Royal United Hospital Bath Research Articles

Universal C-MAC® videolaryngoscope use in adult patients: a single-centre experience.

Universal use of Storz C-MAC® videolaryngoscopes was implemented for adult tracheal intubations in the operating theatres, intensive care unit and emergency department at Royal United Hospitals Bath NHS Foundation Trust in 2017. We report data from 1099 intubations from March 2020 to March 2022, collected contemporaneously and anonymously using a smartphone app, representing an estimated 18% of intubations in operating theatres and 30% of intubations in other locations during this period. Intubation success was 100%. The first-pass success rate was 87.3% overall: 87% with a Macintosh videolaryngoscope, 92% with a hyperangulated videolaryngoscope and 81% for users with ≤ 20 previous uses. First-pass success without complications was 87% overall: 87% in operating theatres (836/962), 93% in the emergency department (38/41) and 83% in the intensive care unit (73/88). Complications occurred during 0.6% of intubations: 0/962 in operating theatres and 7/137 in non-theatre locations. The rate of complications was unaltered by blade type (Macintosh 5/994 vs. hyperangulated 2/105, p = 0.14); intubator experience with the device (≤ 20 previous clinical uses 2/260 vs. > 20 previous uses 5/832, p = 0.67) and use of airborne personal protective equipment (PPE 6/683 vs. no-PPE 1/410, p = 0.27). Complication rates increased outside theatres (theatres 0/963 vs. non-theatre 7/136, p < 0.001) and during rapid sequence induction (RSI 6/379 (1.6%) vs. non-RSI 1/720 (0.1%), p = 0.008).

Investigating the impact of non-gated thoracic CT prior to CTCA to reduce layered testing

To determine the proportion of computed tomography (CT) coronary angiography (CTCA) referrals with coronary artery calcification (CAC) evident on previous non-cardiac CT imaging and how this impacted the diagnostic yield for CTCA, the requirement for additional diagnostic testing, and the associated costs to confirm or refute obstructive coronary artery disease (CAD). A retrospective review of CTCA examinations was undertaken between 01/05/2018 and 31/05/2020 in which the examinations were cross referenced for previous non-gated thoracic CT at Royal United Hospitals Bath. Major epicardial vessel CAC on baseline CT was re-evaluated by published semi-quantitative methods, giving a per-patient CAC score (mild=1-3, moderate=4-6, severe >6). Subsequent incomplete CTCA diagnostic yield, further testing, and cost implications were examined. Of the 2140 CTCA examinations identified, 13% (280/2140) had a preceding non-gated thoracic CT (53% female, age 63±11 years). The incomplete diagnostic rate increased with CAC grade, mild 32%, (RR 12; 95% CI 4-40), moderate 64% (RR 25; 95% CI 8-80), severe 75%, (RR 29; 95% CI 9-94). Additional diagnostic testing occurred in 4% for the mild CAC category, and 14% and 42% for moderate and severe, respectively. When severe CAC was identified on a non-gated thoracic CT a cost saving of £171/patient (dobutamine stress echo [DSE]) and £61/patient (myocardial perfusion scintigraphy [MPS]) was established with a direct to functional testing pathway. In patients referred for CTCA where severe CAC was identified on a preceding non-gated thoracic CT a direct to functional testing altered management in 42% of cases and was cost-effective.

Why Should ACT Work When CBT Has Failed? a Study Assessing Acceptability and Feasibility of Acceptance and Commitment Therapy (ACT) for Paediatric Patients With Chronic Fatigue Syndrome/myalgic Encephalomyelitis (CFS/ME)

AimsPaediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) effects 0.5–3.28% of children. NICE guidance recommends Activity Management, Graded Exercise Therapy or Cognitive Behavioural Therapy for fatigue (CBT-f). Approximately 15% of patients do not achieve full recovery within one year with current treatments. Acceptance and Commitment Therapy (ACT) is an effective treatment in many chronic illnesses. There are no studies investigating ACT for paediatric CFS/ME. This feasability study aimed to assess if ACT is a feasible and acceptable alternative treatment when current treatment has not led to recovery.MethodsThis feasability cohort study aimed to enrol a minimum of 12 participants aged 11–18 yearswith CFS/ME attending the Royal United Hospitals Bath NHS Foundation Trust Specialist Paediatric CFS/ME Service, who were still symptomatic after 12 months or 12 sessions of standard treatment and were offered six to 12 sessions of ACT. Retention and recruitment data were analysed. Participants were asked to complete questionnaires before, during and after treatment. A selection of participants and their parents were interviewed about their experience of the study. Interviews were analysed using thematic analysis.Results19 participants (95% of those approached) were recruited. Only 4 participants of this hard-to-reach group did not complete treatment.In almost all sessions participants reported that they felt ‘totally’ listened to in post session questionnaires (31/33 sessions).Preliminary interviews (n = 12) indicate acceptability of ACT, with all young people and their parents stating that they thought ACT should be offered to this population. Participants particularly commented that the absence of thought challenging (used in CBT-f) was a positive element of ACT. Participant's openness to try new approaches and altruistic desire to be in a study was noted.ConclusionRecruitment data indicate that it is feasible to recruit and retain 11–18-year-olds with CFS/ME to a study offering ACT. Interviews with participants and parents were broadly positive suggesting ACT is an acceptable treatment in this population.Results indicated that it is both feasible and acceptable to offer ACT to 11–18-year-olds with CFS/ME using this protocol, supporting the prospect of an RCT in this area.

P140 Patient experience of osteoporosis telephone consultations

Background/AimsThe COVID-19 pandemic resulted in a rapid change to the use of virtual consultations in both primary and secondary care. Since April 2020, our osteoporosis clinic appointments have predominantly been undertaken by telephone. We wanted to assess our patients’ experience of telephone consultations.MethodsA patient feedback questionnaire was developed by the osteoporosis team which was validated by the Patient Advice and Liaison Service team (PALS) at the Royal United Hospital Bath. A questionnaire consisting of 15 questions was sent to patients following their telephone consultation. Patient consent to receive the questionnaire was requested by the consulting clinician for each participant. The patients were provided with a stamped addressed envelope to return the completed anonymous questionnaire. Thematic analysis was used to identify themes in the qualitative data.ResultsA total of 39 questionnaires were completed. More than 86% of patients reported that their telephone consultation definitely met their needs. Over 89% answered ‘yes definitely’ to questions regarding understanding of the reason for their appointment, opportunities for questions, clear understandable answers, feeling listened to, and treatment plans. 59% of patients responded ‘yes definitely’ that they were given information prior to the appointment about what would happen in the consultation, 10% reported they hadn’t, with 31% responding they had but to some extent only. 72% of respondents reported that it was clear who they should contact if they had any further questions following the consultation. Regarding preference for future appointments, 47% of patients indicated that they would prefer a mixture of telephone, face to face and video consultations; 24% preferred telephone, 16% preferred hospital face to face, and 3% preferred video. 11% reported that they had no preference. Thematic analysis of individual comments identified positive themes such as flexibility, good communication with clinicians and convenience. Areas for development are around communication with regard to physical barriers such as hearing and telephone signal problems. There are also limitations around both physical examination and the transmission of implicit information (non-verbal communication).ConclusionVirtual consultations provide an opportunity to safely assess patients whilst meeting social distancing requirements and minimising patient flow through the hospital. Questionnaire analysis indicates an overall positive experience of telephone consultations. However, most patients would prefer a mixture of face to face, video and telephone consultations in future. There are a number of areas for improvement including: a review of the information provided to patients prior to the consultation, review of contact information for patients following the consultation, and mechanisms for identifying patients with physical/sensory limitations. The information gained through this small review will help us improve the overall telephone consultation experience for our patients.Disclosure J.L. Webb: None. S.A. Hardcastle: None. S.M. Warren: None. D.J. Hart: None. J.A. Shipley: None. T. Ahmed: None.

