were included, being 23 (69.7%) with ERA. The median age at diagnosis was 12.5 y (SpA) vs. 9 y (ERA) (p < 0.01); the time from symptom onset to diagnosis was 5.5 y (SpA) vs. 1.5 y (ERA) (p < 0.03). In both groups, the predominant presentation was a single joint or < 5 lower limb joints and asymmetric involvement, with a high frequency of enthesitis. There was a higher frequency of mid-tarsal and ankle synovitis in the ERA group and hip involvement in those with SpA. The comparison of the frequency of spine symptoms at presentation, 30% SpA vs. 21.7% ERA (p = 0.7), was not significant, and radiographic progression to spinal involvement occurred in 43.5% of ERA patients. The median time for spinal progression and age at onset was 2.2 and 12 y for ERA, and 4 and 16.5 y for SpA, respectively. Activity and damage scores were not significantly different between the groups. Treatment comparison resulted in 91.3% of ERA and 100% SpA being treated, predominantly with NSAIDs in both groups, followed by DMARDs and biologics, with a higher frequency of biologics in SpA.ConclusionThe main differences were the late diagnoses of SpA, and the hip and spine involvement, with higher frequency of biologic treatment in juvenile-onset SpA compared to ERA.

Presentation of Spontaneous Orbital Hemorrhage

Aims: To evaluate the presenting features of patients with nontraumatic orbital hemorrhage (NTOH) based on etiopathological factors. Methods: A retrospective case-note review for demographics and presenting features of patients with nontraumatic orbital hemorrhage. Patients were categorized into 3 groups: group I with known systemic vascular disease, group II with known or newly revealed orbital vascular anomalies, and group III with no known underlying vasculopathy. Results: One hundred and seventeen patients (68 female; 58%), with 37 (32%) in group I, 47 (40%) in group II, and 33 (28%) in group III. The average age at presentation was 70.9, 30.1, and 49.9 years, respectively, but the incidence peaked in the first decade for patients with underlying local vascular anomalies and in the eighth for those without. Of the group I patients with known cardiovascular disease, 43% were on antithrombotic agents. The most common presenting symptoms were orbital pain (59%), proptosis (56%), and diplopia (45%), while 13% had associated nausea or vomiting. Ipsilateral optic neuropathy occurred in 14% of cases, higher in group II (22%), along with nonaxial globe displacement (25%), reduced eye movements (47%), optic disc swelling (10%), and choroidal folds (9%). Imaging in patients without evident vascular anomalies showed that hemorrhages commonly occurred in the inferotemporal quadrant (32%), with about half of these having a “beached whale” configuration (46%). Conclusion: Nontraumatic orbital hemorrhages affect all ages, typically presenting with acute proptosis or pain (over half), various degrees of visual impairment, and reduced motility. About half of those without vascular anomalies had cardiovascular risk factors, imaging often revealing an inferotemporal mass with a “beached whale” appearance.

We Reduced the Incidence of Postoperative Complications in Neonatal Ostomy Patients by Using Simple Devices.

Background: Complications frequently occur after neonatal enterostomy. Enterostomy formation is a common outcome following an emergency neonatal laparotomy. This study investigated whether the incidence of complications after enterostomy could be decreased with a drainage device (composed of foreskin cerclage staple, a condom, and a 0-Mersilk braided nonabsorbable suture) fixed in the proximal ostomy bowel tube to improve proximal enterostomy in newborns. Methods: This study was a retrospective case note review of the incidence of emergency neonatal enterostomy incidence over a 3-year period (2/2016-2/2019) at the authors' center. A single surgeon conducted all surgeries. The incidence of intraoperative and postoperative complications was compared between modified and traditional surgery groups. Results: All 47 surgeries were successfully completed (32 boys and 15 girls; sex ratio: 2.13:1). The mean (±SD) birth weight, gestational period, and daily age were 2.64 ± 0.81 kg 35.62 ± 3.76 weeks and 3.49 ± 5.61 days, respectively. The patients were divided into modified surgery groups (20 cases) and traditional surgery groups (27 cases). The modified surgery group had significantly lower rates of total complications, unplanned reoperations, wound-related complications, and stoma-related complications than the traditional group (p <0.05). Conclusions: The preliminary observations suggested that the simple drainage device was a safe and effective operation device that reduced the risk of stoma-related complications.

