UK National Guidelines Research Articles

PTU-009 Endoscopic Resection of Caecal Lesions ≥10 MM: Incomplete Resection and Complication Rate: Abstract PTU-009 Table 1

Introduction Endoscopic resection (ER) of caecal lesions remains technically challenging due to instability of the scope, bowel preparation and thinner bowel wall. Such limitations can affect completeness of ER. Currently there are very few data on endoscopic outcomes following ER of caecal lesions ≥10 mm. Our aim was to assess completeness and complication of ER. Methods Retrospective data was collected between 2011–2015 from documentation system ENDOBASE for all patients who had caecal ER. All lesions ≥10 mm were included. Morphology was categorised as per Paris classification. The following variables were recorded: lesion size and shape, type of ER (en bloc vs piecemeal), completeness of ER, histology, early complications, endoscopic follow up and remnant neoplasia on follow up. Results Mean (SD). A total of 111 caecal resections were performed. See table 1 for demographic details. Average lesion size was 17.2 (8.3) mm; Ip 15.0 (7.0), Is 14.7 (4.6), non-polypoid lesion 17.9 (8.8) mm. En bloc resection was achieved in 63%. In lesions Conclusion Remnant tissue post ER was similar to the UK national guidelines for colorectal polyps.1 Endoscopic resection of caecal lesions remains a challenge. Incomplete resection lesion invariably has remnant neoplasia on follow up. Strategies such as ESD/hybrid EMR should be considered. Reference 1 Rutter et al. doi:10.1136/gutjl-2015-309576 Disclosure of Interest None Declared

P219 Responding to the LGV epidemic: are the right patients being tested for LGV?: Abstract Table 1

Background UK national guidelines will recommend that samples from all Chlamydia trachomatis (CT)-positive men who have sex with men (MSM) with proctitis and all asymptomatic CT-positive MSM with HIV should be tested for Lymphogranuloma venereum (LGV). Aim To investigate case characteristics and test outcomes of samples referred to the Sexually Transmitted Bacterial Reference Unit (STBRU) for LGV testing. Methods STBRU and GUMCADv2 data for 2014 in England were matched. Test numbers and outcomes for patients in different risk categories were compared to understand targeting of LGV testing. Results In 2014, 3,782 CT samples were tested for LGV, and 2,426 (64%) were matched to GUMCADv2. MSM accounted for 77% (1876/2426), heterosexual men 7% (178/2426) and women 11% (277/2426) of LGV tests (Table 1). Overall, LGV prevalence was 15% (366/2426), and was highest among HIV-positive MSM (33%; 230/692) and lowest in women (0.4%; 1/277). MSM accounted for 93% (342/366) of all positive samples, and 67% (230/342) of MSM with LGV were HIV-positive. In 2014, there were 3,434 CT diagnoses reported by GUM clinics in HIV-positive MSM, but we found only 692 HIV positive MSM had a CT sample tested for LGV, while 1,639 CT samples were from MSM without HIV, heterosexual men, or women, suggesting inadequate testing of CT samples from HIV-positive MSM. Conclusion Although miscoding in GUMCADv2 may partially explain some LGV testing in heterosexual men and women and HIV negative MSM, these data still suggest that LGV testing might be targeted more effectively to conserve resources and maximise identification of LGV.

P063 Staff, Associate Specialist and Specialty (SAS) Doctors’ National Audit on the Management of Gonorrhoea in the UK