P139 The impact of identifying poor adherence to bone protective treatment via postal questionnaire - Bath Fracture Liaison Service (FLS) audit

Abstract Background/Aims As part of the Royal United Hospitals Bath FLS, postal questionnaires assessing adherence to treatment are sent to patients (aged 50 or above) in whom we had recommended initiation of bone protective treatment (BPT) following identification of a low-trauma fracture. Upon receipt by the FLS of a completed adherence questionnaire, correspondence is sent to the GP to report the outcome, with recommendations as appropriate. The aim of this audit was to assess how many patients started (or re-started) treatment after reporting poor adherence. Methods Patients sent an adherence questionnaire in 2019 were screened for inclusion in the audit. These patients had sustained a low-trauma fracture approximately 1 year prior. For those reporting poor adherence (defined as either BPT not prescribed, or non-adherence to treatment), our hospital electronic record system (Millennium) and primary care electronic records (SystmOne) were scrutinised to assess whether BPT was subsequently initiated. Results A total of 1164 questionnaires were sent and 684 (59%) were completed and returned to the FLS. Of the questionnaires returned, 366 (54%) reported good adherence and 257 (38%) reported poor adherence. 61 (9%) of patients reported a decision not to take treatment. 88 of the 257 patients who reported poor adherence were excluded from the audit for the following reasons: 5 patients excluded because an outcome letter was inadvertently not sent to the GP and therefore these patients were not directly comparable with the other patients. 25 subsequently deceased patients were excluded because we were unable to ascertain if they had started/re-started treatment following the poor adherence letter. 51 patients were excluded because the primary care electronic record was unavailable and therefore although there was no evidence on our hospital electronic record system that treatment had been prescribed, we could not be certain that this was the case. 7 patients reported that they had not been prescribed treatment but there was evidence that treatment had been prescribed at the time of the adherence check. This provided us with a final eligible cohort of 169 patients for further analysis. We found evidence that 65 (38%) of 169 patients were prescribed or re-prescribed bone protection treatment following our poor adherence letter to the GP. Treatment was ongoing in 40 (24%) patients at the time of this analysis. Conclusion Our FLS policy of sending outcome letters to GPs following patient-reported poor adherence to BPT is partially effective in prompting prescription/re-prescription of treatment where appropriate. Our FLS will need to employ additional/alternative methods to improve our performance. Disclosure S.M. Warren: None. J.L. Webb: None. T. Ahmed: None.

The Potential Impacts of a Digital Preoperative Assessment Service on Appointments, Travel-Related Carbon Dioxide Emissions, and User Experience: Case Study.

BackgroundThe National Health Service (NHS) cannot keep up with the demand for operations and procedures. Preoperative assessments can be conducted on the internet to improve efficiency and reduce wait times for operations. MyPreOp is a cloud-based platform where patients can complete preoperative questionnaires. These are reviewed by a nurse who determines whether they need a subsequent face-to-face appointment.ObjectiveThe primary objective of this study is to describe the potential impact of MyPreOp (Ultramed Ltd) on the number of face-to-face appointments. The secondary objectives are to examine the time spent on preoperative assessments completed using MyPreOp in NHS Trusts and user ratings of usability and acceptability.MethodsThe study design was a case study service evaluation. Data were collected using the MyPreOp system from 2 NHS Trusts (Guy’s and St Thomas’ and Royal United Hospitals Bath) and the private BMI Bath Clinic during the 4-month period from September to December 2020. Participants were adults of any age and health status at the participating hospitals who used MyPreOp to complete a preoperative assessment before a scheduled surgery. The primary outcome was the number of face-to-face appointments avoided by patients who used MyPreOp. The investigated secondary outcomes included the length of time spent by nurses completing preoperative assessments, associated travel-related carbon dioxide emissions compared with standard care, and quantitative user feedback. User feedback was assessed at all 3 sites; however, the other outcomes could only be examined in the Royal United Hospitals Bath sample because of data limitations.ResultsData from 2500 participants were included. Half of the assessed patients did not need a further face-to-face appointment and required a median of only 5.3 minutes of nurses’ time to review. The reduction in appointments was associated with a small saving of carbon dioxide equivalent emissions (9.05 tons). Patient feedback was generally positive: 79.8% (317/397) of respondents rated MyPreOp as easy or very easy to use, and 85.2% (340/399) thought the overall experience was good or very good.ConclusionsThis evaluation demonstrates the potential benefits of MyPreOp. However, further research using rigorous scientific methodology and a larger sample of NHS Trusts and users is needed to provide strong evidence of MyPreOp’s efficacy, usability, and cost-effectiveness.

