UK Tertiary Centre Research Articles

Zonular dialysis and cataract surgery: results from a UK tertiary eye care referral centre

ObjectifLa dialyse zonulaire (DZ), c'est-à-dire un déficit du soutien de la capsule lenticulaire par la zonule, peut avoir diverses origines et n’être décelée qu'au moment de la chirurgie de la cataracte. Notre étude visait donc à évaluer les caractéristiques pré-, per- et postopératoires dans des yeux dont la DZ a été découverte pendant l'intervention, sans égard à son étiologie. MéthodesIl s'agissait d'une étude d'observation de cohorte rétrospective réalisée dans un seul établissement, soit le Moorfields Eye Hospital (NHS Foundation Trust, Londres, R.-U.), auprès d'une cohorte de patients opérés pour une cataracte entre le 1er janvier 2014 et le 22 août 2019, afin de repérer ceux dont la chirurgie a été jugée compliquée par la découverte peropératoire d'une DZ. Ont été notés les caractéristiques des patients, les observations cliniques peropératoires, les résultats visuels et réfractifs de même que les complications postopératoires. RésultatsOn a découvert une DZ pendant l'opération dans 447 yeux. La plupart des patients (213 sur 223; 96,8 %), ont subi une phacoémulsification, sans conversion vers une extraction intracapsulaire ni extracapsulaire. Le taux de complications peropératoires s'est chiffré à 46,2 % (103 sur 223), sans corrélation significative avec l’étendue de la DZ. On a implanté un anneau de tension capsulaire (ATC) chez 43,4 % des patients (97 sur 223); enfin, on a pu établir une corrélation entre le recours à un ATC et l'amélioration des résultats visuels et réfractifs postopératoires. ConclusionsLa DZ est une complication grave de la chirurgie de la cataracte qui doit être diagnostiquée et prise en charge sans délai pendant l'intervention. Les résultats de la chirurgie tendent à être moins bons en présence de DZ, mais l'implantation peropératoire d'un ATC semble améliorer les résultats visuels et réfractifs postopératoires.

Simultaneous resection of primary tumour and metastases for colorectal cancer with synchronous liver metastases: a single centre experience.

Introduction: Approximately 22% of patients with colorectal cancer present with synchronous metastases. More patients are undergoing resection of liver metastases as surgical strategies and neoadjuvant treatments advance, shifting management from palliation to disease control. Surgical management of colorectal cancer with synchronous liver metastases is traditionally performed separately. Multiple retrospective simultaneous surgery reports deem synchronous resection feasible but outcome data are heterogeneous data and limited. The aim of this study was to analyse the experience of simultaneous resection of the primary tumour and liver metastasis at a UK tertiary centre with attention to surgical, oncological outcomes and survival benefit.

COVID-19 vaccine allergy advice and guidance: The experience of a UK tertiary referral centre