Outcomes of patients with Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia caused by pathogenic SMAD4 variants in a pan-Scotland cohort

AbstractConstitutional loss of SMAD4 function results in Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia Overlap Syndrome (JP-HHT). A retrospective multi-centre case-note review identified 28 patients with a pathogenic SMAD4 variant from 13 families across all Scottish Clinical Genetics Centres. This provided a complete clinical picture of the Scottish JP-HHT cohort. Colonic polyps were identified in 87% (23/28) and gastric polyps in 67% (12/18) of screened patients. Complication rates were high: 43% (10/23) of patients with polyps required a colectomy and 42% (5/12) required a gastrectomy. Colorectal cancer occurred in 25% (7/28) of patients, at a median age of 33 years. Pulmonary arteriovenous malformations were identified in 42% (8/19) of screened patients. 88% (23/26) and 81% (17/21) of patients exhibited JP and HHT features respectively, with 70% (14/20) demonstrating features of both conditions. We have shown that individuals with a pathogenic SMAD4 variant are all at high risk of both gastrointestinal neoplasia and HHT-related vascular complications, requiring a comprehensive screening programme.

Impact of Colorectal Nurse Specialist supervised parental administration of rectal washouts on Hirschsprung's disease outcomes: a retrospective review.

To highlight the utility of Colorectal Nurse Specialist (CNS) supervised parental administration of rectal washouts in the management of Hirschsprung's disease (HD). Retrospective case note review of HD patients treated at a tertiary children's hospital in United Kingdom from January 2011 to December 2022. Data collected included demographics, complications, enterocolitis, obstructive symptoms and stomas. Primary pull-through (PT) is done 8-12weeks after birth. Parental expertise in performing rectal washouts at home is ensured by our CNS team before and after PT. PT was completed in 69 of 74 HD patients. Rectal washouts were attempted on 63 patients before PT. Failure of rectal washout efficacy necessitated a stoma in four patients (6.4%). Of the 65 patients who had PT and stoma closed, three (4.5%) required a further stoma over a mean follow-up period of 57 months (Range 7-144 months). Two of these had intractable diarrhoea due to Total Colonic Aganglionosis (TCA). One patient (1.5%) had unmanageable obstructive symptoms requiring re-diversion. Hirschsprung-associated enterocolitis (HAEC) requiring hospital admission occurred in 14 patients (21%). Our stoma rates are lower compared to recent UK data. This could potentially be due to emphasis on parental ability to perform effective rectal washouts at home under CNS supervision.

Speech and Language Development, Hearing, and Feeding in Patients With Genetically Confirmed Crouzon Syndrome With Acanthosis Nigricans: A 36-Year Longitudinal Retrospective Review of Patients at the Oxford Craniofacial Unit.

