Specialist Registrars Research Articles

76 The Cinema and Geriatric Medicine: An Approach to ‘Hard-To-Reach’ Places in the Curriculum

Abstract Introduction Cinema is powerful - it can depict complex stories, spark discussion and foster reflection.1 Potentially, in geriatric medicine, the impact of serious diagnoses could be explored and learners’ preconceptions concerning ageing challenged. Thus, could film be used to explore and assess ‘hard-to-reach’ curriculum areas? The Mental Health in Older Adults module (MSc in Geriatric Medicine - Salford University) uses film in the oral assessed presentation. We wished to explore the utility of this Methods Learners (North-West Speciality Registrars) were allocated different feature films exploring mental health themes. 8 learners each delivered a ten-minute presentation focusing on a topic selected after viewing the film. The audience comprised Speciality Registrars who could ask questions. The content of the presentations was reviewed. The key topics/themes tackled were analysed. Results Learners watched one of the following: Iris, Tokyo Story, Still Alice, My Feral Heart, Firefly Dreams, The Carer, Away from Her and Amour. Each film generated 3 or more topics/themes. These were diverse and included: depression in chronic illness; loneliness; neuropsychological complications of stroke and the management and impact of dementia. Presenters set these into the film’s context and reflected on the interaction between physical health and social and psychological factors. ‘Hard-to-reach’ areas included: culture and social care, filial piety, and preconceptions of intellectual disability. Neglected areas tackled included suicide in older adults and the impact of dementia in younger adults. Audience feedback was positive. The reflective nature of the session provided new insights and was engaging Conclusions Film is a medium that allows ‘hard-to-reach’ (and teach) areas to be tackled and assessed. The use of film was well received and importantly had utility. The topics learners reflected upon were complex and challenged their own and their audiences’ conceptions of clinical problems. Reference 1. Law M, et al, Perspect Med Educ. 2015 4(5): 218–224.

78 Does Time ‘Out of Programme’ Offer Increased Academic Output? The South East London Geriatrics Training Programme Experience

Abstract Introduction In contrast to other medical specialties, trainees in Geriatrics have historically provided an increased contribution to clinical workload in General Internal Medicine and a reduced output of academic achievements. More recently, development of non-clinical skills has been recognised to have similar importance to clinical skills and the South East (SE) London Geriatrics Training Programme has thus supported trainees in applications for Out of Programme (OOP) opportunities to optimise career progression. Methods Doctors who had undertaken specialist registrar training in the SE London Geriatrics Training Programme at any time between 2011 and 2019 were sent a questionnaire to assess whether they had completed time OOP and whether they had been awarded research grants, published papers in peer-reviewed journals, had abstracts accepted for presentation at conferences, and/or published book chapters during their training programme. Chi-squared and Wilcoxon rank-sum tests were used to compare data between registrars who had completed time OOP and those who had not taken time OOP. Results 77 (24 male; 53 female) registrars completed training in the SE London Geriatrics Training Programme between 2011 and 2019. 71 registrars (92%) completed the questionnaire, of whom 31 (44%) completed time OOP. In total, registrars were awarded 15 research grants, published 86 papers in peer-reviewed journals, had abstracts accepted for 184 conference presentations and published 20 book chapters. A notably increased proportion of registrars who took time OOP had an output of research grants, papers published in peer-reviewed journals, abstracts accepted for presentation at conferences and/or book chapters respectively compared with registrars who had not taken time OOP (23% vs 5% ; 61% vs 23%; 84% vs 33%; 45% vs 5%). This equated to a combined academic output in 94% of registrars who completed time OOP compared with 48% who did not (p <0.001). Conclusions A very strong association existed between registrars in Geriatrics taking time OOP and academic achievement substantiating the training programme’s aspiration to support development of non-clinical skills that may be helpful to trainees in their future careers. It would be worthwhile further work being undertaken in this area in other regions.

Microsurgical Training Opportunities at the Queen Victoria Hospital: A Retrospective Review of 848 Free Flaps for Breast Reconstruction.