ObjectiveThe objective was to review COVID-19 vaccine allergy advice and guidance requests received and assess the impact of advice outcome on vaccination outcome. DesignA retrospective analysis of requests for advice and guidance regarding COVID-19 vaccine allergy was completed using an electronic referral system from February 2021 to January 2022. ParticipantsA total of 1265 independent patient requests for advice were received from primary care. Full vaccination information was available on 1210 patients who were included in the analysis. Main outcome measuresWe evaluated the specific outcome of request for advice (written advice versus allergy consultation), rate of vaccination, vaccination combinations, and tolerance of vaccination. ResultsOf the 1210 patients included, 959 (79%) were female. Eight hundred and ninety-six (74%) requests were managed with written advice only and of these 675 (75%) patients went on to be vaccinated. Overall, 891 (74%) of the population were vaccinated with 2 or more doses.Two hundred and nineteen patient consultations were undertaken with 109 (50%) prior to the first vaccination. Forty-nine (45%) consultations prior to vaccination were undertaken due to a label of anaphylaxis to vaccination in the past. Vaccination was recommended for all patients, and 78 (72%) of these received a first dose. Eight of these patients (10%) had symptoms within 1 h of vaccine administration.One hundred and ten (50%) consultations were undertaken for adverse reactions post COVID-19 vaccination, with 84 (76%) concerning immediate symptoms. Thirty patients (27%) who had a consultation had had adrenaline administered post vaccination. One patient had biopsy confirmed Stevens Johnson Syndrome and was referred to Dermatology. All others due for further doses (107 patients) were recommended to have subsequent doses with 49 (45%) offered the same vaccine. Eighty-nine patients had a vaccine administered post adverse reaction and 79 (88%) tolerated the dose.Skin testing and challenge to polyethylene glycol were negative in the 8 patients tested. ConclusionsOver 1000 requests for advice and guidance were received during the review period, managed mainly with written advice. The overwhelming majority of requests for advice and consultations were for females, with equal distribution both pre- and post-COVID-19 vaccine administration. Vaccination was recommended in all but 1 patient (with biopsy confirmed Stevens Johnson Syndrome). Polyethylene glycol allergy was not confirmed in any patient, nor did any patient have confirmed anaphylaxis when the vaccine was administered under our supervision, suggesting that type 1 mediated hypersensitivity is uncommon even in this "high risk" population.

Atrial fibrillation virtual ward: reshaping the future of AF care

Abstract Background Atrial fibrillation (AF) hospital admissions represent significant AF related treatment costs nationally. In the year 2019–2020 our hospital reported 1,333 admissions with a primary diagnosis of AF, with a 10% annual increase. A virtual ambulatory AF ward providing multidisciplinary care with remote hospital-level monitoring could reshape the future model of AF management. Methods An AF virtual ward was implemented at our UK tertiary centre, as a proof-of-concept model of care. Patients admitted with a primary diagnosis of AF satisfying the AF virtual ward (AFVW) entry criteria (i.e., haemodynamically stable, HR <140 bpm with other acute conditions excluded) were given access to a single lead ECG recording device, a Bluetooth integrated blood pressure machine and pulse oximeter with instruction to record daily ECGs, blood pressure readings, oxygen saturations and fill an online AF symptom questionnaire via a smart phone or electronic tablet. Data were uploaded to an integrated digital platform for review by the clinical team who undertook twice daily virtual ward rounds. Medication adjustment was arranged through the hospital pharmacy. Data was collected prospectively for patients admitted to the AF virtual ward between 31 January and 11 March 2022. Outcomes included length of hospital stay, admission avoidance and re-admissions. Re-admission avoidance was assessed using the index admission criteria as a parameter for re-admission likelihood. Patients' satisfaction was assessed using the NHS family and friends' test (FFT). Results Over the 6-week period a total of 14 patients were enrolled. One patient was unable to be onboarded because of technology related anxiety with 13 patients onboarded to the virtual ward, 30.7% (n=4) did not have smart phones and were provided with electronic tablets. The age on admission was 64±10 years (mean±SD) with the oldest at 78 years of age. All patients were in AF with a mean heart rate of 122±24 bpm, and 38.5% (n=5) were discharged from the virtual ward in sinus rhythm. One patient was onboarded directly from pacemaker clinic and hence hospital admission was completely avoided, and 5 re-admissions were avoided for 3 patients. One patient required brief readmission due to persistent tachycardia requiring acute cardioversion. The FFT yielded 100% positive responses among patients. Conclusion This proof-of-concept is a first real world experience of a virtual ward for hospital patients with fast AF. It demonstrates a promising new telemedicine-based care model and with clear appetite among both patients and health professionals. This model of care has the potential to reduce the financial and backlog pressures caused by AF admissions without compromising patients' care or safety. Work is ongoing to further confirm the safety and cost-effectiveness upon further progress in a larger patient cohort. Funding Acknowledgement Type of funding sources: None.

