Royal London Research Articles

An assessment of resolved head and neck lesions on the two week wait pathway at The Royal London Hospital

Introduction: The aim of this project is to understand how many patients referred to the OMFS

Nicholas Wilson-Holt

Nicholas Wilson-Holt (“Nick”) decided from an early age that his future career lay in medicine. He was educated at Aldenham School in Hertfordshire, and as a young boy he supplemented...

Revisiting D.W. Smithers’s “Cancer: An Attack on Cytologism” (1962)

David Waldron Smithers was, among other things, a physician and a pioneer of cancer radiotherapy and a well-respected figure in British medicine and public health. From the 1940s until his retirement from medical practice in 1973, he was the director of the Radiotherapy Department at the Royal Marsden Hospital and London University Chair of Radiotherapy at the Institute of Cancer Research. Using massive amounts of clinical observations, which he interpreted from an organicist viewpoint, and his impressive synthetic thinking, he proposed a coherent alternative perspective to the somatic mutation theory (SMT) which was then, and still is, the dominant theory of cancer. The purpose of this essay is to acquaint the modern audience with his seminal paper, published in 1962, because it deserves to be recognized as a true classic. In it, he examined the lack of fit between clinical observations and the SMT and proposed the rejection of this reductionist perspective. In addition, he built an organicist alternative in which carcinogenesis is seen as a problem of biological organization. His conceptual contribution to the cancer problem has inspired us and other authors over the last two decades. His essay “Cancer: An Attack on Cytologism,” originally published in The Lancet in 1962, is available as supplementary material in the online version of this article.

Positive direct antiglobulin tests in patients with COVID‐19

TransfusionVolume 61, Issue 1 p. 333-334 LETTERS TO THE EDITOR Positive direct antiglobulin tests in patients with COVID-19 Sean Platton, Corresponding Author Sean Platton [email protected] orcid.org/0000-0002-5466-0448 Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK Correspondence Sean Platton, Royal London Hospital, 4th Floor, Pathology and Pharmacy Building, 80 Newark Street, Whitechapel, London E1 2ES, UK. Email: [email protected]Search for more papers by this authorNicole Mendes, Nicole Mendes Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorCatherine Booth, Catherine Booth Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK NHS Blood and Transplant, London, UKSearch for more papers by this authorJulia Lancut, Julia Lancut Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorKurtis Lee, Kurtis Lee Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorFiona Regan, Fiona Regan NHS Blood and Transplant, London, UKSearch for more papers by this authorLaura Green, Laura Green Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK NHS Blood and Transplant, London, UK Blizard Institute, Queen Mary University of London, London, UKSearch for more papers by this author Sean Platton, Corresponding Author Sean Platton [email protected] orcid.org/0000-0002-5466-0448 Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK Correspondence Sean Platton, Royal London Hospital, 4th Floor, Pathology and Pharmacy Building, 80 Newark Street, Whitechapel, London E1 2ES, UK. Email: [email protected]Search for more papers by this authorNicole Mendes, Nicole Mendes Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorCatherine Booth, Catherine Booth Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK NHS Blood and Transplant, London, UKSearch for more papers by this authorJulia Lancut, Julia Lancut Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorKurtis Lee, Kurtis Lee Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UKSearch for more papers by this authorFiona Regan, Fiona Regan NHS Blood and Transplant, London, UKSearch for more papers by this authorLaura Green, Laura Green Haematology and Blood Transfusion Laboratories, Royal London Hospital, Barts Health NHS Trust, London, UK NHS Blood and Transplant, London, UK Blizard Institute, Queen Mary University of London, London, UKSearch for more papers by this author First published: 12 October 2020 https://doi.org/10.1111/trf.16156Citations: 6Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume61, Issue1January 2021Pages 333-334 RelatedInformation