Becoming a competent microsurgeon requires training in a variety of skills and competences. However, instructing the next generation of microsurgeons seems to be a challenging task, considering the current trend to reduce training hours along with increased patient expectations. To evaluate the microsurgical training opportunities at the Queen Victoria Hospital, we conducted a retrospective review of the last 3 and a half years, to identify the opportunities given to trainees during breast reconstruction cases. We also surveyed the microsurgical fellows who worked in our unit during the same period. A total of 848 free flaps were performed between November 2015 and May 2019 for 699 patients undergoing breast reconstruction, with a flap failure rate of 0.47%. For unilateral cases, more than half of the flaps were raised by trainees: 39% by fellows and 12% by specialist registrars. For bilateral breast and bipedicled reconstructions, these figures were 44% and 2%, respectively. A total of 1835 microvascular anastomoses were performed, of which 33% were done by fellows and 17% by specialist registrars, with the remaining 50% being done by consultants. Six of 8 fellows who worked in our unit during the studied period replied to our survey. All of them were pleased with their training experience, and the majority of them progressed to a consultant post after their fellowship. We consider that a standardized surgical approach, along with a high-volume caseload, allows delivering an outstanding training experience while maintaining low complications rates.

UK Oral and Maxillofacial Surgery Trainee Perceptions of Flexible Nasal Endoscopy.

Flexible nasal endoscopy (FNE) is a useful adjunct in diagnosis and follow-up of oncology patients as well as in airway assessment. Proficiency in this technique is also listed as part of the Oral and Maxillofacial Surgery (OMFS) curriculum. We aimed to explore OMFS trainee perceptions of training and confidence in this technique. An electronic survey was undertaken of OMFS higher surgical trainees in the UK. A 10-item questionnaire was formulated using online survey software (SurveyMonkey) and distributed to Specialty Registrars in all deaneries via their regional representatives. Questions on training, exposure to and confidence in FNE were asked. A total of 43 responses were received which included all grades of higher surgical trainees. A large proportion had undertaken FNE in oncology rotations (78.6%) and as part of airway assessment (85.6%). Nearly half of trainees (47.6%) were confident in diagnosing pathology using FNE although 16.6% had low levels of confidence in the technique. Only 38% had received formal training, and the majority of this training was a teaching session from a senior. A very large proportion of trainees (90.5%) feel formal training should be available in FNE and 76% would undertake a formal OMFS training course in FNE if available. Trainees have high levels of exposure to FNE but variable levels of confidence in the technique. Trainees appear to receive limited formal training in the technique, and the introduction of more formalised training could be explored.

Special care dentistry trainee views on the medical and oral medicine elements of the specialist training curriculum

Specialty training curricula are subject to periodic update, and trainee views are an important element in identifying which areas need particular focus. In this study, we wished to examine specialty trainee opinions on two areas of a curriculum for special care dentistry, in particular oral medicine, and the component elements of related systemic disease and therapies (RSDT), namely pathology, pharmacology and therapeutics, and human systemic disease. Following ethical approval, we identified 35 specialty registrars in special care dentistry in the UK and Ireland who were invited to use an online survey tool to gather demographic data and then to ask their views on the delivery of training in oral medicine and RSDT. Respondents were also asked whether sufficient importance was placed on these topics and whether they could be accessed and delivered appropriately. The 23 registrars surveyed comprised a representative group from all parts of the UK and Ireland and were at different stages of specialty training. The majority thought oral medicine and RSDT were key elements of the curriculum and could be given more prominence, especially in the context of an increasingly ageing population with associated oral manifestations of chronic disease, multiple drugs and disabilities. The registrars surveyed felt that oral medicine and RSDT and were integral to training and that emphasis and opportunities for training in these areas could be improved, especially for those trainees based outside of a dental hospital setting.

