Units In Scotland Research Articles

The impact of Scotland's minimum unit pricing for alcohol policy on people accessing services for alcohol dependence: A difference-in-difference structured interview study.

A minimum unit price (MUP) for alcohol of £0.50 per unit (1 UK unit = 10 mL/8 g alcohol) was introduced in Scotland in May 2018. Few previous studies have examined the impact of alcohol pricing policies on people who are alcohol dependent. This study aimed to evaluate the effect of MUP on people who are alcohol dependent including changes in alcohol consumption and health status, as well as potential unintended consequences. Three waves of cross-sectional data were collected in Scotland (intervention) and Northern England (control) at 0-6 months pre-implementation then 3-9 months and 18-22 months post-implementation. The sample was N = 706 people receiving treatment related to their alcohol use. We collected structured interview data including recent drinking information via a 7-day timeline-follow-back drinking diary. Difference-in-difference analyses estimated change in indicators in Scotland compared to England at both post-implementation timepoints. The proportion of participants consuming alcohol costing on average <£0.50 per unit in Scotland decreased from 60.6% at 0-6 months prior to MUP implementation to 6.3% at 3-9 months post-implementation (p < 0.0004). There was no significant change in the indicators for alcohol consumption, severity of dependence, health status, other substance use, deprivation level or parenting. The introduction of MUP in Scotland was associated with increases in the prices paid for alcohol by people with dependence and presenting to treatment services. There was no evidence of changes in their alcohol consumption or health status. There was also no evidence of harmful unintended consequences for this population.

Provision of oral medicine in Scottish oral and maxillofacial surgery units: where are we and where are we going?

Introduction Oral medicine (OM) care occupies a significant quantity of oral and maxillofacial surgery (OMFS) outpatient clinical time. This survey aims to examine the current provision of OM care in OMFS units and explore opinions on how to improve the delivery of OM services across Scotland.Method An anonymous online questionnaire was distributed to all (33) OMFS consultants in Scotland. A range of questions were asked, covering place of work, formal OM training, proportion of time spent delivering OM clinical care, referral practices and support for a managed clinical network (MCN) in Scotland.Results A total of 18 (55%) OMFS consultants completed the survey. The majority of respondents (72%) worked in a university teaching hospital (UTH) setting. While none of the respondents were on the OM specialist register, most (72%) had received formal training in OM during their OMFS specialty training. Time dedicated to OM in outpatient clinics varied between less than 20% and 20-40% of clinical time. The majority of respondents (50%) referred 1-2 patients per month to OM. Most OMFS consultants (72%) felt that local OM services should be expanded and 78% would support the inclusion of OM specialists as part of the OMFS outpatient clinic team.Conclusion This study highlights the significant contribution to OM care within OMFS units in Scotland and emphasises the need for close collaboration between specialties. There is support for OM specialists to form part of the OMFS clinical team in UTHs or district general hospitals. Additionally, there is widespread support for the development of a MCN model of OM care in Scotland.

The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study

Background: Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 ‘A’s test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking. Aim: To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients. Design: A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment. Setting/participants: Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years. Results: A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%–98%) and a specificity of 94% (95% CI 90%–99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94–1). Conclusion: The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings. Trial registry: ISCRTN 97417474.

#5475 SAFETY OF NATIVE AND TRANSPLANT KIDNEY BIOPSY IN A NATIONAL COHORT

Abstract Background and Aims Safety of kidney biopsy is variably reported in different published series. Since 2014, all native kidney biopsies undertaken in the 9 adult renal units in Scotland have been recorded by the Scottish Renal Registry (SRR) and since 2015 all transplant kidney biopsies were included. In this complete national dataset, we report data on safety of kidney biopsy in a current real world setting. Method Major complications of kidney biopsy are recorded using pre-defined terms and include: arteriography and embolisation, arteriography no embolisation, clot retention, blood transfusion only, death within 28 days directly attributable to biopsy, nephrectomy and other. Biopsies are undertaken under ultrasound guidance using 16G or 18G spring loaded biopsy guns. All centres discontinue clopidogrel, DOACs and warfarin. Some centres continue aspirin. In some centres biopsy is performed by nephrologists and in others by radiologists Results In total, 6979 biopsies in 5755 patients were recorded between 2014 and 2021 (5095 native biopsies and 1884 transplant biopsies), with an adequacy for diagnosis of 98.1%. Table 1 describes the demographics, indications, operator and diagnoses made by biopsy type. Overall, in patients undergoing native kidney biopsy 2.4% suffered a major complication and 1.4% of patients undergoing transplant biopsy. The commonest complication was the requirement for arteriography, with or without embolisation. We included CT angiography in this group. There were 8 deaths within 28 days attributable to renal biopsy. Conclusion Kidney biopsy remains safe for the vast majority of patients and complications are less likely with transplant biopsy.

COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study

BackgroundPrevious research has shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die. At present there are limited data in relation to outcomes and healthcare utilisation following hospital discharge of pregnant and recently pregnant women admitted to critical care. MethodsA national cohort study of pregnant and recently pregnant women who were admitted to critical care in Scotland with confirmed or suspected COVID-19. We examined hospital outcomes as well as hospital re-admission rates. ResultsBetween March 2020 and March 2022, 75 pregnant or recently pregnant women with laboratory-confirmed COVID-19 were admitted to 24 Intensive Care Units across Scotland. Almost two thirds (n=49, 65%) were from the most deprived socio-economic areas. Complete 90-day acute hospital re-admission data were available for 74 (99%) patients. Nine (12%) women required an emergency non-obstetric hospital re-admission within 90 days. Less than 5% of the cohort had received any form of vaccination. ConclusionsThis national cohort study has demonstrated that pregnant or recently pregnant women admitted to critical care with COVID-19 were more likely to reside in areas of socio-economic deprivation, and fewer than 5% of the cohort had received any form of vaccination. More targeted public health campaigning across the socio-economic gradient is urgently required.

An exploration of the use of photobiomodulation for management of oral mucositis in children and young people undergoing cancer treatment in the UK

PurposeOral mucositis affects up to 80% of children and young people (CYP) receiving chemotherapy. This can result in pain, reduced oral intake and, in severe cases, hospitalisation for parental nutrition and pain relief. Photobiomodulation is recommended by multiple bodies for mucositis management for those undergoing cancer treatments. The current use of photobiomodulation within the UK, and the barriers and facilitators to implementation is unknown.MethodAn online mixed-methods survey was administered to representatives from the Children’s Cancer and Leukaemia Group (CCLG) between October 2021 and March 2022. This explored: use of photobiomodulation, planned future use, barriers and facilitators to implementation and dental assessment. Quantitative data underwent descriptive statistics. Barriers and facilitators to the implementation of photobiomodulation were analysed using the Theoretical Domains Framework (TDF).ResultsAll UK CCLG centres responded (n = 20, a response rate of 100%). Two units in Scotland were delivering photobiomodulation. A further four units were planning to implement a service. Most units, 65% (n = 13) utilised specialist Paediatric Dentistry services for dental assessment. In the TDF analysis, five domains were most frequently populated: knowledge, skills, environmental context and resources, social influences, and social/professional role and identity.ConclusionPhotobiomodulation was only available in Scotland in two children’s cancer units. Lack of knowledge and skills, and insufficient environmental resources were identified as barriers. Collaboration with paediatric dental services was identified as a facilitator. The establishment of a national network of Paediatric Dentists and Oncologists would promote collaboration to standardise protocols and to address the identified barriers to wider implementation of photobiomodulation.

Case-mix and outcome variability in people with diabetic foot complications in England and Scotland

Abstract Background We assessed the difference in survival rates for people with diabetes experiencing LEA in England and Scotland, using large databases held by the Royal College of General Practitioners (RCGP) and the Scottish Diabetes Register (SCI-DC). Methods Observational retrospective study of T2D adults 18+ years with LEA between 1/1/2008-1/1/2018 from 1,800 general practices in England (7.4%) and all primary, secondary care units in Scotland. Significance tests were carried out using univariate odds ratios within each database. Results On 1/1/2018, N = 127,100 people with T2D were registered alive in RCGP, with N = 1,052 (832 per 100,000) experiencing prior LEA, vs N = 2,200 (783 per 100,000) out of 280,908 in SCI-DC. Among them, England recorded N = 405 patients (72.5%) with prior DFU diagnosis vs N = 993 in Scotland (74.3%), with a median time DFU to LEA of 2.0 vs 2.4 years. The median time spent with LEA was 3.4 years in England vs 3.9 years in Scotland. After including those dying earlier, different univariate patterns were found for England and Scotland. In both networks, increased risk was found for those aged 50+ at first LEA, with prior history of acute myocardial infarction, peripheral arterial disease, ischemic heart disease, cerebrovascular event, higher glomerular filtration rate and major LEA first. In England, reduced risks were found for males (OR = 0.77, 95%CI: 0.64-0.93) and people with retinopathy (0.69; 0.57-0.82), while higher risk were found for hypertension (1.29; 1.09-1.54). In Scotland, lower risks were found for obese (0.59; 0.52-0.66) and those with DFU after LEA (0.74; 0.62-0.89), vs higher rates among those of non-white ethnicity (1.63; 1.19-2.23) and dyalisis (2.31; 1.75-3.07). Conclusions Notable differences were found between England and Scotland in terms of characteristics associated with different outcomes following LEA among T2D adults. Multivariate analyses of aggregate patterns are currently ongoing to adjust for potential confounding. Key messages • Routine datasets from England and Scotland showed a differential impact of case-mix characteristics on lower extremity amputations among adults with Type 2 diabetes. • Information available from different clinical networks can be mapped against the available standard sets to compare health care outcomes of people with different complex conditions.