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience

To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment. Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy. The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI. Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP, is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals, UK, and Honorary Senior Lecturer in Obstetrics and Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop menstrual disorders clinic at St Bartholomew's Hospital. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals, UK. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists, UK. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Ruben AlveroRuben AlveroDr Ruben Alvero is Professor of Obstetrics and Gynecology at Stanford Medical School, USA, and is the Division Director of Reproductive Endocrinology and Infertility at the Lucille Packard Children's Hospital, USA. He is Board Certified in obstetrics and gynecology, and in reproductive endocrinology and infertility. He is a fellow of the American College of Obstetrics and Gynecology and the American College of Surgeons. Following undergraduate training at Harvard College, USA (BA, Economics, 1980), Dr Alvero received his medical degree from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, USA, in 1986. He completed his residency in Obstetrics and Gynecology at Walter Reed Army Medical Center, USA (1990), and a fellowship in Reproductive Endocrinology and Infertility at the National Institutes of Health, USA (NIH, 1995). Dr Alvero was the Division Director for Infertility Services at the National Naval Medical Center, Bethesda, USA, and Walter Reed Army Medical Center and faculty in the NIH-sponsored fellowship in Reproductive Endocrinology and Infertility. Dr Alvero remained a reserve Colonel in the US Army Medical Corps until 2012, and during 27 years in the Army was mobilized several times for missions around the world, including service in Iraq, Kuwait, Mongolia, Germany and various locations in the United States. Dr Alvero was Professor of Obstetrics and Gynecology and Vice Chair for Education at the University of Colorado Health Sciences Center, USA, and the Director of the Assisted Reproductive Technologies, and founding member of the Center for Surgical Innovation. Dr Alvero was Residency Program Director in Obstetrics and Gynecology at the University of Colorado, USA. He was subsequently Division and Fellowship Director at Brown University, USA. The Council in Residency Education in Obstetrics and Gynecology awarded him its National Faculty Award for Excellence three times. He has been NIH-funded, most recently as part of the Reproductive Medicine Network. Dr Alvero is currently the Vice President of the Society for Reproductive Endocrinology, the national organization of fertility specialists and will take over as President in October 2020. Dr Alvero's clinical interests include IVF, polycystic ovary syndrome, endometriosis and robotic surgery. Dr Alvero's research interests include non-invasive evaluation of embryo quality, cost-effectiveness analysis, and the role of critical thinking in medical education. A fluent Spanish-speaker, Dr Alvero is also dedicated to improving the health of the Latinx community.

Delivering high quality documentation on operative consent forms: a UK major trauma center Quality Improvement Project

Background: Royal College of Surgeons guidelines exist on the importance of full, accurate and legible completion of consent forms as a key part of the process of gaining informed consent. In addition to this, consent forms serve as an important medico-legal document to protect clinicians and patients should problems arise. It is therefore in all parties’ interests that they are correctly completed. It was noted that consent forms within the Royal London Hospital Plastic Surgery department were often not correctly completed. A Quality Improvement Project was undertaken to improve the completion of consent forms within the department. Materials and methods: Common problem areas on consent forms were identified and Quality Improvement (QI) methodology was used to design the study including selection of appropriate outcome, process and balancing measures. Baseline information on completion of: (1) patient details, (2) consultant details, (3) legibility, (4) use of abbreviations in description of operation/complications, and (5) patient signatures was collected. Four weekly interventions were made which were accompanied by 4 further data collection cycles. A further reaudit took place 4 months following the completion of the project to establish whether improvements had been sustained. Results: Over the 5 QI data collection cycles the average completion of the 3 outcome measures rose from 59% to 93% and 4 months later was sustained at 91%. Outcome measure 1 (legibility of documentation) rose from 62% to 100%. Outcome measure 2 (omission of abbreviations) rose from 33% to 79%. Outcome measure 3 (patient signature) rose from 81% to 100%. Conclusion: This Quality Improvement Project led to a significant and sustained improvement in quality of completion of consent forms within the department with the most marked improvement in omission of abbreviations. This quality improvement methodology could easily be adapted for other surgical specialities.

Children's dentistry in secondary care during COVID-19

The COVID-19 pandemic has brought a unique set of challenges to assessing and treating paediatric dental patients in the secondary care setting. These children often present with high disease burdens and high levels of anxiety. In addition, they may have medical conditions which add to their treatment complexity. At the Royal London Dental Hospital, innovations have been put in place to improve the patient journey in a time where access to both out-patient and general anaesthetic services have been severely limited. Long term these innovations will help us to improve our service and facilitate communication with patients/carers, general dental and medical practitioners, safeguarding and specialist medical teams. It will create more flexible and creative work patterns for the dental team. CPD/Clinical Relevance: This paper illustrates the innovations that were introduced to overcome the challenges faced during the COVID-19 pandemic.