Crouzon syndrome with acanthosis nigricans (CAN) is caused by the specific mutation c.1172C>A (p.Ala391Glu) in the fibroblast growth factor receptor 3 gene, and has an estimated prevalence of 1:1,000,000 births. Most cases occur de novo; however, autosomal dominant inheritance may occur. The clinical presentation typically includes craniosynostosis, midface and maxillary hypoplasia, choanal atresia/stenosis, hydrocephalus, and intracranial hypertension. Patients develop acanthosis nigricans, a hyperkeratotic skin disorder. The authors present the first known study to investigate the speech, language, hearing, and feeding of patients with CAN. A retrospective case-note review of patients with a genetically confirmed diagnosis of CAN attending the Oxford Craniofacial Unit during a 36-year period (1987-2023) was undertaken. Participants were 6 patients with genetically-confirmed CAN (5 females, 1 male), all cases arose de novo. All patients had craniosynostosis (n = 5/6 multisuture synostosis, n = 1/6 left unicoronal synostosis). Hydrocephalus was managed through ventriculoperitoneal shunt in 67% (n = 4/6) of patients, and 67% (n = 4/6) had a Chiari 1 malformation. Patients had a complex, multifactorial feeding history complicated by choanal atresia/stenosis (100%; n = 6/6), and significant midface hypoplasia. All patients required airway management through tracheostomy (83%; n = 5/6); and/or continuous positive airway pressure (67%; n = 4/6). All patients underwent adenotonsillectomy (100%; n = 6/6). Initial failure to thrive, low weight, and/or height were seen in 100% (n = 6/6) patients; 80% (n = 4/5) had reflux; 100% (n = 6/6) had nasogastric, or percutaneous endoscopic gastrostomy based feeding during their treatment journey. All patients had hearing loss (100%; n = 6/6). Early communication difficulties were common: receptive language disorder (50%; n = 3/6); expressive language disorder (50%; n = 3/6); and speech sound disorder in 50% (n = 3/6)-necessitating the use of Makaton in 80% of patients (n = 3/5). Patients with CAN experience significant respiratory, neurological, and structural obstacles to hearing, speech, language, and feeding. The authors present a recommended pathway for management to support patients in these domains.

Classification and reconstructive algorithm for nasal alar defect in Asians

BackgroundThe nasal alar defect in Asians remains a challenging issue, as do clear classification and algorithm guidance, despite numerous previously described surgical techniques. The aim of this study is to propose a surgical algorithm that addresses the appropriate surgical procedures for different types of nasal alar defects in Asian patients. MethodsA retrospective case note review was conducted on 32 patients with nasal alar defect who underwent reconstruction between 2008 and 2022. Based on careful analysis and our clinical experience, we proposed a classification system for nasal alar defects and presented a reconstructive algorithm. Patient data, including age, sex, diagnosis, surgical options, and complications, were assessed. The extent of surgical scar formation was evaluated using standard photography based on a 4-grade scar scale. ResultsAmong the 32 patients, there were 20 males and 12 females with nasal alar defects. The predominant cause of trauma in China was industrial factors. The majority of alar defects were classified as type I C (n=8, 25%), comprising 18 cases (56.2%); there were 5 cases (15.6%) of type II defect, 7 (21.9%) of type III defect, and 2 (6.3%) of type IV defect. The most common surgical option was auricular composite graft (n=8, 25%), followed by bilobed flap (n=6, 18.8%), free auricular composite flap (n=4, 12.5%), and primary closure (n=3, 9.4%). Satisfactory improvements were observed postoperatively. ConclusionFactors contributing to classifications were analyzed and defined, providing a framework for the proposed classification system. The reconstructive algorithm offers surgeons appropriate procedures for treating nasal alar defect in Asians.

Impact on patient outcomes of spondyloarthritis-inflammatory bowel disease multi-disciplinary meetings.

To assess the impact on patient outcomes of the spondyloarthritis (SpA) and inflammatory bowel disease (IBD) multidisciplinary team (MDT) meetings in a large university hospital. A single-centre retrospective observational case-note review was conducted assessing the outcome of all 226 cases discussed at the SpA-IBD MDT meetings in a large UK university hospital between 2017-2022. A total of 226 patients were discussed. It was deemed that 97% of MDT meetings helped to improve communication between teams, and 100% were educational. A total of 57% of discussions led to an instant change of disease management, while 40% of discussions resulted in a treatment plan that avoided the use of dual advanced therapy. This improved patient safety by reducing immunosuppression. The MDT meetings were highly cost and time efficient; 125 referrals between specialists were avoided, and in 51 cases there was a significant chance of reducing future drug costs. A timely investigation or appointment was arranged following 50% of MDT discussions, helping to clarify the diagnosis and optimise patient care. 9% of meetings enabled drugs to be prescribed to patients that are not yet licenced for the other speciality, thereby improving treatment options available in the management of complex cases. The MDT meetings have been beneficial for patients, the clinical team and the institution. This approach might be considered by other rheumatology and gastroenterology departments.