OGC P26 The role of inadequate analgesia in care escalation after oesophagectomy

Abstract Background There is a paucity of data describing the incidence and causes of escalation in level of care after oesophagectomy for cancer. This study aimed to address this, including the description of baseline predisposing variables, and contrasting the profile of care escalation among different surgical approaches to oesophagectomy. Methods This was a retrospective analysis of a prospectively maintained database (‘CODA’) at a UK tertiary centre. CODA is a bespoke, high-quality resource, based on senior clinician and data scientist data entry at every stage of the care of the patient's pathway. Complications are updated weekly using the Esophageal Complications Consensus group definition-set. The inclusion criteria were anyone undergoing cancer oesophagectomy between 01/06/2015 and 31/05/2021. Exclusion criteria included patients not on the ‘Enhanced Recovery after Surgery’ pathway and patients with delayed extubation (>2 days post-operatively). Escalation of care was defined as re-admission to the intensive care unit (ICU) or re-intubation on ICU. Standard care at our centre is to maintain epidural analgesia for four days after surgery. Inadequate analgesia was defined as more than one reference to inadequate pain control in the first four days after surgery when the patient deteriorated and required care escalation. Characteristics were compared between patients with and without care escalation, and between patients with and without respiratory failure related to inadequate analgesia. Results From 448 oesophagectomys, 42 patients had escalation in their level of care (9.38%). Baseline characteristics between oesophagectomy patients with and without escalation in care were similar, except for escalated patients more likely to have squamous cell carcinoma histology (28.6% vs 14.3%, P = 0.02). 20.0% of 3-phase oesophagectomy patients required care escalation but this just failed to achieve significance when compared with other oesophagectomy approaches (9.6%, P = 0.06). Of escalated patients, 35.7% had respiratory failure related to inadequate analgesia, 33.3% had respiratory failure not related to inadequate analgesia and 31.0% did not have respiratory failure as the reason for care escalation. The major cause of respiratory failure not related to analgesia was pneumonia (6 of 14, 42.9%) and the most frequent cause of non-respiratory failure associated escalation in care was re-operation (5 of 13, 38.5%). Inadequate analgesia was more commonly a contributing factor to escalation in care after left thoracoabdominal oesophagectomy compared to all other approaches (11 of 18 [61.1%] vs 4 of 24 [16.7%], P = 0.003). Conclusions The overall rate for escalation in care in this centre was low at 9.38%. This figure may be useful for benchmarking and ongoing research into morbidity after oesophagectomy. There was no clear influence from baseline characteristics or surgical approach on the rate of escalation in care. Respiratory failure contributed to escalation in care for the majority of patients. Our data indicates that left thoraco-abdominal incisions are particularly sensitive to inadequate analgesia, which suggests that effective analgesic rescue plans are especially critical after this type of oesophagectomy.

Risk factors associated with readmission within 30 days following stoma surgery: Development of a 'traffic light' prediction model.

Patients undergoing stoma surgery have a higher risk for early readmission. Some patients may benefit from closer postdischarge surveillance to provide early detection of complications and timely intervention. However, there is a paucity of validated tools to identify those at higher risk of readmission. Here, we aim to determine the independent risk factors associated with readmission within 30 days of discharge following stoma surgery, attempt to validate previous predictive models and develop a novel prediction tool. A retrospective review of 423 patients who underwent ileostomy or colostomy stoma formation at a UK tertiary colorectal centre between 2019 and 2021. Univariate, multivariate and logistic regression analyses were used to analyse a large number of demographics and risk factors and the association with readmission. This study cohort included 220 ileostomy and 203 colostomy patients. Of these, 87 (20.6%) were readmitted within 30 days of discharge following index surgery. A large number of demographics were evaluated for association with readmission. Readmission was associated with chronic heart failure (p< 0.05), postoperative stoma-specific complications (bleeding, p= 0.02; high-output stoma, p= 0.01) and those with a loop ileostomy (34.0% vs. 18.6%; p= 0.01). A previous predictive model was ineffective in this cohort, therefore a simplified 'traffic light' risk scoring system was developed and found to have improved discrimination. Readmission following stoma formation is associated with key variables that could provide the means to triage, risk score and potentially predict readmissions. We found that a novel and simplified scoring system may provide improved prediction.