The 7th UK National Audit Project (NAP7). The challenges of defining, studying and learning from peri‐operative cardiac arrest

AnaesthesiaVolume 76, Issue 8 p. 1026-1030 Editorial The 7th UK National Audit Project (NAP7). The challenges of defining, studying and learning from peri-operative cardiac arrest A. D. Kane, A. D. Kane Honorary Research Fellow/Specialty Registrar @adk300 orcid.org/0000-0001-9488-4086 Division of Surgery and Interventional Science, University College London, London, UK Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UKSearch for more papers by this authorR. A. Armstrong, R. A. Armstrong Academic Clinical Fellow/Specialty Registrar @drrichstrong orcid.org/0000-0001-9479-0143 Department of Anaesthesia, Severn Deanery, Bristol, UKSearch for more papers by this authorE. Kursumovic, E. Kursumovic Honorary Research Fellow/Specialty Registrar @emirakur orcid.org/0000-0003-0864-3564 Division of Surgery and Interventional Science, University College London, London, UK Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UKSearch for more papers by this authorT. M. Cook, T. M. Cook Consultant/Honorary Professor @doctimcook orcid.org/0000-0002-3654-497X Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK Anaesthesia, University of Bristol, Bristol, UKSearch for more papers by this authorJ. Soar, Corresponding Author J. Soar Consultant jasmeets.soar@nbt.nhs.uk @jas_soar @NAPs_RCoA orcid.org/0000-0001-5970-6073 Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK Correspondence to: J. Soar Email: jasmeet.soar@nbt.nhs.ukSearch for more papers by this author A. D. Kane, A. D. Kane Honorary Research Fellow/Specialty Registrar @adk300 orcid.org/0000-0001-9488-4086 Division of Surgery and Interventional Science, University College London, London, UK Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UKSearch for more papers by this authorR. A. Armstrong, R. A. Armstrong Academic Clinical Fellow/Specialty Registrar @drrichstrong orcid.org/0000-0001-9479-0143 Department of Anaesthesia, Severn Deanery, Bristol, UKSearch for more papers by this authorE. Kursumovic, E. Kursumovic Honorary Research Fellow/Specialty Registrar @emirakur orcid.org/0000-0003-0864-3564 Division of Surgery and Interventional Science, University College London, London, UK Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UKSearch for more papers by this authorT. M. Cook, T. M. Cook Consultant/Honorary Professor @doctimcook orcid.org/0000-0002-3654-497X Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK Anaesthesia, University of Bristol, Bristol, UKSearch for more papers by this authorJ. Soar, Corresponding Author J. Soar Consultant jasmeets.soar@nbt.nhs.uk @jas_soar @NAPs_RCoA orcid.org/0000-0001-5970-6073 Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK Correspondence to: J. Soar Email: jasmeet.soar@nbt.nhs.ukSearch for more papers by this author First published: 13 May 2021 https://doi.org/10.1111/anae.15509Read 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 onFacebookTwitterLinked InRedditWechat Volume76, Issue8August 2021Pages 1026-1030 RelatedInformation

A UK-wide British Society of Thoracic Imaging COVID-19 imaging repository and database: design, rationale and implications for education and research

A UK-wide British Society of Thoracic Imaging COVID-19 imaging repository and database: design, rationale and implications for education and research

Osteoradionecrosis rates in patients receiving radical radiotherapy for head and neck cancer at the Royal United Hospital Bath

Osteoradionecrosis rates in patients receiving radical radiotherapy for head and neck cancer at the Royal United Hospital Bath

Remodelling holistic care: a service improvement project to develop a Ward Therapist role

Purpose: The problem of recruiting and retaining nursing staff is a national concern. A lack of nurses within the NHS has stretched patient care and led to a reduction in patient flow and low staff morale. In 2017 staff at the Royal United Hospital Bath (RUHB) developed and introduced a Band 5 Ward Therapist role in supporting nursing staff on one respiratory ward over 12 months. The role aimed to promote patient independence, introduce a rehabilitative approach to a ward environment and increase the amount of nursing care time. The aim of this service improvement project was to develop, introduce and evaluate the effect of a Ward Therapist within a secondary care ward environment.