Письма в Лондон: новое о первом зарубежном выступлении Сергея Рахманинова

The article includes the first publication and commentaries to Sergei Rachmaninoff’s letters to London connected to his first tour abroad in April 1899 preserved in the British Library. The addressee of the letters is Francesco Berger, who at that time held the post of the merited secretary of the London Royal Philharmonic Society. The letters are presented in the original German and in Russian translation by the author of the article. The material of the letters makes it possible to specify certain details of his work on the Second Concerto for Piano and Orchestra. The additional sources brought in for examination provide new information about the composer’s sojourn in London in the spring of 1899. Keywords: Sergei Rachmaninoff, Rachmaninoff’s letters to London, Rachmaninoff’s Second Concerto for Piano and Orchestra, Rachmaninoff’s debut abroad.

Features of the interpretation of female images of W. Shakespeare's late play "The Winter's Tale" in Christopher Wheeldon's ballet of the same name

The subject of this article is K. Wheeldon's interpretation of the female images of Shakespeare's "Winter's Tale" in the context of its ideological and figurative identity to the literary source. The research is carried out in order to determine the expressive means and elements of choreographic vocabulary used by the choreographer in the production of female roles, as well as their contextual comparison with the text of the original source. In the course of the research, the author of the article, due to the versatility of the problem of interpreting W. Shakespeare's play on the ballet stage, used an integrated approach. The theoretical basis of the work was the principles of critical and semantic analysis of choreographic vocabulary developed by historians and theorists of ballet art (Dobrovolskaya, Krasovskaya, Slonimsky, Lopukhov, Surits). In the process of source analysis, English-language reviews of the world premiere of the ballet were reviewed (quotes from the articles are translated by the author), as well as video materials from the archives of the London Royal Opera House and the Moscow Bolshoi Theater. In addition, the included observation method was used (based on personal experience of working with Wheeldon as a performer of the Loss part in a Bolshoi Theater performance), accompanied by an analysis of rehearsal recordings for March – April 2019, which are in the author's archive. So, the detailed semantic analysis of the composition and choreographic vocabulary of female images of Shakespeare's late play "The Winter's Tale", interpreted by Wheeldon in the ballet of the same name, carried out in this article, was the main tool in the development of the scientific problem posed. The new results of the study include a significant groundwork in the aspect of identifying classical and innovative artistic elements of the dance language developed and used by Wheeldon, which allowed us to draw the following conclusions. Conceptually starting from Shakespeare's text, the choreographer adapts the interpretation of female images to a certain extent, guided by the expressive potential of conventional ballet art. At the same time, in the production of female roles, individualized plastic interpretations of the heroines become the main means of expression.

Prognostic Information for Known Genetic Carriers of RB1 Pathogenic Variants (Germline and Mosaic)

To compare the number of tumors per eye for mosaic carriers of RB1 pathogenic variants with full germline variants and the conversion from unilateral to bilateral disease. Retrospective cohort study comparing patients with retinoblastoma and different genetic subtypes: high penetrance (HP), low penetrance (LP), and mosaicism. Data were analyzed between 1992 and 2018 at the Retinoblastoma Unit, Royal London Hospital, London, United Kingdom. All familial patients had a parent with a known pathogenic variant even if the parent did not manifest the disease. Number of tumors per eye in children who developed retinoblastoma in that eye. Other outcomes included total number of tumors per patient, age at diagnosis, laterality at presentation and later, sex, and stage according to International Intraocular Retinoblastoma Classification. A total of 111 patients were included: 64 full germline, familial patients (53 HP and 11 LP) and 47 mosaic patients. Twelve HP patients (23%) were unilateral, and 8 of 12 patients (67%) developed tumors in their previously unaffected eye. A total of 34 mosaic patients (72%) were unilateral, and only 2 (6%) developed tumors in their unaffected eye. Age at diagnosis was higher in mosaic patients (median, 22 months) than in HP patients (median 7) (P < 0.00002). The number of tumors per eye was fewer in patients with mosaic alleles (median, 1.0; range, 1-6) compared with patients with HP alleles (median, 3.0; range, 1-8) (P < 0.0003). All 3 children (4 eyes) with mosaicism and more than 2 tumors per eye had high levels of mosaicism. Children with mosaic alleles have fewer tumors per eye compared with those with known high-penetrant pathogenic variants and are more likely to remain unilateral. The level of mosaicism has an impact on laterality and number of tumors.

What are the limitations of the non-patient-specific implant in titanium reconstruction of the orbit?