Prognostic factors in oral cancer surgery - results from a UK tertiary centre

IntroductionOral cancer surgery is complicated by the diverse nature of clinical and histopathological presentations that occur. Current National guidance recognises the significant role that surgical margin status plays in the overall survival of patients. Many other histopathological factors influence patient survival, the importance of which varies between the literature. Materials and methodsIn this prospective longitudinal study, all patients diagnosed with squamous cell carcinoma who had primary surgical treatment under general anaesthesia were included. Surgery was performed by one surgical team within this tertiary referral centre. Patients were followed up for a maximum of 7 years following their surgery. ResultsA total of 250 patients were included from 2015 to 2022. Patients were 61.44 years old (SD 13.23) at diagnosis, and 56.4% were male (n = 141). Pathology was mainly pT1 (39.1%) and the most common sites were the border of tongue (31.2%) and floor of mouth (18.8%). 43.4% of patients had clear surgical margins, with overall survival being significantly associated with margin status (p = 0.0079). Extra-capsular spread was significantly associated with higher risk of death from metastatic head and neck cancer (p = 0.014), whereas presence of high-grade dysplasia at surgical margins and depth of invasion of tumour were not. ConclusionThis study has reinforced the importance of surgical margin clearance and as such the development of intra-operative techniques to ensure this is imperative. The significance of extra-capsular spread in survival has also been demonstrated. Discussion regarding the current deficiency in accurate pre-operative diagnostic methods for extra capsular spread is covered.

Pyrocarbon Lunate Replacements Perform Well at Two Years: A Retrospective Case Series and Technique from Two UK Tertiary Centres.

Background: We report medium-term results in our case series of patients with Kienböck disease receiving a pyrocarbon lunate replacement (Integra, Smith and Nephew, Watford, UK). Methods: Patients with Kienböck receiving a pyrocarbon lunate between September 2012 and November 2020, with stage 3b and above were included. Patients were staged preoperatively with radiographs and MRIs. Pre- and postoperative visual analogue scores and movement were documented. Postoperative radiographs were obtained at 6 weeks, 6 months and 1 year. Results: Seven patients were identified, all female, with a median age of 28.0 years. All but one had 3b disease and the median follow-up was 2 years (range 13-112 months). A mean 9/10 preoperative VAS score improved to 1/10 by 3 months postoperatively (p < 0.001, paired t-test). No major complications were seen, and implants were stable radiologically. Conclusions: A semi-constrained pyrocarbon lunate can provide good results for patients with advanced Kienböck's disease, offering an alternative to proximal row carpectomy salvage surgery. Level of Evidence: Level IV (Therapeutic).

84P Ambulatory management of ICI-induced hepatitis: A safe and effective management approach

The incidence of immune related adverse events (irAEs) secondary to oncological immune checkpoint inhibitors (ICIs) are treated as standard with high dose corticosteroids (CST). Grade 3-4 hepatitis is managed with intravenous methylprednisolone (IVMP) as per international protocols. CST treatment is effective but if administered in the inpatient setting can lead to long hospital stays, psychological distress and increased risk of hospital related illness. Clatterbridge Cancer Centre (CCC), a UK tertiary cancer centre, has an established regional pan-tumour immunotherapy (IO) service to support all patients with irAEs and delivers a ambulatory IVMP pathway as part of that service.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AimThis study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre. MethodsThis study included 128 consecutive PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05. ResultsAcross the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05). ConclusionPFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

NCOG-02. STEREOTACTIC RADIOSURGERY (SRS) FOR BRAIN METASTASES FROM MELANOMA: AN EVALUATION OF OUTCOMES AT A UK TERTIARY CENTRE