Vigabatrin with hormonal treatment versus hormonal treatment alone (ICISS) for infantile spasms: 18-month outcomes of an open-label, randomised controlled trial

Infantile spasms constitute a severe form of epileptic encephalopathy. In the International Collaborative Infantile Spasms Study (ICISS), we showed that combining vigabatrin with hormonal therapy was more effective than hormonal therapy alone at stopping spasms between days 14 and 42 of treatment. In this planned follow-up, we aimed to assess whether combination therapy was associated with improved developmental and epilepsy outcomes at 18 months of age. In ICISS, a multicentre, open-label, randomised controlled trial, infants were enrolled from 102 hospitals (three in Australia, 11 in Germany, two in New Zealand, three in Switzerland, and 83 in the UK). Eligible infants had a clinical diagnosis of infantile spasms and a hypsarrhythmic (or similar) electroencephalogram (EEG) no more than 7 days before enrolment. Participants were randomly assigned (1:1) by a secure website to receive hormonal therapy with vigabatrin or hormonal therapy alone. If parents consented, there was an additional randomisation (1:1) of type of hormonal therapy used (prednisolone or tetracosactide depot). Block randomisation was stratified for hormonal treatment and risk of developmental impairment. Parents and clinicians were not masked to therapy, but investigators assessing epilepsy and developmental outcomes at 18 months were masked to treatment allocation. Minimum doses were oral prednisolone 10 mg four times a day or intramuscular tetracosactide depot 0·5 mg (40 IU) on alternate days with or without oral vigabatrin 100 mg/kg per day. The primary outcome at 18 months was development as assessed by the Vineland Adaptive Behaviour Scales (VABS) composite score. Secondary outcomes were the presence or absence of epileptic seizures or infantile spasms in the previous 28 days, as recorded by parents and carers, and the use of any anti-epileptic treatment (including ketogenic diet) in the previous 28 days. Analysis was by intention to treat. The trial is registered with the ISRCTN registry, number 54363174, and EudraCT, number 2006-000788-27. Between March 7, 2007, and May 22, 2014, 766 infants were screened and, of those, 377 were randomly assigned to hormonal therapy with vigabatrin (n=186) or hormonal therapy alone (n=191). 362 infants were assessed for developmental and epilepsy outcomes at 18 months, 181 in each treatment group. Mean VABS scores did not differ significantly between the combination therapy group and the hormonal therapy alone group (73·9 [SE 1·3] vs 72·7 [1·4], difference -1·2 [95% CI -4·9 to 2·6], p=0·55). Presence of epilepsy at the assessment at age 18 months was similar in both treatment groups (54 [30·0%] of 180 infants who received combination therapy vs 52 [29·2%] of 178 who received hormonal therapy alone; difference 0·8% [95% CI -8·8 to 10·4], p=0·90). Presence of spasms was also similar in both treatment groups (27 [15·0%] of 180 infants on combination therapy vs 28 [15·7%] of 178 on hormonal therapy alone; difference 0·7% [95% CI -6·9 to 8·3], p=0·85). At the 18-month assessment, 158 (44·1%) of 358 infants were on some form of anti-epileptic treatment. Initial control of spasms between days 14 and 42 of treatment was associated with higher mean VABS scores at 18 months (79·1 [SE 1·2] vs 63·2 [1·1], difference 15·9 [95% CI 12·4 to 19·5], p<0·001) and with higher likelihood of absence of seizures at 18 months (in 39 [17·0%] of 229 infants who achieved spasm cessation vs 67 [51·9%] of 129 who did not; difference 34·9% [24·8 to 45·0], p<0·001). Increasing lead-time to treatment was associated with lower VABS scores (analysis of variance: F[4,354]=6·38, p<0·001) and worse epilepsy outcomes (p=0·023). Combination therapy did not result in improved developmental or epilepsy outcomes at 18 months. However, early clinical response to treatment was associated with improved developmental and epilepsy outcomes at 18 months. Longer lead-time to treatment was associated with poorer outcomes. Rapid diagnosis and effective treatment of infantile spasms could therefore improve outcomes. The Castang Foundation, Bath Unit for Research in Paediatrics, National Institute of Health Research, the Royal United Hospitals Bath NHS Foundation Trust, BRONNER-BENDER Stiftung/Gernsbach, University Children's Hospital Zurich.