There is ongoing discussion about patient-specific implants (PSI) to reconstruct orbital defects. Although PSI offer excellent clinical outcome, they are expensive. Subsequently, their routine application is not indicated. The purpose of this study was to estimate the frequency of implant malposition and revision procedures after primary orbital repair with preformed plates and to identify cases where primary use of PSI would help to prevent revision surgery. All patients included in the study were operated on for orbital fractures at the Royal London Hospital between August 2017 and July 2018. Selection criteria included adult patients treated for orbital fractures with a titanium plate. Revision was planned in symptomatic patients presenting with clear implant malposition. Seventy-nine patients with 81 implants were included, 33 of whom had multiple orbital wall fractures (medial wall and floor or all four walls) and were summarised as group 2. Group 1 consisted of single orbital floor/medial wall fractures. The five patients for whom revision surgery was planned or undertaken because of radiological poorly positioned implants and substantial clinical symptoms all had multiple wall fractures. This finding was significant (p=0.006). The major reason for revision was a defect that was too large for the prescribed plate. Patients with large orbital defects needing surgical treatment are at risk of implant malposition. The orbital reconstruction with preformed plate evidences good outcome in single wall fractures. However, the risk of malposition increases massively with fracture size. We therefore postulate that in large, two-wall fractures, primary treatment with a PSI has to be considered.

Standard operating procedure of image-guided intervention during the COVID-19 pandemic: a combined tertiary musculoskeletal oncology centre experience

AIMTo evaluate the response measures in continuing an image-guided intervention service in two tertiary-level musculoskeletal oncology centres during the COVID-19 pandemic.MATERIALS AND METHODSThis study was a retrospective review of all patients undergoing image-guided intervention in the computed tomography (CT) and normal ultrasound (US) rooms from 24 March 2020 to 24 May 2020 (during the COVID-19 pandemic peak) at Royal National Orthopaedic Hospital, London, and Royal Orthopaedic Hospital, Birmingham, UK. Measures were put in place to address air pressures, airflow direction, aerosol generation, and the safe utilisation of existing scanning rooms and work lists for interventional procedures.RESULTSThree hundred and thirty-one patients (164 at Royal National Orthopaedic Hospital and 167 at Royal Orthopaedic Hospital) underwent image-guided procedures at both sites in the CT and US rooms. At the Royal National Orthopaedic Hospital, 40% of all procedures were performed under general anaesthesia. These consisted of 47 CT biopsies, 7 CT radiofrequency ablations (RFAs), and 12 US biopsies. At the Royal Orthopaedic Hospital, 86% of all procedures were performed under local anaesthetic, with no general anaesthetic procedures. These consisted of 61 CT biopsies and 83 US biopsies. All 256 patients having procedures in the CT room had no post-procedural complications or COVID-19-related symptoms and morbidity on follow-up.CONCLUSIONBy adopting a pragmatic approach with meticulous planning, a limited, but fully functional image-guided interventional list can be run without any adverse patient outcomes.

Fresh Fish: Observation up Close in Late Seventeenth-Century England.

The traditional view of London's Royal Society as a closed circle has been subject to revision in the past decades. Historians have shown the considerable extent to which the Fellows of the Society drew on a broad range of men of practice for their respective skill sets. This article offers an in-depth analysis of the contributions of fishermen and fishmongers to the creation of natural knowledge. It centres on the Historia piscium (Oxford, 1686), written by Francis Willughby and John Ray, and its surrounding sources. This natural history of fishes aspired to give a concise and precise overview of species, and to uncover the divine order in which they were created. While men of practice contributed to this project in multiple ways, their first-hand observations carried particular weight. Through their cumulative experience of working with fish they saw a great number of living species, rather than the dried exemplars that naturalists would usually consult in cabinets of curiosities, or the indirect evidence that images might present. This article examines what kind of exchanges took place between fishermen and fishmongers on the one hand and Fellows on the other, and where, how and why these were incorporated into the fish book. In so doing, it also aims to qualify the value attached to direct (natural historical) observation in the socio-cultural context of late seventeenth-century England.

Buccal bone width adjacent to the lower left third molar and loss of Root Pulp Visibility (RPV)

Abstract Introduction .The use of dental panoramic radiographs to assess dental development is hindered by the distortion and artefacts associated with such radiographic exposure techniques. Objective The purpose of this communication is to explore the feasibility of using CBCT to measure the bone buccal to lower third molars to determine the possible cause of loss of root pulp visibility as visualised on conventional dental panoramic tomographs. Material and Methods The radiographic archives of The Royal London Hospital were searched for suitable CBCT images. These were examined using Vatech Ewoo CBCT scanner and Pax Reve 3D software. Scans were reformatted into the required parasagittal, axial and coronal sections using SECTRA PACS (Picture Archiving & Communication) software. Measurements of specified parameters were made and the average of these measurements was used to estimate the width of tooth and bone buccal to the pulp that contributed to the loss of Root Pulp Visibility. Results There was concordance between the measurements for the left and right side for the average measurement of the dentine and bone buccal to the pulp. Conclusions The dentine and bone buccal to the pulp of the lower third molar roots is symmetrical. Further work is needed to explore the value of this technique to Dental Age Estimation.