Abstract INTRODUCTION Brain metastases (BM) are common in melanoma and historically associated with poor prognosis. Targeted systemic treatment have improved prognosis, and stereotactic radiosurgery (SRS) may offer an effective and less neurotoxic option. We evaluated the outcomes and potential prognostic factors of patients treated with SRS. METHODS Retrospective study of patients treated with linac-based SRS for BM from melanoma in a UK tertiary centre between August 2017-September 2021. Overall survival (OS), intracranial progression-free survival (IPFS), and prognostic factors were evaluated using Kaplan–Meier analysis, log-rank test, and Cox proportional-hazards model. RESULTS Median follow up was 32 months. 69 patients were included. Median age was 59 years old (range 30-93), and 63% were male. 99% had performance status of 0/1. 45% had BRAF mutation, and 68% had stable extracranial disease at SRS. 62 patients had first-line treatment with SRS. 133 BM were treated, with mean volume of 0.39 cm3(range 0.02-18.82). Median prescription dose was 23 Gy (range 14-24Gy), prescribed to 100% isodose. Median OS and IPFS from SRS was 18 months (95% CI 5-31), and 12 months (95% CI 6-18), respectively. 6 months and 1 year local control (LC) rate were 79% and 64 %, respectively. 91% had out-of-field recurrences. Patients with BRAF mutation had shorter IPFS compared to BRAF WT (7 months vs 18 months, HR 2, p=0.04). 36% were on BRAF inhibitors, and IPFS were longer for patients on immunotherapy within 3 months of SRS (15 months vs 4 months, HR 2.6, p=0.03). There was non-significant trend towards shorter OS and IPFS for patients who were male, ≥ 65 years old, BRAF mutant, progressive extracranial disease, &amp;gt; 4 BM, and total volume of ≥ 5cm3. CONCLUSION SRS demonstrates good OS and LC for treatment of BM from melanoma. Prospective studies should establish the synergistic effects between targeted treatment and SRS.

A selective anticoagulation policy for splanchnic vein thrombosis in acute pancreatitis is associated with favourable outcomes: experience from a UK tertiary referral centre.

There is a paucity of data on the incidence, risk factors, and treatment of splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). All AP admissions between 2018 and 2021 across North East of England were included. Anticoagulation was considered in the presence of superior mesenteric vein/portal vein (SMV/PV) thrombus or progressive splenic vein thrombus (SpVT). The impact of such a selective anticoagulation policy, on vein recanalisation rates and bleeding complications were explored. 401 patients (median age 58) were admitted with AP. 109 patients (27.2%) developed SVT. The splenic vein in isolation was the most common site (n=46) followed by SMV/PV (n=36) and combined SMV/PV and SpVT (n=27). On multivariate logistic regression alcohol aetiology (OR 2.64, 95% CI [1.43-5.01]) and >50% necrosis of the pancreas (OR 14.6, 95% CI [1.43-383.9]) increased the risk of developing SVT. The rate of recanalization with anticoagulation was higher for PVT (66.7%; 42/63) than in SpVT (2/11; p=0.003). 5/74 of anticoagulated patients developed bleeding complications while 0/35 patients not anticoagulated had bleeding complications (p=0.4). The risk of SVT increases with AP severity and with extent of pancreatic necrosis. A selective anticoagulation policy for PVT and progressive SpVT in AP is associated with favourable outcomes with no increased risk of bleeding complications.

ALBI grade predicts suitability for further systemic therapy following sorafenib in patients with advanced hepatocellular carcinoma