The effects of centralisation of vascular surgical services in the Bath, Bristol and Weston area on the carotid endarterectomy pathway.

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Safety and effectiveness of hormonal treatment versus hormonal treatment with vigabatrin for infantile spasms (ICISS): a randomised, multicentre, open-label trial

Infantile spasms constitutes a severe infantile epilepsy syndrome that is difficult to treat and has a high morbidity. Hormonal therapies or vigabatrin are the most commonly used treatments. We aimed to assess whether combining the treatments would be more effective than hormonal therapy alone. In this multicentre, open-label randomised trial, 102 hospitals (Australia [three], Germany [11], New Zealand [two], Switzerland [three], and the UK [83]) enrolled infants who had a clinical diagnosis of infantile spasms and a hypsarrhythmic (or similar) EEG no more than 7 days before enrolment. Participants were randomly assigned (1:1) by a secure website to receive hormonal therapy with vigabatrin or hormonal therapy alone. If parents consented, there was an additional randomisation (1:1) of type of hormonal therapy used (prednisolone or tetracosactide depot). Block randomisation was stratified for hormonal treatment and risk of developmental impairment. Parents and clinicians were not masked to therapy, but investigators assessing electro-clinical outcome were masked to treatment allocation. Minimum doses were prednisolone 10 mg four times a day or intramuscular tetracosactide depot 0·5 mg (40 IU) on alternate days with or without vigabatrin 100 mg/kg per day. The primary outcome was cessation of spasms, which was defined as no witnessed spasms on and between day 14 and day 42 from trial entry, as recorded by parents and carers in a seizure diary. Analysis was by intention to treat. The trial is registered with The International Standard Randomised Controlled Trial Number (ISRCTN), number 54363174, and the European Union Drug Regulating Authorities Clinical Trials (EUDRACT), number 2006-000788-27. Between March 7, 2007, and May 22, 2014, 766 infants were screened and, of those, 377 were randomly assigned to hormonal therapy with vigabatrin (186) or hormonal therapy alone (191). All 377 infants were assessed for the primary outcome. Between days 14 and 42 inclusive no spasms were witnessed in 133 (72%) of 186 patients on hormonal therapy with vigabatrin compared with 108 (57%) of 191 patients on hormonal therapy alone (difference 15·0%, 95% CI 5·1-24·9, p=0·002). Serious adverse reactions necessitating hospitalisation occurred in 33 infants (16 on hormonal therapy alone and 17 on hormonal therapy with vigabatrin). The most common serious adverse reaction was infection occurring in five infants on hormonal therapy alone and four on hormonal therapy with vigabatrin. There were no deaths attributable to treatment. Hormonal therapy with vigabatrin is significantly more effective at stopping infantile spasms than hormonal therapy alone. The 4 week period of spasm cessation required to achieve a primary clinical response to treatment suggests that the effect seen might be sustained, but this needs to be confirmed at the 18 month follow-up. The Castang Foundation, Bath Unit for Research in Paediatrics, National Institute of Health Research, the Royal United Hospitals Bath NHS Foundation Trust, the BRONNER-BENDUNG Stifung/Gernsbach, and University Children's Hospital Zurich.