759 A UK National Survey of Therapeutic Drug Monitoring With Anti-TNF Medications in IBD

INTRODUCTION: A growing body of evidence supports use of therapeutic drug monitoring (TDM) in improving efficacy and cost-effectiveness of anti-TNF therapy in patients with inflammatory bowel disease (IBD). Existing and evolving knowledge of TDM in clinical practice is less well understood. Our objective was to assess attitudes and barriers to TDM use with anti-TNF's in the UK. METHODS: A 17-question survey was distributed to members of the British Society of Gastroenterology. Information on clinician characteristics, demographics, use and barriers towards implementing TDM with anti-TNF's was collected. Logistic regression was used to predict factors influencing TDM use. RESULTS: 243 respondents participated (51.6% male) of which 237 respondents met inclusion criteria; treating >5 IBD patients and at least 1 with an anti-TNF per month. Of the total respondents, 45% were Consultant Gastroenterologists (GI), 40% IBD Nurse Specialists (CNS) and 15% GI Specialist Registrars (SPR). Of these 237 respondents, TDM was used by 95.7% for secondary loss of response; 71.4% for primary non-response and 53.6% used TDM proactively. Barriers for TDM use were time lag in receiving results (27.1%), lack of awareness of guidelines (15.6%), and cost (11.9%). Clinicians working at a teaching hospital were more likely to use TDM compared to a district hospital (OR 2.6, 95% CI 0.71-9.8). IBD CNS and GI SPR used TDM more often, when compared to Consultant GI (OR 2.6, 95% CI 0.69-10 & OR 1.5, 95% CI 0.3-7.2 respectively). Clinicians practising for >20 years were more likely to check TDM than less experienced clinicians (OR 4.1, 95% CI 0.4-41.8). Clinicians with large volume IBD practice (>50% IBD patients per month) were more likely to check TDM than those seeing fewer IBD patients (OR 45.6, 95% CI 7.5-275). Proactive TDM was more likely to be used by clinicians working in a tertiary care setting (OR 2.25, 95% CI 0.84-6.05), IBD CNS (OR 1.2, 95% CI 0.6-2.1), clinicians managing large volume IBD practice (OR 10.8, 95% CI 1.2-90) and clinicians with 5-9 years of experience in practice (OR 2.6 & CI 1.04-6.42). CONCLUSION: Significant barriers to TDM implementation in the UK are time lag from test to result, lack of awareness of current guidelines and evolving knowledge, cost and less experience. Validation of point of care testing, lower cost assays, and wider dissemination of current evolving paradigms with updated recommendations may further optimise treatment with anti-TNF therapies.

A cross sectional study of dental implant service provision in British and Irish dental hospitals.

Introduction There are multiple ways in which treatment using dental implants is provided in a secondary care setting, not only in terms of the groups of patients treated, but also the clinicians who provide that care.Methods An online survey was circulated to speciality registrars in restorative dentistry in all UK dental hospitals and to postgraduate students in prosthodontics in the Republic of Ireland, consisting of nine questions aimed at understanding which patient groups are treated using dental implants in a hospital setting, how cases are planned, executed and to explore the underlying reasons for each unit's method of provision.Results Completed surveys were received from 67% of dental hospitals in Britain and Ireland. Treatment planning was undertaken by the restorative team alone in 64% of units in patients with hypodontia, 57% with trauma and 71% with an atrophic edentulous ridge and by a multi-disciplinary team in 50% of units for patients with cleft lip and palate (CLP) and 45% with head and neck (H&N) cancer. The restorative team place all or most of the implant fixtures in 50% of units in patients with CLP, 71% in trauma patients, 71% in hypodontia patients, 64% in edentulous patients and 43% in H&N oncology patients. Stents are produced and used by the restorative team in 64% of units for edentulous patients, 79% of patients with hypodontia, 79% of those suffering trauma, 58% of CLP patients and 50% of patients with H&N cancer. Twenty-one percent of responding units had stents made by the restorative team and used by the surgical team. The median percentage of implant-supported restorations that are screw retained is 90% (SD: 4.93, range: 25-95%) and the median percentage of zirconia abutments being used is 22.5% (SD: 5.24, range: 0-50%). Use of zygomatic implants varies hugely between responding units with 43% of them not placing any zygomatic implants.Conclusions There is a wide range of protocols and team members involved in the provision of dental implant rehabilitations throughout the British Isles reflecting the lack of any single evidence-based approach. A multi-disciplinary team approach with the restorative dentist as a key member is likely to yield the most favourable long term outcomes.