AbstractBackground &amp; AimsPreserved performance status (PS) and liver function are required for systemic therapy in patients with advanced hepatocellular carcinoma (aHCC). We investigated the frequency of suitability for further systemic therapies following sorafenib in aHCC.MethodsDemographic, tumour and therapy‐related data were collected retrospectively for patients with aHCC who received sorafenib at a UK tertiary referral centre (training cohort), and an independent French centre (validation cohort). The primary endpoint was percentage of patients with Child‐Pugh class A (CP‐A) liver disease and PS 0–1 after sorafenib discontinuation.ResultsSorafenib was received by 182 patients. After sorafenib discontinuation, 93 patients (51%) were CP‐A and 60 patients (33%) were PS 0–1; 43 patients (24%) were both CP‐A and PS 0–1. On multivariable analysis, patients with Albumin‐Bilirubin (ALBI) score of 1 at time of sorafenib commencement were more likely to be suitable for post‐sorafenib therapy, (44% grade 1 vs 15% grade 2) (OR 3.76, 95%CI 1.72–8.25, P = .0009). In the validation cohort of 216 patients baseline ALBI grade was also significantly associated with suitability for further systemic therapy (P = .008).ConclusionsMost patients with aHCC are not suitable for further systemic therapy after sorafenib, but those with ALBI grade 1 have a greater likelihood of suitability.

Variation in management of porocarcinoma: a 10-year retrospective review of 75 cases across three UK tertiary centres.

Variation in management of porocarcinoma: a 10-year retrospective review of 75 cases across three UK tertiary centres.

Hepatic benign and malignant masses in children: a single UK tertiary centre experience.

The aim of this study was to review the incidence, spectrum and investigation of liver masses presenting to our tertiary liver unit. A retrospective single-centre cohort study of paediatric patients (age < 16years) diagnosed with a liver mass who were investigated at a UK paediatric hepatobiliary tertiary referral centre. Data relating to the clinical findings at presentation, source of referral, diagnostic investigations and histopathology findings were recorded and analysed. 107 patients were identified between July 2012 and July 2019 (55 females). 69 (64%) patients had benign liver lesions, whereas the remaining 38 (36%) were found to have malignant masses. The liver lesions were most commonly detected incidentally (33%) with the second most common presentation being with palpable mass(29%). 82 (77%) patients were referred from other hospitals. All patients underwent USS, 74% MRI, 36% CT, 5% CEUS, 1% PET and 5% HIDA scan with 47% ultimately undergoing biopsy. 72% of patients had AFP measured. The most common benign liver masses were haemangioma 33 (48%), hepatic cyst 17 (25%) and FNH 12 (19%). Amongst the malignant lesions, 29 (76%) were hepatoblastoma and 3 (8%) were hepatocellular carcinoma. This large review series demonstrates that just over 1/3 of patients presenting to a paediatric tertiary referral centre with a focal liver lesion had neoplastic liver lesions, despite the published literature commonly stating that 2/3 of paediatric liver masses are malignant.

A low rate of end-stage kidney disease in membranous nephropathy: A single centre study over 2 decades.

Membranous nephropathy is the commonest cause of nephrotic syndrome in non-diabetic Caucasian adults over the age of 40 years. Primary membranous nephropathy is limited to the kidneys. Clinical management aims to induce remission, either spontaneously with supportive care, or with immunosuppression. Here, we describe the natural history of this condition in a large tertiary centre in the UK. 178 patients with primary membranous nephropathy were identified over 2 decades. We collected data on demographics, baseline laboratory values, treatment received and outcomes including progression to renal replacement therapy and death. Analysis was performed on the whole cohort and specific subgroups. Univariate and multivariate Cox regression was also performed. Median age was 58.3 years with 63.5% male. Median baseline creatinine was 90μmol/L and urine protein-creatinine ratio 664g/mol. Remission (partial or complete) was achieved in 134 (75.3%), either spontaneous in 60 (33.7%) or after treatment with immunosuppression in 74 (41.6%), and of these 57 (42.5%) relapsed. Progression to renal replacement therapy was seen in 10.1% (much lower than classically reported) with mortality in 29.8%. Amongst the whole cohort, those who went into remission had improved outcomes compared to those who did not go into remission (less progression to renal replacement therapy [4.5% vs 28%] and death [20.1% vs 67%]. Those classified as high-risk (based on parameters including eGFR, proteinuria, serum albumin, PLA2R antibody level, rate of renal function decline) also had worse outcomes than those at low-risk (mortality seen in 52.6% vs 10.8%, p<0.001). The median follow-up period was 59.5 months. We provide a comprehensive epidemiologic analysis of primary membranous nephropathy at a large tertiary UK centre. Only 10.1% progressed to renal replacement therapy. For novelty, the KDIGO risk classification was linked to outcomes, highlighting the utility of this classification system for identifying patients most likely to progress.