A multi-lesional analysis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a single-centre analysis

To conduct a multi-lesional computed tomography (CT) analysis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) patients to determine volumetric changes in lesions over 5 years. A retrospective case-note review was undertaken to identify 16 patients with histological and radiological features of DIPNECH between 2012-2021. Area and volume were calculated for 17 sets of lesions identified on high-resolution CT. Clinical data were extracted from electronic patient records, which included demographic data, outpatient clinic letters, histology reports, and imaging reports. One hundred and twenty-eight lesions were identified in 16 patients (one male, 15 female) and followed-up annually over a median 1,985 days (range 1,450-2,290). At year 1 follow-up, lesion area ranged from 1-48 mm2, and lesion volume ranged from 8-18,380 mm3; lesion area ranged from 1-45mm2 and lesion volume ranged from 11-17,800 mm3 and year 5. Half (8/16) of the patients had concomitant typical carcinoid tumours and one patient had an atypical carcinoid tumour. No statistically significant correlation (p<0.05) was found between lesion cross-sectional area or volume and duration of follow-up (years and days). No metastatic spread was observed at the time of analysis. No significant increase was observed in the size of over 100 lesions in patients with DIPNECH over a 5-year period and no metastasis occurred during the study period affirming the relatively indolent course of the disease.

Childhood-onset systemic lupus erythematosus (cSLE) and malignancy: a nationwide multicentre series review

BackgroundIncreased malignancy frequency is well documented in adult-systemic lupus erythematosus (SLE), but with limited reports in childhood-onset SLE (cSLE) series. We explored the frequency of malignancy associated with cSLE, describing clinical and demographic characteristics, disease activity and cumulative damage, by the time of malignancy diagnosis.MethodA retrospective case-notes review, in a nationwide cohort from 27 Pediatric Rheumatology centres, with descriptive biopsy-proven malignancy, disease activity/damage accrual, and immunosuppressive treatment were compiled in each participating centre, using a standard protocol.ResultsOf the 1757 cSLE cases in the updated cohort, 12 (0.7%) developed malignancy with median time 10 years after cSLE diagnosis. There were 91% females, median age at cSLE diagnosis 12 years, median age at malignancy diagnosis 23 years. Of all diagnosed malignancies, 11 were single-site, and a single case with concomitant multiple sites; four had haematological (0.22%) and 8 solid malignancy (0.45%). Median (min–max) SLEDAI-2 K scores were 9 (0–38), median (min–max) SLICC/ACR-DI (SDI) score were 1 (1–5) Histopathology defined 1 Hodgkin's lymphoma, 2 non-Hodgkin's lymphoma, 1 acute lymphoblastic leukaemia; 4 gastrointestinal carcinoma, 1 squamous cell carcinoma of the tongue and 1 anal carcinoma; 1 had sigmoid adenocarcinoma and 1 stomach carcinoid; 3 had genital malignancy, being 1 vulvae, 1 cervix and 1 vulvae and cervix carcinomas; 1 had central nervous system oligodendroglioma; and 1 testicle germ cell teratoma.ConclusionEstimated malignancy frequency of 0.7% was reported during cSLE follow up in a multicentric series. Median disease activity and cumulative damage scores, by the time of malignancy diagnoses, were high; considering that reported in adult series.

Spontaneous abscess of the nasal septum in children: a 10-year series.