304 ED-FASU: A Novel ‘Front Door’ Multidisciplinary Service Assessing Patients with Falls and Syncope in the Emergency Department

Abstract Background Patients with falls/syncope/presyncope frequently present to the emergency department (ED) and many that could be managed safely in an ambulatory care setting are admitted for extensive diagnostic work-up. A pilot intervention commenced in March 2019, with direct access to specialist assessment in the ED for patients presenting with falls/syncope/presyncope, aiming to provide appropriate testing and early diagnosis to reduce unnecessary hospitalizations. This pilot study assessed the feasibility of embedding this service within the ED, as well as the effectiveness of the intervention in terms of admission avoidance. Methods The study was conducted between 25th March and 19th April 2019 in a large urban teaching hospital with a dedicated Falls & Syncope Unit and compared to similar data from March/April 2018. The core ED-FASU team comprised a consultant geriatrician, specialist registrar in geriatric medicine and clinical nurse specialist. Inclusion criteria were those of all ages, presenting with falls/syncope/presyncope/dizziness between 0800-1800 Monday-Friday. Patients were reviewed directly from triage or after referral from the ED team. Results In total, 203 patients were assessed during the pilot, an average of 10 assessments per day. The median age of those seen was 63 (58.0-67.0) years. Almost one third (57/203) were aged ≥75 years. After excluding those who were already admitted to the acute hospital and awaiting a bed when seen in the ED (n=29), 24% (41/174) of those seen were admitted to hospital. This compares to an admission rate of 33% (73/223) for the 2018 comparison group (p = 0.045). Conclusion This pilot study shows that it is feasible to embed specialist assessment for falls/syncope/presyncope in the ED. Initial pilot data suggests a significant reduction in admission rates for those seen by this service but needs to be confirmed over a more prolonged assessment period and alongside data on readmission and length of stay.

144 The Use of a Multidisciplinary Team Discharge “Huddle” to Improve Patient Flow and Planning

Abstract Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.

Interview with an NHS speciality registrar

LD: How many years have you been working for the NHS and why did you choose this profession? A: Nine years. I chose this profession because I enjoyed studying and learning about biological science, as well as the human interaction and contact that being a doctor gives you. LD: How do you find the working conditions/generally working life? A: Much better now that I am a registrar. There was a lot of administrative and amanuensis work when I was an SHO (Senior House Officer, that is, the grade...

Professional burnout, work patterns and career satisfaction in medical oncologists in Ireland.

Burnout is an occupational syndrome frequently encountered within the healthcare profession. It is characterised by emotional exhaustion (EE), depersonalisation (DP) and a low sense of personal accomplishment (PA). Its negative impact extends to the physician, patient and overall service provision. The aim of this study was to evaluate work patterns, the prevalence of burnout and its associations in medical oncology consultants and specialist registrars (SpRs) in Ireland. Participants were invited to partake in an anonymised online survey. Burnout domains were measured using the validated Maslach Burnout Inventory. Associations between variables were evaluated using the Mann-Whitney U and Kruskal-Wallis tests (continuous), and chi-square and Fisher's exact testing (categorical). Seventy-four physicians were contacted to participate, 44 (59%) completed the survey. The majority (71%) work ≥ 50h a week, with 57% having additional on-call commitments of ≥ 5days/month. Burnout is defined by a high score in EE combined with a high DP and/or low PA was identified in 45% of consultants and 20% of SpRs. Longer working hours (≥ 60h/ week) were found to be associated with both high EE (p = 0.049) and DP (p = 0.019). Higher EE scores were demonstrated in those ≥ 40years (p = 0.04). The majority (86%) reported they would become an oncologist again. One or more of the symptoms of burnout is highly prevalent in medical oncologists in Ireland. With increasing pressure on resources, burnout is expected to increase. Attention to strategies for prevention needs to be prioritised within our healthcare system.

British Heart Rhythm Society Clinical Practice Guidelines on the Management of Patients Developing QT Prolongation on Antipsychotic Medication.

The British Heart Rhythm Society’s Clinical Practice Guidelines on the Management of Patients Developing QT Prolongation on Antipsychotic Medication are written for heart rhythm consultants, primary care physicians, specialist registrars, nurses and physiologists who may be requested to review ECGs or advise on cases where antipsychotic-induced QT prolongation is suspected or proven. The guidance is adapted from the latest Maudsley Prescribing Guidelines in Psychiatry, published in 2018.