Atrial fibrillation virtual ward: reshaping the future of AF care

Abstract Background Atrial fibrillation (AF) hospital admissions represent significant AF related treatment costs nationally. In the year 2019–2020 our hospital reported 1,333 admissions with a primary diagnosis of AF, with a 10% annual increase. A virtual ambulatory AF ward providing multidisciplinary care with remote hospital-level monitoring could reshape the future model of AF management. Methods An AF virtual ward was implemented at our UK tertiary centre, as a proof-of-concept model of care. Patients admitted with a primary diagnosis of AF satisfying the AF virtual ward (AFVW) entry criteria (i.e., haemodynamically stable, HR &amp;lt;140 bpm with other acute conditions excluded) were given access to a single lead ECG recording device, a Bluetooth integrated blood pressure machine and pulse oximeter with instruction to record daily ECGs, blood pressure readings, oxygen saturations and fill an online AF symptom questionnaire via a smart phone or electronic tablet. Data were uploaded to an integrated digital platform for review by the clinical team who undertook twice daily virtual ward rounds. Medication adjustment was arranged through the hospital pharmacy. Data was collected prospectively for patients admitted to the AF virtual ward between 31 January and 11 March 2022. Outcomes included length of hospital stay, admission avoidance and re-admissions. Re-admission avoidance was assessed using the index admission criteria as a parameter for re-admission likelihood. Patients' satisfaction was assessed using the NHS family and friends' test (FFT). Results Over the 6-week period a total of 14 patients were enrolled. One patient was unable to be onboarded because of technology related anxiety with 13 patients onboarded to the virtual ward, 30.7% (n=4) did not have smart phones and were provided with electronic tablets. The age on admission was 64±10 years (mean±SD) with the oldest at 78 years of age. All patients were in AF with a mean heart rate of 122±24 bpm, and 38.5% (n=5) were discharged from the virtual ward in sinus rhythm. One patient was onboarded directly from pacemaker clinic and hence hospital admission was completely avoided, and 5 re-admissions were avoided for 3 patients. One patient required brief readmission due to persistent tachycardia requiring acute cardioversion. The FFT yielded 100% positive responses among patients. Conclusion This proof-of-concept is a first real world experience of a virtual ward for hospital patients with fast AF. It demonstrates a promising new telemedicine-based care model and with clear appetite among both patients and health professionals. This model of care has the potential to reduce the financial and backlog pressures caused by AF admissions without compromising patients' care or safety. Work is ongoing to further confirm the safety and cost-effectiveness upon further progress in a larger patient cohort. Funding Acknowledgement Type of funding sources: None.

Role of routine chest xrays and device checks in detecting peri-procedural complications associated with cardiac device implantation: a UK tertiary centre experience