Sa1368 Generation of a Human Oesophageal Tissue Culture Model From Forceps Biopsies

Introduction Barrett’s oesophagus is the condition whereby the normal stratified squamous epithelium at the lower oesophagus is replaced with simple columnar epithelium in the context of gastro-oesophageal reflux disease. This increases the risk of oesophageal adenocarcinoma (OA) ten-fold, and the majority of people diagnosed with OA do not survive for 12 months. Our understanding of the molecular and cellular mechanisms underlying Barrett’s oesophagus is hindered due to lack of at a suitable model. We set out to develop a model from explant tissue biopsies of adult human oesophagus, as opposed to murine models (mice have a keratinised oesophageal epithelium and do not get Barrett’s oesophagus) or the use of cell lines (which do not recapitulate the normal tissue). Method We devised a study protocol and secured ethical approval (REC reference number 13/YH/0197) to obtain forceps biopsy specimens from consenting adults attending for routine diagnostic gastroscopies at the Royal United Hospital Bath. Specimens were then transported to the University of Bath where we have tested multiple culture conditions. These include choice of culture media, substrate (eg glass, plastic – coated or uncoated, semi-permeable membrane at air/liquid interface), cell adhesion factors (eg collagen I, collagen IV, fibronectin, Matrigel®), choice of tissue preparation (enzyme treatment with dispase in the absence or presence of trypsin, dissection with scissors or minced with a blade), plating density, media volume and use of a cell feeder layer. Results We have recruited 42 participants to date and attempted tissue culture on 36 of these. (Biopsies from 6 patients have been processed for RNA analysis.) Over time we have gradually optimised culture conditions. Of the most recent 6 participants, 5 have cultured successfully with cell survival for at least 14 days. Explant colony growth had been particularly vigorous (>12 mm) when plated on Matrigel® and a feeder layer cell line (mitomycin C-inactivated mouse embryonic fibroblast (iMEF) cell line 3T3-Swiss albino, ATCC® CCL-92™) on plastic coverslips. Explants have also adhered and cultured successfully on collagen IV-coated (sc-29010, Santa Cruz Biotech) plastic coverslips without a feeder layer. Explant colonies were fixed/permeabalised before immunofluorescent staining was performed for cytokeratin 14 (K14), smooth muscle actin (SMA), p63, E-cadherin and SLUG antigens. iMEFs are clearly delineated with SMA staining and the explant outgrowths are positive for K14, p63, E-cadherin and SLUG. Conclusion It is possible to culture adult human oesophageal tissue in vitro from standard pinch-biopsy forceps specimens at gastroscopy and we are in the final stages of optimising conditions, confirming characterisation by repeating experiments and devising a protocol. Disclosure of interest None Declared.

Supportive role

Clinical nurse specialist at Royal United Hospitals Bath NHS Foundation Trust Tracie Miles talks about her new role as lead for the Eve Appeal charity’s specialist gynaecological nurse information service, Ask Eve, as well as her passion for improving the support and advice available to women on gynaecological cancers

PTH-166 Generation of a human oesophageal tissue culture model from forceps biopsies

<h3>Introduction</h3> Barrett’s oesophagus is the condition whereby the normal stratified squamous epithelium at the lower oesophagus is replaced with simple columnar epithelium in the context of gastro-oesophageal reflux disease. This increases the risk of oesophageal adenocarcinoma (OA) ten-fold, and the majority of people diagnosed with OA do not survive for 12 months. Our understanding of the molecular and cellular mechanisms underlying Barrett’s oesophagus is hindered due to lack of at a suitable model. We set out to develop a model from explant tissue biopsies of adult human oesophagus, as opposed to murine models (mice have a keratinised oesophageal epithelium and do not get Barrett’s oesophagus) or the use of cell lines (which do not recapitulate the normal tissue). <h3>Method</h3> We devised a study protocol and secured ethical approval (REC reference number 13/YH/0197) to obtain forceps biopsy specimens from consenting adults attending for routine diagnostic gastroscopies at the Royal United Hospital Bath. Specimens were then transported to the University of Bath where we have tested multiple culture conditions. These include choice of culture media, substrate (eg glass, plastic – coated or uncoated, semi-permeable membrane at air/liquid interface), cell adhesion factors (eg collagen I, collagen IV, fibronectin, Matrigel®), choice of tissue preparation (enzyme treatment with dispase in the absence or presence of trypsin, dissection with scissors or minced with a blade), plating density, media volume and use of a cell feeder layer. <h3>Results</h3> We have recruited 42 participants to date and attempted tissue culture on 36 of these. (Biopsies from 6 patients have been processed for RNA analysis.) Over time we have gradually optimised culture conditions. Of the most recent 6 participants, 5 have cultured successfully with cell survival for at least 14 days. Explant colony growth had been particularly vigorous (&gt;12 mm) when plated on Matrigel® and a feeder layer cell line (mitomycin C-inactivated mouse embryonic fibroblast (iMEF) cell line 3T3-Swiss albino, ATCC® CCL-92™) on plastic coverslips. Explants have also adhered and cultured successfully on collagen IV-coated (sc-29010, Santa Cruz Biotech) plastic coverslips without a feeder layer. Explant colonies were fixed/permeabalised before immunofluorescent staining was performed for cytokeratin 14 (K14), smooth muscle actin (SMA), p63, E-cadherin and SLUG antigens. iMEFs are clearly delineated with SMA staining and the explant outgrowths are positive for K14, p63, E-cadherin and SLUG. <h3>Conclusion</h3> It is possible to culture adult human oesophageal tissue <i>in vitro</i>from standard pinch-biopsy forceps specimens at gastroscopy and we are in the final stages of optimising conditions, confirming characterisation by repeating experiments and devising a protocol. <h3>Disclosure of interest</h3> None Declared.