Additional qualifications of trainees in specialist training programs in Australia

BackgroundIn Australia, the number of medical graduates per year has increased at a greater rate than the increase in the number of specialist training places. Consequently, competition for training positions is intensifying. There is anecdotal evidence to suggest that medical graduates are acquiring additional qualifications to compete with their peers Stevenson 2017 (https://insightplus.mja.com.au/2017/36/specialty-training-places-the-other-looming-crisis/). Our study investigates this phenomenon of additional credentialing and demonstrates the number and type of postgraduate and research qualifications obtained by specialists in training in Australia. This is the first study to assess the number and type of credentials acquired by registrars in each specialty and to provide insight into differences between specialities.MethodsInformation on specialists in training was obtained through the Medicine in Australia: Balancing Employment and Life (MABEL) survey conducted between 2008 and 2014. The number of any additional qualifications and specific PhD, Master’s degree, postgraduate diploma/certificate and research degrees from medical school were assessed for each specialist training scheme in the database.ResultsOverall, 995 registrars representing 13 specialties were included. Just under a third (30.4%) completed a research-based degree during their medical degree and almost half (46.7%) of specialist registrars obtained further qualifications after completing medicine. A significantly higher proportion of ophthalmology (78.6%) and paediatric (67.5%) registrars, and a lower percentage of emergency medicine (36.7%) registrars, held postgraduate qualifications. Overall, 2.4% of registrars held a PhD and 10.1% held a Master’s degree. A higher percentage of either PhD or Master’s was held by ophthalmology (64.3%) and surgical (30.6%) trainees and a lower percentage by anaesthetics (6.3%) and physician trainees (7.9%). Postgraduate diplomas or certificates were most common among paediatric (41.2%) and obstetrics and gynaecology (25.6%) registrars.ConclusionThis is the first study to investigate the additional qualifications of specialists in training in Australia. Almost half of specialists in training surveyed (46.7%) have completed some form of additional study, whether it is a PhD, Master’s, postgraduate diploma/certificate or research degree from medical school. Trainees of specialist training schemes are more qualified than specialists who trained in the past Aust Fam Physician 32:92-4, 2003.

Modular working for gastroenterology specialist registrars: delivering higher quality training and improved service provision

Gastroenterology specialist registrars (SpRs) have competing demands on their time. Cover by all grades of trainees for inpatient ward work is often limited. General internal medicine (GIM) on-call frequency and subsequent ‘off days’ increased with the introduction of the 2016 contract. SpRs can

Modular working for gastroenterology specialist registrars: delivering higher quality training and improved service provision

Gastroenterology specialist registrars (SpRs) have competing demands on their time. Cover by all grades of trainees for inpatient ward work is often limited. General internal medicine (GIM) on-call frequency and subsequent ‘off days’ increased with the introduction of the 2016 contract. SpRs can

Patient and Clinician Perspectives on Electronic Patient-Reported Outcome Measures in the Management of Advanced CKD: A Qualitative Study

Chronic kidney disease (CKD) can substantially affect patients' health-related quality of life. Electronic patient-reported outcome measures (ePROMs) may capture symptoms and health-related quality of life and assist in the management of CKD. This study explored patient and clinician views on the use of a renal ePROM system. Qualitative study. 12 patients with stage 4 or 5 CKD (non-dialysis dependent); 22 clinicians (6 CKD community nurses, 1 clinical psychologist, 10 nephrologists, 3 specialist registrars, and 2 renal surgeons) in the United Kingdom. Semi-structured interviews and focus group discussion during which patients received paper versions of the Kidney Disease Quality of Life-36 and the Integrated Patient Outcome Scale-Renal to exemplify the type of content that could be included in an ePROM. Thematic analysis of interview transcripts. 4 themes were identified: (1) general opinions of PROMs, (2) potential benefits and applications of an ePROM system, (3) practical considerations for the implementation of ePROMs, and (4) concerns, barriers, and facilitators. Patients were willing to complete ePROMs on a regular basis as part of their care despite clinician concerns about patient burden. Patients assessed the questionnaires favorably. Clinicians suggested that the extent of adoption of renal ePROM systems in routine clinical settings should be based on evidence of significant impact on patient outcomes. Clinicians were concerned that an ePROM system may raise patient expectations to unrealistic levels and expose clinicians to the risk for litigation. Patients and clinicians identified potential benefits and highlighted issues and concerns that need to be addressed to ensure the successful implementation of the renal ePROM system. Transferability of the findings may be limited because only English-speaking participants were recruited to the study. A renal ePROM system may play a supportive role in the routine clinical management of patients with advanced CKD if the concerns of clinicians and patients can be sufficiently addressed.

How long does it take a registrar to complete the compulsory research project enabling specialist registration?