This paper reports a 10-year series of spontaneous nasal septal abscesses in immune-competent children, with suggestions for optimal management. A retrospective case note review was conducted of children undergoing an operation for incision and drainage of nasal septal abscesses between 2013 and 2023. Six children were identified via electronic hospital records during the 10-year review period, five with a spontaneous abscess. The children were aged 10-14 years. All were immunocompetent and none had active sinus infection. The most common presenting features were nasal swelling, facial swelling, headache, nasal congestion and fever. The most common bacterial isolate was Staphylococcus aureus. All children received prompt surgical drainage and intravenous antibiotic therapy. Complications were seen in three children, with one child developing significant intracranial complications. To our knowledge, this is the first series of spontaneous nasal septal abscesses in immunocompetent children. The high prevalence of Staphylococcus aureus suggests spread from the nasal mucosa or vestibule. Early recognition, computed tomography scanning, surgical drainage and antibiotic therapy are the mainstays of treatment, to prevent potentially life-threatening complications.

Hearing preservation in paediatric cochlear implantation with the Nucleus Slim Straight Electrode – our experience

Objective to evaluate the levels of successful hearing preservation and preservation of functional hearing following cochlear implantation (HPCI) in children using the Cochlear Nucleus® Slim Straight Electrode (SSE). Design retrospective case note review of paediatric HPCI cases in our CI centre from 2013 to 2023. Inclusion criteria were attempted hearing preservation surgery, SSE used for implantation, pre-operative hearing thresholds ≤80dBHL at 250 Hz, CI before 18 years of age. Patients were excluded if no postoperative unaided PTA was obtained (poor attendance). Primairy outcome was hearing preservation using the HEARRING group formula; secondary outcome was residual functional hearing (≤80dBHL at 250 Hz/<90dB LFPTA). Study sample 56 patients with 94 CI’s were included for review. Results Hearing preservation was achieved in 94.7% (89/94) of ears and complete preservation in 72% (68/94)). Average functional hearing was preserved in 89% using both criteria for preservation. Long-term follow up data was available for 36 ears (average 35.2 months), demonstrating 88.9% (32/36) complete preservation. Conclusion We have reliably achieved and maintained a high success rate of HPCI using the SSE in our paediatric population. The field of HPCI would benefit from unification of outcome reporting in order to optimise the evidence available to professionals, patients and their carers

Long-term Airway Outcomes and Interventions in Children With Oesophageal Atresia With Tracheoesophageal Fistula: A 20-year Single Centre Observational Study

BackgroundAirway anomalies, symptoms and interventions are commonly reported in children with oesophageal atresia with tracheoesophageal fistula (OA/TOF). The purpose of this study was to assess the incidence of these airway pathologies and those requiring interventions in the long-term. MethodsA retrospective case note review of all patients admitted to the Neonatal Unit at the Royal Hospital for Children, Glasgow between January 2000 and December 2015 diagnosed with OA/TOF. Included patients had a minimum of 5 years follow-up. Results121 patients were identified. 118 proceeded to OA/TOF repair. 115 patients had long-term follow-up data. Ninety-five (83%) children had one or more airway symptom recorded. Thirty-six (31%) neonates underwent airway endoscopy at the time of their initial OA/TOF repair. Forty-six (40%) children underwent airway endoscopy at a later date due to airway symptoms. Airway pathologies identified included airway malacia, thirty-two (28%), subglottic stenosis, eleven (10%), tracheal pouch, twenty-five (22%), laryngeal cleft, seven (6%) and recurrent fistula, five (4%). Airway interventions included endoscopic division of tracheal pouch, ten (9%), tracheostomy, seven (6%), aortopexy, six (5%), repair of recurrent fistula, five (4%), endoscopic repair of laryngeal cleft, three (3%) and four (3%) required open airway reconstruction for subglottic stenosis. One child (1%) remains tracheostomy dependent. ConclusionsLong-term airway pathologies are common in children with OA/TOF. Many of these are remediable with surgical intervention. Clinicians should be cognisant of this and refer to Airway Services appropriately.

One-stage Intraconal Volume Modification for Exposed and Nonexposed Ball Implants.