Background/introduction The British Society for Sexual Health and HIV (BASHH) revised United Kingdom national guideline for the management of gonorrhoea in adults, 2011, identified five auditable outcome measures. The UK National Guideline for Gonorrhoea Testing, Clinical Effectiveness Group, BASHH, 2012, suggested a further three. Aim(s)/objectives The aim was to audit national management of gonorrhoea against the standards recommended in these two documents. Only SAS doctors were eligible to participate. Methods SAS doctors, whose details were registered on the SAS database, were invited to contribute. All clinics were asked to designate a Local Co-ordinator who would register that clinic and allocate patients to the other participating doctors. Results for the individual clinics were sent to the Local Co-ordinator for dissemination. All information was submitted via a secure online link. Data from forty patients was requested. Results 3233 cases were submitted from 78 centres by 168 doctors. 68% cases were male and 44% were MSM. 83% received first line treatment. 97% were tested or treated for CT. 41% offered written information on GC. Culture attempted in 86% of those GC NAAT positive. Sensitivity testing performed on 94% culture positive. Supplementary testing performed on 61% throat and 60% rectal NAAT reactive. TOC performed on 61%; 41% of these within 2 weeks. Partner notification was done in 92% cases. Discussion/conclusion 83% patients received first-line treatment. A reason was provided for 11% treated with other regimens. The number offered written information was low at 41%. Results about supplementary testing were inconsistent. The results for the other outcomes were satisfactory.

P080 Audit of the Management of Sexual Assault Complainants attending Genitourinary Medicine against The British Association for Sexual Health and HIV UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault 2011

Background/introduction Patients attending clinic following an alleged sexual assault (SA) involve a complex history and management plan. The regional Sexual Assault Referral Centre (SARC) is on site and so the clinic receives significant numbers of SA referrals. As a clinic we felt that the proforma for documenting such histories was not fit for purpose. Aim(s)/objectives To compare the documentation and management of SA complainants against standards set out by The British Association for Sexual Health and HIV UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault 2011. Methods A retrospective case note review of notes coded for SA between 1/1/13 and 31/3/14. 36 case notes were identified for inclusion. Results 32/36 patients were female, 29/36 were heterosexual. 30/36 were of white British origin. 26/36 were referred from the local SARC. Age range 13–79 yrs. Areas which performed well in relation to the auditable outcomes were documentation in relation to: when the assault took place (100%), child protection needs (100%),who the assailant was (94%), if baseline testing occurred (94%), follow up advice (91%), what type of assault (87%). Areas which performed less well included documentation in relation to: bleeding at time of assault (8%), physical injuries (12.5%), ejaculation (24%), self harm (16%), mental state assessment (33%). Discussion/conclusion Documentation of a number of standards requires significant improvement. Safeguarding was well managed, particularly in those under 18. As a result of gaps in documentation a SA proforma has been devised to capture all the detailed information required when assessing SA patients.

UK national guidelines on the management of syphilis 2015.

These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.

Breathing exercises for adults with asthma

Asthma is a common long-term condition that remains poorly controlled in many people despite the availability of pharmacological interventions, evidence-based treatment guidelines and care pathways.1 There is considerable public interest...

The Development of a Screening Questionnaire for Obstructive Sleep Apnea in Children with Down Syndrome.

Obstructive sleep apnea is a condition which affects an estimated 50% of children with Down syndrome, particularly in their early years. It can cause serious sequelae in affected children but may not be recognized by parents or health professionals. Routine screening has been recommended in some countries, but is not standard practice. There are no validated questionnaire-based tools available to screen this population of children for this particular sleep-related disorder. Using existing validated sleep questionnaire items, we have developed a questionnaire to screen children with Down syndrome up to 6 years of age for obstructive sleep apnea, which corresponds with the recommendations made in UK national guidelines. This paper describes these first steps in demonstrating content validity for a new questionnaire, which will be subject to further in-depth psychometric analysis. Relevance, clarity, and age appropriateness were rated for 33 items using a content review questionnaire by a group of 18 health professionals with expertise in respiratory pediatrics, neurodevelopmental pediatrics, and sleep physiology. The content validity index was calculated for individual items and contributed to decisions about item inclusion. Scale level content validity index for the modified questionnaire of 14 items was at an accepted level of 0.78. Two parents of children with Down syndrome took part in cognitive interviews after completing the modified questionnaire. We describe the development of this 14 item questionnaire to screen for OSA in children with DS from infancy to 6 years.

Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS).

This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.

Four-Stage Audit Demonstrating Increased Uptake of HIV Testing in Acute Neurology Admissions Using Staged Practical Interventions.

BackgroundUK National Guidelines (UKNG) advise HIV testing in clinically indicated neurological presentations. We audited the impact of our practical strategies to increase uptake of HIV testing at a regional acute neurology admissions unit.MethodsWe audited HIV testing in 4 periods over 2 years: before we designed a UKNG-based “HIV testing in Neurology” protocol (“pre-protocol”); after dissemination of the protocol alone (“post-protocol”); post-protocol dissemination combined with both a tailored departmental admissions clerking proforma to prompt for HIV testing & consenting, and regular focussed tutorials to doctors on HIV testing in neurological patients (“post-proforma”); and finally one year after the post-proforma period (“+1 year”). We also looked at the total number of HIV tests sent from the unit during the two-year period. We assessed significance using Fisher’s exact test.Results47.8% of all acute neurology non-stroke admissions were eligible for HIV testing during all the audit periods. Testing rates were as follows: pre-protocol 21.9%; post-protocol 36.6%; post-proforma 83.3%; and at +1 year 65.4% (p<0.05 for both post-protocol and +1 year when compared to pre-protocol). Documentation of consent for HIV testing improved from 25% to 67.6% with the HIV-tailored clerking proforma. The total number of HIV tests requested from the unit doubled in the post-proforma period compared to pre-protocol (p<0.05).ConclusionIn conclusion: the combination of an HIV testing protocol, a tailored departmental clerking proforma and regular focussed teaching to doctors on indications for HIV testing led to a sustained increase in HIV testing uptake in our regional acute neurology admissions unit.

The changing etiology of liver cancer.

Shahid A Khan* speaks to Georgia Patey, Commissioning editor: Shahid Khan qualified in Medicine at Guys Hospital Medical School (London, UK) in 1994. His studies in liver cancer led to a PhD from the University of London in 2003 and he was appointed Consultant in Gastroenterology and Hepatology at St Mary’s and Hammersmith Hospitals, Imperial College London Healthcare NHS Trust; and a Clinical Senior Lecturer at Imperial College London in 2007. He is currently an Adjunct Reader in the University in addition to being a full-time NHS consultant, is Deputy Admissions Tutor for the Medical School and Director of Clinical Studies at St Mary’s Hospital Campus, Imperial College London. He has lectured on liver disease nationally and internationally at hepatology and gastroenterology conferences, including state-of-the art and invited presentations. He is the lead author on the UK National Guidelines for biliary cancer and was on the International Liver Cancer Association panel for the International Guidelines. He has published extensively in the medical literature, including original research articles, reviews and book chapters and has supervised and examined several postgraduate research degrees in this area. He is a Fellow of the Royal College of Physicians of the UK, and a member of the British Medical Association, the British Association for the Study of the Liver, the British Society of Gastroenterology, the European Association for the Study of the Liver, the American Association for the Study of the Liver Diseases and Chair of the Special Interest Group for non-HCC liver cancers for the International Liver Cancer Association.

Managing acute central nervous system infections in the UK adult intensive care unit in the wake of UK encephalitis guidelines.

The acute central nervous system infections meningitis and encephalitis commonly require management on intensive care units. The clinical features often overlap and in the acute phase-altered consciousness and seizures may also need to be managed. In April 2012, the first UK national guideline for the management of suspected viral encephalitis was published by the British Infection Association and Association of British Neurologists, and other key stakeholders, and included a simple management algorithm. The new guideline results from evidence demonstrating a number of common oversights in the standard management of suspected viral encephalitis in many settings. In combination with British Infection Association meningitis guidelines, evidence-based approaches now exist to facilitate the non-expert managing patients with suspected central nervous system infections. Here we bring together these guidelines and the supporting evidence applicable for intensivists into a single resource.