PC.92 Invasive Group B Streptococcus in the neonate: To screen or not to screen? Experience from a level 2 NICU

Many developed countries screen for Group B Strep (GBS); however, the UK employs a Risk Based approach for selecting mothers to receive intrapartum antibiotic prophylaxis (IAP). There is pressure for...

Combination therapy of 177Lu and 90Y Dotatate for treatment of neuroendocrine cancer

aDepartment of Medical Physics, Royal United Hospital Bath NHS Trust, Bath Departments of bNuclear Medicine cMedical Oncology, The Christie NHS Foundation Trust, Manchester, UK Correspondence to Ceri E. Ashton, MPhys (Hons), MSc, Department of Medical Physics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK Tel: +44 1225 821280; fax: +44 1225 821508; e-mail: [email protected] Received August 17, 2013 Accepted January 24, 2014

Developing a nurse-led paracentesis service in an ambulatory care unit

Ambulatory emergency care units are present in many hospitals and accommodate patients who need urgent medical assessment or procedures but do not require inpatient admission to achieve this. This article reports on a project undertaken in the ambulatory care unit at the Royal United Hospital Bath, which introduced a nurse-led paracentesis service with the intention of reducing waiting times and improving the service for patients. To evaluate the effect of the project, patient satisfaction levels and waiting times were measured before and after the introduction of nurse-led paracentesis. The results confirmed a significant reduction in waiting times after the nurse-led intervention was introduced and high levels of satisfaction. The results provide evidence that nurses are acquiring the knowledge and skills required to undertake interventional procedures that improve the patient's experience while contributing to pioneering developments in ambulatory emergency care services.

Further withdrawals from south west pay consortium welcomed

A total of ten NHS trusts have now pulled out of a consortium set up to introduce regional pay, terms and conditions for staff in the south west. Since unions and employers agreed an overhaul of Agenda for Change in February, which includes the introduction of performance-related incremental pay rises, five trusts have withdrawn from the south west pay, terms and conditions consortium. The latest to pull out are the North Bristol NHS Trust, Devon Partnership NHS Trust, University Hospitals Bristol NHS Foundation Trust, Weston Area Health NHS Trust, and Royal United Hospital Bath NHS Trust. They follow five other consortium members who previously withdrew – Northern Devon Healthcare NHS Trust, Yeovil District Hospital NHS Foundation Trust, Dorset County Hospital NHS Foundation Trust, Dorset Healthcare University NHS Foundation Trust and Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. The cartel, set up in June 2012, had been examining ways of saving money that included cutting nurses’ annual and maternity leave, and limiting sick pay and redundancy rights. Trusts that joined the consortium paid £10,000 each for consultants to draw up money saving options. The remaining six consortium members will make a final decision about whether to abandon the ‘cartel’ and stick with nationally agreed terms