Abstract Introduction Complications associated with Cardiac implantable electronic devices (CIEDs) are not uncommon, most of which occur in the perioperative phase. Until recently, guidance on implemented measures for early detection of peri-operative complications were lacking. The ESC guidelines on pacing recommend routine follow up of all newly implanted devices within 72 hours of implant. While the recently published EHRA expert consensus and practical guide on CIEDs recommend that a chest x-ray should be performed within 24 hours in all patients to rule out pneumothorax and document lead positions. Purpose At our tertiary centre for CIEDs, it is routine practice to perform CIEDs implantations on a day-case basis, targeting same day discharge for uncomplicated procedures. CXRs are performed 4 hours after the implant, and CIEDs are fully checked twice, once “on table” at the end of the procedure, and again after mobilisation and prior to discharge. In our analysis, we aimed to identify the yield of complications that could be detected early-on using these routine measures in all our implant procedures. Methods We performed a retrospective analysis of consecutive CIED implants performed between January and December 2019. The following information were collected; types and indications for device therapy, device checks reports, CXR reports, and clinical notes for documented symptoms or signs suggestive of peri-procedural complications. Results A total of 578 patients (Age 74±16 years, 68% male) were included in our analysis, for demographics see table. All patients had routine CXRs and 2 device checks. There were 16 (2.8%) peri-procedural complications associated with our device implants, 7 (1.2%) pneumothoraxes, 6 (1%) pericardial effusions, and 3 (0.5%) lead displacements. In 4 out of the 7 peri-procedural pneumothoraxes, the operator reported difficulty gaining access. 2 patients with pneumothorax reported chest pain, 1 patient reported shortness of breath and 1 had low O2 saturations. There were 2 asymptomatic cases of pneumothorax after reportedly straightforward procedures and were only detected on the routine CXRs, one of them required chest drain insertion and the other treated conservatively. 2 out of the 3 lead displacements were detected on both CXRs and pre-discharge pacing checks and didn't require intervention, while 1 case of lead displacement occurred after the pacing checks and CXRs were reported to be satisfactory, further pacing checks triggered by patient's symptoms and bradycardia on the monitor revealed lead displacement requiring intervention prior to discharge. Conclusion Routine post CIED implantation CXRs can detect early – otherwise clinically silent-periprocedural complications and appropriately remains a requirement for all CIED implants. While repeat post mobilisation device checks has low yield of detection of complications and can be reasonably abandoned provided that initial “on-table” checks are satisfactory. Funding Acknowledgement Type of funding sources: None.

Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective

The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort.To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre.We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment.In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.

P17.08.B Single institutional retrospective review of re-irradiation in High Grade Gliomas in a tertiary UK centre

Abstract Background Recurrent high grade gliomas (HGG) pose a treatment challenge as no definite guidelines exist. Re-excision could be appropriate in some cases while systemic therapy options are only a handful. We thus need to resort to the option of re-irradiation at some point but there could be a wide variety of techniques, volumes &amp; doses to choose from due to lack of robust evidence. The UK wide BRIOCHe study for Glioblastoma Multiforme (GBM) will help in providing some standardisation. With this retrospective study, we aim to review our institutional practice with re-irradiation &amp; our patient outcomes. Material and Methods Electronic health records over a period of 3 years from 1 Jun 2019 to 30 May 2021 were searched for patients with HGG that underwent a course of re-irradiation. Various patient factors, tumour &amp; treatment factors at baseline and at recurrence and survival data were collected. Results Total of 8 patients received re-irradiation with all except one having a performance status of 1 at the time of treatment. Seven patients had GBM, one had transformation from baseline G2 glioma and the eighth patient had anaplastic oligodendroglioma (ODG). MGMT was methylated in 62.5% patients while IDH mutation was present only in the transformed glioma. Majority patients had radiotherapy dose of 60Gy/30 fractions with concurrent temozolomide (TMZ) at baseline to a median CTV volume of 186cc. A median of 6 cycles of TMZ were given in the adjuvant setting. Median time to recurrence from completion of adjuvant treatment was 6.7 months (range: 0.9 - 171.6 months). Most recurrences were in the same or an adjacent lobe whereas 1 patient had a multi-focal recurrence. Half the patients at recurrence underwent a re-resection. All patients had salvage chemotherapy at the time of recurrence with a median of 2 regimens and a median of 6 cycles prior to re-irradiation. All patients received a re-irradiation dose of 35Gy in 10 fractions to a median CTV volume of 149cc. The median interval from previous radiotherapy was 18.9 months (range: 11.6 - 190.5 months). The median time to progression from re-RT was 5.4 months (CI: 3.4 - 7.4) and median survival from re-RT was 7 months (CI: 6.2 - 7.8). The median overall survival since diagnosis was 35.1 months (CI: 22.2 - 48.1), one patient was lost to follow up. Conclusion Re-irradiation is a safe &amp; feasible treatment option in carefully selected cases of high grade glioma.