2015 UK National Guideline on the management of non-gonococcal urethritis.

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

P172 Implementation of alcohol screening in patients attending a large walk-in sexual health service within london

Background UK national guidelines advocate a role for sexual health services to offer routine screening for high-risk alcohol consumption in patients. Screening for alcohol misuse and offering brief interventions in this setting has been shown to be acceptable to clinicians and patients. In August 2014 the Fast Alcohol Screening Test (FAST) was incorporated into the sexual history proforma in a London Genitourinary Medicine (GUM) clinic. Aim An audit was undertaken to assess the use of the FAST tool and management of patients with a positive FAST result. Methods A retrospective case-notes review of randomly selected patients attending the GUM clinic in October 2014 was performed. Information was collected on patient demographics, sexual history, sexually transmitted infections, completion of FAST tool and action dependent on outcome of risk assessment. Results 169 case notes were reviewed: 55% female and 45% male, mean age was 30 (range 17–74) years. The FAST tool was completed in 87% (147/169) of case notes. Of patients screened, 86% (127) identified as low risk, 10% (15) increasing and 4% (5) high risk (hazardous drinkers). Of hazardous drinkers, 90% (18) had a documented action for risk reduction; 56% (10) had verbal advice documented, 22% (4) accepted written advice, 22% (4) accepted referral to a sexual health advisor. Conclusion Clinician completion of the FAST tool within the sexual history proforma in a busy clinic was high, with some scope for improvement. Of the relatively low number of hazardous drinkers identified, most accepted only brief verbal advice in clinic.

P88 Routine HIV testing in acute general medicine using a non-physician implemented model

Background/introduction UK national guidelines recommend routine HIV testing in general medical admissions and primary care in areas where the HIV prevalence exceeds 2/1000 in the local population. The guidelines recommend further operational research to assess the feasibility and efficacy of different approaches to routine testing. A recent study showed that when a physician led model of testing is in place, 39.7% of all general medical patients are offered HIV tests. Aim(s)/objectives Assess the feasibility and acceptability of a non-physician directed (NPD) model of HIV testing. Methods Retrospective cohort study involving a review of the proportion of all medical admissions offered tests by a NPD model of HIV testing. Results 57.9% (1973/3409) of all general medical admissions aged 18–79 were offered HIV tests. Acceptability was high with 96.7% (1908/1973) of offered patients having HIV tests. The mean age of patients offered and tested was 56.8 years. Discussion/conclusion This study demonstrates superior feasibility and efficacy of a non-physician directed model of routine HIV testing. Although cost and culture remain important barriers of employing this strategy in many hospitals, the use of allied health professionals may be an important step in achieving National and International guidelines for HIV testing.

P101 How soon are patients testing outside gum receiving a positive HIV result?

Introduction UK national guidelines for HIV testing 2008, recommend that any individual testing positive for HIV should see a specialist preferably within 48 h and certainly two weeks of receiving the result. Methods All HIV positive test results performed outside the GUM clinic between January 2013 and December 2014 were obtained from the microbiology database at Frimley Park Hospital. 35 patients were identified. 20 were excluded because they were previously known to have HIV, had a “non-specific” or “weakly reactive” result. Results Of the 15 new diagnosis, 8/15 were inpatients, 4/15 outpatients and 3/15 GP diagnosis. Two-thirds were male, 53% White British and 73% heterosexual. The average age was 46 (31–65) years. All the patients had a fourth generation HIV test and a confirmatory test. The majority (87%) were late diagnosis with symptomatic HIV/AIDS and an average CD4 count of 50 cells/mm³. One inpatient diagnosis was missed for 5 weeks until the patient re-presented with PCP. The rest were all seen by a specialist (HIV consultant or health advisor) within 2 weeks of receiving their diagnosis with 64% seen within 24–48 h. Discussion/conclusion The majority were late, symptomatic patients with AIDS. All but one result which was initially missed were seen by a specialist within the recommended 2 to 14 days after diagnosis. The recommendation now is that all positive results are phoned to the named consultant/GP responsible for the patient as well as the HIV/GUM team.