The 2011 Health Professions Council of South Africa mandate requires a research component in the form of an MMed degree to permit specialist registration. Registrars consider that the time required to complete an MMed interferes with clinical training, service delivery obligations, and study and exam time. Net research time to completion is difficult to establish because MMed research activity is often intermittent, starting and finishing anywhere within the 4-year clinical training period. Conversely, gross dissertation completion time (DCT) is easily calculated by subtracting the ethics approval date from the dissertation submission date. To use gross DCT as a proxy to assess the time needed by registrars to finish the required research project. Additionally, the effect of four variables, namely dissertation format, clinical discipline, university research resources and the introduction of the 2011 ruling on gross DCT, was determined. The sample was 213 MMed dissertations, downloaded from the public domain. The dissertation submission date was subtracted from the ethics approval date to give the gross DCT in months. Descriptive analysis and χ2 testing were used to determine the effects of the four variables on gross DCT, with significance set at p<0.05. A 12-month proposal preparation time was added to the gross DCT to fully reflect the MMed research timeline. Sampled dissertations were from 2005 to 2017 and all eight MMed training universities were represented, as were 23 clinical disciplines. The mean (standard deviation) gross DCT was 31.0 (19.6) months, with a wide completion range of 0.2 - 109 months. When 12 months' proposal preparation time was added, gross mean research completion time rose to 43 months (31 + 12 = 43). A mere 41% of dissertations were sufficiently concluded to free up the final year for exam preparation. Gross DCT was not significantly affected by the 2011 requirement, university resources or clinical discipline. Dissertation format (publication ready v. monograph) significantly decreased gross DCT (p=0.01). Large standard deviations and a wide range of finishing times detract from the positive findings that most dissertations were completed within the 4-year clinical training time period. Publication-ready dissertations significantly shortened MMed completion time. Unique study and work commitments and lack of research experience challenge speedy MMed completion. Existing research and supervisory supportive structures should be remodelled to better suit the research needs of the andragogic specialist registrar.

Added value of diffusion-weighted MRI for nodal radiotherapy planning in pelvic malignancies.

To evaluate the added value of diffusion-weighted imaging (DWI) to T2-weighted imaging (T2WI) for improved identification of pelvic lymph nodes (LN) by radiation oncologists. This retrospective study included 20 patients with histopathologically proven node-negative prostate cancer. All patients underwent 3T-MRI of the prostate; matched axial T2WI and DWI sequences were assessed by an experienced uro-radiologist as the reference standard. Consultant and specialist registrar radiation oncologists were asked to identify all LN first on T2WI alone (read 1) and then on T2WI and DWI combined (read 2); LN were measured in size and divided into true positives (TP), false positives (FP) and false negatives (FN). Sensitivity, positive predictive value (PPV) and false negative rate (FNR) were then calculated and compared using Pearson's Chi square test. A total of 177 LN comprised the reference standard. 16 TP, 16 FP and 161 FN LN (sensitivity 9.0%, PPV 50.0%, FNR 91.0%) and 124, 15 and 53 LN (70.1%, 89.2%, 30%) were identified by reader 1 on reads 1 and 2, respectively; χ2 (2, N = 385) = 137.8, p < 0.0001. 27, 21 and 150 LN (15.3%, 56.3%, 84.8%) and 120, 13 and 57 LN (67.8%, 90.2%, 32.2%) were identified by reader 2 on the two reads; χ2 (2, N = 388) = 102.4, p < 0.0001. Adding DWI to T2WI significantly improved identification of pelvic LN by radiation oncologists and can therefore be regarded as a useful LN contouring technique for RT planning in pelvic malignancies.

Development of the Department of Medicine for the Elderly Liaison Team

To improve the care of patients with complexity, multimorbidity and frailty within the acute hospital, through the development of a specialist liaison team. Older people undergoing emergency surgery encounter more postoperative medical problems. The National Emergency Laparotomy Audit (NELA) includes the process measure that patients over 70 should have access to specialists in the care of older patients. This led to the collaboration between critical care and surgical teams and development of the liaison service – a consultant geriatrician, specialist registrar and nurse consultant. This began an integrated way of working to improve care for emergency laparotomy patients over 70. …

Care homes learning together initiative: a collaborative approach to care home medicine

Using a multiprofessional team led by a primary care physician supported by a primary care pharmacist, general practitioner (GP) trainee, specialist registrars in geriatric medicine and adult mental health services, and …