MON-LB018 Paediatric Type 2 Diabetes in a Single Centre in East London in the Period 2009-2018

Background: The incidence of Paediatric type 2 diabetes is increasing, especially in areas of deprivation. Aim: To describe the cohort of CYP with T2D in Royal London Hospital over the period 2009-2018. Methods: Retrospective analysis of patient cohort. Results: Number of new patients doubled from 2.6/year in 2009-2013 to 5.3/year in 2014-2018. Prevalence in our cohort is 7.5% (national average of 2.5%, NPDA 2017-2018). Fourty patients (25 female, 15 male) were diagnosed in 2009-2018, with a mean age at diagnosis of 13.9+/-1.7 yrs. Males had more frequently learning difficulties compared to females (40% vs 20%). Sixty % of patients were Asian compared to 28% in our T1D cohort.BMI at presentation was 31.5 kg/m2 (23 females) and 33.85 kg/m2 (13 males). BMI remained stable for females for the first year after diagnosis but in males increased to 34.6 kg/m2 (n=10, non significant (ns)).At diagnosis, Metformin was started in 38/40 patients although 7 patients reduced the dose and 6 stopped due to side effects. 12/36 patients started also on long-acting insulin (0.28+/-0.17U/kg), in 6 combined with prandial insulin (0.42+/-0.20U/kg). Seven patients started long-acting insulin at a later stage and 6 required prandial insulin too. 1 patient was treated with Sitagliptin.HbA1c at diagnosis (n=27) was 75.2+/- 20mmol/mol, similar for males and females.HbA1c dropped to 55.0+/-17.4mmol/mol after 3 months (P<0.0001), to increase again to 63.0+/-25.8 and 67+/-28 after one (n=25, ns) and 2 years (n=23, ns).Nineteen of 38 patients achieved a HbA1c < 48 at least once, but only 9 of 35 achieved an HbA1c < 48 for a year. Of these, 3 continued to be on insulin and in 1 patient insulin was stopped. Two patients relapsed.Complications were as follows: 11/21 hypertension, 6/28 sleep apnoea, 10/30 raised ALT and 9/24 fatty liver.Conclusion: Learning difficulties in patients with T2D are frequent. Complications of obesity/T2D are common in this cohort. Current treatment does not achieve permanent reduction in BMI and HbA1c in most patients although temporary reduction of HbA1c is possible. New treatment approaches are needed to improve outcomes.

Histology at diagnostic gastroscopy predicts outcome after intestinal resection in pediatric Crohn's disease.

Pediatric Crohn's disease (CD) has been shown to have a high recurrence rate following surgical resection. Risk factors for postoperative CD recurrence in children are not well known. The aim of this study was to identify factors influencing postoperative recurrence in pediatric CD. Pediatric CD patients who underwent surgical resection with primary anastomosis with a minimum follow up of 2years were identified from databases at the Royal London Hospital and Massachusetts General Hospital. Patients were subdivided into a recurrence group defined by clinical, endoscopic, histological, radiological and/or surgical outcomes, and a nonrecurrence group. Patient demographics, initial gastroscopy and colonoscopy findings, Paris classification, and preoperative and postoperative pharmacotherapy were analyzed. Ninety-six children who underwent an ileal or ileocolonic resection with primary anastomosis were identified. Fifty-seven children had postoperative recurrence. Recurrence was associated with abnormal initial gastroscopy findings (P=0.0077), ileocolonic disease location (P=0.03), and perianal disease involvement (P=0.04). Patients with abnormal initial gastroscopy had higher rates of relapse (hazard ratio 3.42, 95% confidence interval [CI] [1.86-6.30], P=0.001). Multivariate analysis demonstrated that abnormal diagnostic gastroscopy histology was a significant independent predictor of postoperative recurrence in this cohort (odds ratio 1.33, 95% CI [1.04-1.70], P=0.024). The most common histological abnormality was non-Helicobacter gastritis, found in 29/46 (63%). This dual-center study has shown that the presence of upper gastrointestinal tract inflammation, especially non-Helicobacter gastritis, at the time of diagnosis, is associated with an increased risk of postoperative recurrence in pediatric CD.