To assess long-term outcomes and reinterventions for exposed and nonexposed intraconal orbital implants after single-stage socket revisional surgery. Retrospective case-note review of patients with exposed or nonexposed orbital ball implants, who underwent a single-stage ball exchange (Group I) or ball removal with dermis-fat graft (Group II); Group I was subdivided as having either exposed (A) or nonexposed (B) implants. Outcomes were compared with similar cohorts undergoing multistage surgery. Of 172 patients (54% male), 153 (89%) underwent ball exchange (Group I) and 19 (11%) had dermis-fat graft (Group II). With a mean follow up of 7.8 years, Group I patients without ball exposure (Group IB) had a slightly higher rate of reintervention for persistent volume deficit (21% vs. 9%; p = 0.163) and implant migration (6% vs. 0%; p = 0.091), while Group IA patients-having surgery for exposed implants-had more reexposures (7% vs. 3%; p = 0.270). Single-stage and 2-stage surgery had similar reintervention rates, with the exception of a trend toward fewer volume enhancements for those with nonexposed implants (17% vs. 30%; p = 0.380), and a shorter time to (re)exposure for exposed implants after 2-stage procedures (mean 0.33 vs. 3.5 years; p = 0.571). Group II patients required further volume enhancement in 32% of 1-stage procedures, and one patient needed graft removal. Single-stage volume modification is effective and the results are comparable to staged surgery for either exposed or nonexposed implants. Most patients report a stable prosthesis and satisfactory cosmesis, after a faster rehabilitation.

Inherited Optic Neuropathies: Real-World Experience in the Paediatric Neuro-Ophthalmology Clinic.

Inherited optic neuropathies affect around 1 in 10,000 people in England; in these conditions, vision is lost as retinal ganglion cells lose function or die (usually due to pathological variants in genes concerned with mitochondrial function). Emerging gene therapies for these conditions have emphasised the importance of early and expedient molecular diagnoses, particularly in the paediatric population. Here, we report our real-world clinical experience of such a population, exploring which children presented with the condition, how they were investigated and the time taken for a molecular diagnosis to be reached. A retrospective case-note review of paediatric inherited optic neuropathy patients (0-16 years) in the tertiary neuro-ophthalmology service at Moorfields Eye Hospital between 2016 and 2020 identified 19 patients. Their mean age was 9.3 ± 4.6 (mean ± SD) years at presentation; 68% were male, and 32% were female; and 26% had comorbidities, with diversity of ethnicity. Most patients had undergone genetic testing (95% (n = 18)), of whom 43% (n = 8) received a molecular diagnosis. On average, this took 54.8 ± 19.5 weeks from presentation. A cerebral MRI was performed in 70% (n = 14) and blood testing in 75% (n = 15) of patients as part of their workup. Continual improvement in the investigative pathways for inherited optic neuropathies will be paramount as novel therapeutics become available.

Hidradenitis suppurativa in children and young adults: a retrospective cross-sectional observational study in the United Kingdom.

Hidradenitis suppurativa (HS) in children and young adults (CYA) (<18 years) is uncommon. No previous observational studies have been carried out in a UK CYA HS population. This study was based on retrospective case note reviews of CYA HS patients attending tertiary-level care in the CYA HS service in a UK hospital. Patients <18 years old with a known diagnosis of HS were screened for inclusion. Exclusion criteria were those with less than one follow-up appointment. Twenty-eight CYA HS patients were identified, with an M:F ratio of 1:8.3. Mean BMI was 25.2 (SD: 7.6). 17 (61%) of cases had a relevant family history. Long-term antibiotic monotherapy was the most common treatment initiated. Lymecycline was the most commonly prescribed antibiotic, accounting for 23 (56%) of the 41 courses prescribed. Additional treatments initiated included dual therapy with rifampicin and clindamycin, isotretinoin, and adalimumab, which were more commonly prescribed in patients with Hurley Stage II or III. This group had a female predominance with an apparent strong genetic predisposition which is seen in other HS CYA cross-sectional research. Treatment was varied in this cohort, however long courses of antibiotics, including combined therapy with rifampicin and clindamycin, were the mainstay of treatment, similar to management in the adult population. This study therefore adds to the limited information on the demographics and management of the HS CYA population.