Physical Therapists' Views and Experiences of Pregnancy-Related Low Back Pain and the Role of Acupuncture: Qualitative Exploration.

Low back pain is often accepted as a "normal" part of pregnancy. Despite research suggesting that quality of life for women who are pregnant is adversely affected, most are advised to self-manage. Although the use of acupuncture for the management of persistent nonspecific low back pain has been recommended in recent UK national guidelines, its use in the management of pregnancy-related low back pain remains limited. This study aimed to explore the perceptions and experiences of physical therapists involved in treating women who are pregnant and have low back pain with the objective of informing the pretrial training program for a pilot randomized trial (Evaluating Acupuncture and Standard care for pregnant womEn with Back pain [EASE Back]). A qualitative phenomenological method with purposive sampling was used in the study. Three focus groups and 3 individual semistructured interviews were undertaken, and an iterative exploratory thematic analysis was performed. To ensure transparency of the research process and the decisions made, an audit trail was created. Twenty-one physical therapists participated, and emergent issues included: a lack of experience in treating pregnancy-related complaints, mixed messages from previous acupuncture education, a mistrust of the current evidence for acupuncture safety and effectiveness, and personal and professional fear of causing harm. The findings suggest that UK physical therapists are reluctant to use acupuncture in the management of pregnancy-related low back pain. The explanations for these findings include perceived lack of knowledge and confidence, as well as a pervasive professional culture of caution, particularly fears of inducing early labor and of litigation. These findings have been key to informing the content of the training program for physical therapists delivering acupuncture within the pilot EASE Back trial.

Excision versus incision biopsy in the management of malignant melanoma

Introduction: The incidence of melanoma has increased over the last decade. The Breslow thickness is one of the most important histological parameters. The gold standard for histological diagnosis is an excision biopsy. Incisional, punch or shave biopsies are not recommended as they are often incomplete and can result in false negatives. Objective: To assess the validity of incision versus excision biopsies in the prediction of Breslow thickness in the histopathological analysis of malignant melanoma. Methods: A retrospective review of histopathological records was conducted for all patients undergoing incision biopsy for malignant melanoma. The Breslow thicknesses of the incisional biopsies were matched to the later corresponding excisional biopsies. The demographical data, site of melanoma and histological subtype were also examined. Results: Sixty patients between 1st January 2005 and 31st December 2013 were identified. The most common area biopsied was the upper and lower limbs – 50%. The Breslow thickness and Clark's level were found to be significantly increased in excision versus incision biopsy specimens. Nine patients had differing mitotic rates which were all higher in the excision biopsy samples. Conclusion: Our data supports the UK national guidelines on the management of malignant melanoma in that incisional biopsies are not indicated in the diagnostic pathway of malignant melanoma.

Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines

Objective To identify the number of drug-disease and drug-drug interactions for exemplar index conditions within National Institute of Health and Care Excellence (NICE) clinical guidelines.Design Systematic identification, quantification, and classification...

Case studies in childhood vaccination

Immunization is one of the most important public health measures that primary care offers the population. All health professionals, regardless of whether they administer vaccines or not, should be well-informed on this topic and should know where to get the latest information on the UK national schedule and evidence-based guidelines on the use of vaccines. Nurse prescribers are in a particularly good position to make the most of opportunistic encounters to ensure that individuals who have missed routine or recommended vaccines are able to catch up without delay.

UK national guideline for the management of Genital Molluscum in adults, 2014 Clinical Effectiveness Group, British Association for Sexual Health and HIV.

UK national guideline for the management of Genital Molluscum in adults, 2014 Clinical Effectiveness Group, British Association for Sexual Health and HIV.