SUN-306 The Interaction Between Thiazide-Associated Hyponatremia and Acute Illness in Hospitalised Patients

Thiazide diuretics, widely used in the management of hypertension, are associated with a five times greater risk of hyponatremia (serum Na <135mmol/L) than in the general population. Hyponatremia in hospitalised patients warrants special consideration since it is associated with increased morbidity and mortality.The aim of this study was to describe the clinical characteristics and outcomes in acutely ill medical patients with thiazide-associated hyponatremia (TAH).We performed a retrospective, case control study examining all acute, unselected medical admissions, over a six week period, to The Royal London Hospital. Cases were defined as adults admitted to hospital with TAH (hyponatremia and a history of being prescribed thiazide diuretic pre-admission). Each case was matched by age, gender and degree of hyponatremia to a similar control - admitted with hyponatremia and no pre-admission exposure to thiazide (non-TAH). Clinical characteristics and treatment outcomes were compared between TAH and non-TAH cohorts.A total of 1,341 consecutive acute medical admissions (49.7% men) were evaluated. Hyponatremia was detected in 240 (17.9%) admissions. Median (±SD) length of stay was longer among patients with hyponatremia compared to normonatremic patients (5.0±12.4 versus 3.0±9.2 days; p=<0.0001). In-hospital mortality was higher in the hyponatremic group (8.8% versus 4.4% p=0.005). Twenty-two cases (11 men) of TAH accounted for 9.2% of patients with hyponatremia. Median age 64±14 years was similar to other patients with hyponatremia 68±20 years. The median admission serum sodium for TAH cases was 131.5 mmol/L (IQR 126.8 - 134) with a discharge serum sodium of 136.5 mmol/L (IQR 133.8 - 139.3). When compared to matched controls, patients with TAH had similar presenting symptoms - most commonly confusion, headache and dizziness. Length of stay among TAH cases was similar to controls; 5.5±5.1 versus 4.0±3.7 days; p=0.24. Mortality (10%) was the same in both groups. Thiazide was withdrawn during admission in 14 (64%) cases.In conclusion, acute, clinical outcomes for hospitalised patients with TAH are similar to those with comparable degrees of hyponatremia due to other causes.

Society and the slow burn of inequality

On June 14, 2017, Grenfell Tower, a high-rise housing block in the Royal London Borough of Kensington and Chelsea, UK, went up in flames. 72 people died, among the poorest and most marginalised in society. A dramatic conflagration such as this could teach us two kinds of lessons, if we were but open to receiving them. This event exposed underlying problems in society and it showed us that we have to do things differently. In the case of Grenfell, the underlying societal problem was deep-seated and enduring social inequalities and resultant health inequalities.

The impact of social capital on patients with multiple sclerosis.

To evaluate the association between social capital (SC) and the physical and psychological impact of multiple sclerosis (MS). A cross-sectional study was conducted among people with MS (pwMS) at The Royal London Hospital, London, UK. Participants completed a survey including the Multiple Sclerosis Impact Scale-29 (MSIS-29), the Hospital Anxiety and Depression Scale (HADS), the self-reported EDSS and a SC questionnaire (SCQ). The SCQ assessed personal relationships, social support networks, civic engagement, and trust and cooperative norms. Kendall's tau correlation test was performed to measure the correlation between SC and MSIS-29 scores, and multiple linear regressions were conducted to find the best outcome prediction model. 236 pwMS participated in the study. Median age was 43.5years (IQR 35-52). Of the total, 168 (71.2%) were female and 180 (76.3%) had relapsing-remitting MS. Median MSIS-29 scores were 23.7 (IQR 8.8-57.5) for the physical scale and 38.9 (IQR 16.7-55.6) for the psychological scales. Total SC scores were significantly correlated with the MSIS-29 physical (τb=-0.09, P=.02) and psychological scores (τb=-0.23, P<.001). After adjusting for possible confounders, the "personal relationships" domain had a significant effect on the MSIS-29 physical scores (β=-2.70, SE=1.34; P=.045). Total SC (β=-1.08, SE=0.33; P=.001) and the "personal relationships" (β=-2.60, SE=1.20; P=.031) and "trust and cooperative norms" (β=-1.40, SE=0.61; P=.024) domains had a significant effect on the MSIS-29 psychological scores. Higher levels of SC were associated with lower physical and psychological impact of MS. Emerging evidence on SC and its effects on MS should be translated into interventions designed to promote the health and well-being of pwMS.