1756 Improvement in the number of discharges prior to 3 p.m. using quality improvement methodology

Abstract Introduction Under current nationwide clinical pressures, hospitals are running at full capacity. Late discharges can lead to poor flow throughout the hospital, overcrowding in the emergency department and out of hours transfers, leading to a poor patient experience and impacts on patient safety. Early morning and afternoon discharges create better flow and improve patient satisfaction, by being home in time for tea. The discharge collaborative within Leeds Teaching Hospitals NHS Trust is a multidisciplinary team (MDT) of junior doctors, pharmacists, nurses and discharge co-ordinators. The aim of the team is to improve discharges in the trust prior to 3 p.m. to 70%. Discharging patients earlier in the day is a complex multifactorial issue which requires an MDT approach. Method To understand this further a retrospective case note review was conducted to look at avoidable and unavoidable causes of delayed discharges. Each team also received a questionnaire, to discover their perceived barriers to early discharges. This was communicated to teams to empower them to develop their own solutions which were shared within the trust. Run charts of discharges before 3 p.m. are published for each ward in the hospital every two weeks, which is available to wards, but also monitored by the discharge collaborative. Changes to practice include; education of the medical team regarding importance of timely discharge, use of discharge boards, the increase use of discharge lounge, identifying ‘golden patients’ for early morning discharges, prioritisation of community discharges the previous day and achievement recognition for wards with the most improvement. Results/Conclusions Within the trust, several departments have improved their discharges prior to 3 p.m. through the improvements implemented from the discharge collaborative, including speciality and integrated medicine (SIM), oncology, and trauma services. This project resulted in two step improvements within the Trust with 40% of patients being discharged before 3 p.m.

Complete Primary Pathological Response Following Neoadjuvant Treatment and Radical Resection for Pancreatic Ductal Adenocarcinoma.

Neoadjuvant treatment (NAT) for borderline (BD) or locally advanced (LA) primary pancreatic cancer (PDAC) is now a widely adopted approach. We present a case series of patients who have achieved a complete pathological response of the primary tumour on final histology following neoadjuvant chemotherapy +/- chemoradiation and radical surgery. Patients who underwent radical pancreatic resection following neoadjuvant treatment between March 2006 and March 2023 at a single institution were identified by retrospective case note review of a prospectively maintained database. Ten patients were identified to have a complete primary pathological response (ypT0) on postoperative histology. Before treatment, five patients were considered BD and five were LA according to National Comprehensive Cancer Network guidelines. All patients underwent staging Computed Tomography (CT) and nine underwent 18Fluorodeoxyglucose Positron Emission Tomography (18FDG-PET/CT) imaging, with a mean maximum standardized uptake value (SUVmax) of the primary lesion at 6.14 ± 1.98 units. All patients received neoadjuvant chemotherapy, and eight received further chemoradiotherapy prior to resection. Mean pre- and post-neoadjuvant treatment serum Ca19-9 was 148.0 ± 146.3 IU/L and 18.0 ± 18.7 IU/L, respectively (p = 0.01). The mean duration of NAT was 5.6 ± 1.7 months. The mean time from completion of NAT to surgery was 13.1 ± 8.3 weeks. The mean lymph node yield was 21.1 ± 10.4 nodes, with one patient found to have 1 lymph node involved. All resections were reported to be R0. The mean length of stay was 11.8 ± 6.2 days. At the time of analysis, one death was reported at 35 months postoperatively. Two cases of recurrence were reported at 16 months (surgical bed) and 33 months (pulmonary). All other patients remain alive and under active surveillance. The current overall survival is 26.6 ± 20.7 months and counting. Complete primary pathological response is uncommon but possible following neoadjuvant treatment in patients with PDAC. Further work to identify the common denominator within this unique cohort may lead to advances in the therapeutic approach and offer hope for patients diagnosed with borderline or locally advanced pancreatic ductal adenocarcinoma.