P11.29: Improving Tissue Donation Referral Rates From the Emergency Department - A QI Project

Background: This project was undertaken by a Junior Dr a hospital Emergency Department (ED) in Scotland. The aim was to increase tissue donation referral rates for deceased patients, by referring at least 50% of potential donors. Eligbale potential donors were those who did not have dementia, haematological malignancy or blood borne virus. The number of potential donor deaths monthly was around 7, making tissue referrals a low frequency but high acuity event. It was a small project but so successful that the materials developed were rolled out Nationally. Method: Using the Plan Do Study Act approach, multiple departmental interventions were undertaken. These included surveying staff to identify barriers to tissue donation; focused teaching moments; posters to prompt staff in key clinical areas; development of a clear process algorithm, pocket sized laminated Tissue Donation Information cards for staff, as well as a suggested “script” to raise donation with families, and regular progress updates on referral rates both written and verbal. The Potential Donor Audit data was collected monthly from August 2017 until June 2019 by the Tissue Donor Co-ordinator on all deaths and referrals from the department. Prior to this there had been no referrals made. Before approaching families to discuss tissue donation the Tissue Donor Co-ordinator should be contacted to check the Organ Donor Register and confirm eligibility for donation. This is considered as a ‘referral’ for audit purposes irrespective of whether donation proceeds. Results: □The aim of referring 50% of eligible potential tissue donors to the tissue donor co-ordinator was achieved during the data collection period (average 55%). □The project commenced in August 2017 and data was collected until June 2019. □The interventions implemented are outlined in the table and correspond to the arrows on the chart. □Anecdotal feedback from staff involved has demonstrated many families took comfort from donation and staff felt more comfortable approaching families using the suggested wording. □In total, 2 hearts (for valve donation) and 26 eyes (for corneal donation) were donated by patients. Two further hearts were accepted for donation but unable to be retrieved due to operational reasons. Conclusion: This project resulted in significant improvement in referral rates. The cumulative effects of the interventions are most likely to have resulted in the improvement. Anecdotally staff fed back that the process flow chart and the pocket information cards have been the most helpful interventions in their day to day practice. The methods used in this Quality Improvement Project could readily be applied in other ED’s who are introducing tissue donation or looking to improve referral rates. During 2021 the prompt cards developed were disseminated Nationally to ED’s and Intensive Care Units in Scotland who are able to facilitate Tissue Donation.

Post-stroke emotionalism (PSE): a qualitative longitudinal study exploring individuals’ experience with PSE

Purpose Post-stroke emotionalism (PSE) is a common consequence of stroke characterised by episodes of crying or laughing. There is only one published qualitative study exploring the experience of emotionalism to date. This study aimed to explore individual’s experience of PSE and develop a theoretical client-derived framework to shape future psychological interventions. Materials and methods A primary analysis of the qualitative pseudonymised pre-collected semi-structured interview data of the TEARS study was completed. Participants were recruited from nine acute stroke units in Scotland with participants commencing the study at baseline (two-weeks) and they either continued or dropped out. Interviews were completed at two-weeks, six-months and 12-months post-stroke. Results Data was analysed from 52 participants at two-weeks, 25 participants at six-months and 23 participants at 12-months. Three major themes were identified: “In the moment,” describing characteristics and triggers, “Ways of coping,” highlighted a variation of coping strategies including avoidance or acceptance and “Impact,” outlining the longer-term effects of PSE such as individuals’ beliefs. Conclusion The results indicate specific psychological aspects of PSE which could be viable targets in psychological interventions such as increasing adaptive coping strategies and challenging negatively held beliefs. IMPLICATIONS FOR REHABILITATION Emotionalism can cause emotional consequences such as distress, embarrassment and fear. Helping individuals to develop insight into triggers for emotionalism could be beneficial to help gain understanding and awareness whereby post-stroke emotionalism (PSE) has the potential to be anticipated and adapted to psychologically. Potential adaptive responses such as acceptance or control and better anticipation of episodes of emotionalism could help to reduce the emotional consequences of PSE.

A new stratigraphic framework for the early Neoproterozoic successions of Scotland

The circum-North Atlantic region archives three major late-Mesoproterozoic to Neoproterozoic tectonic episodes, the Grenville–Sveconorwegian and Renlandian orogenies followed by rifting and formation of the Iapetus Ocean, and each is bracketed by sedimentary successions that define three megasequences. In this context, we summarize sedimentological and geochronological data and propose a new stratigraphic framework for the iconic Torridonian–Moine successions and related units in Scotland. The Iona, Sleat, Torridon and Morar groups of the Scottish mainland and Inner Hebrides, and the Westing, Sand Voe and Yell Sound groups in Shetland, form the newly named Wester Ross Supergroup. They were deposited c. 1000–950 Ma within a foreland basin to the Grenville Orogen and, collectively, are in Megasequence 1. Some of these units record Renlandian orogenesis at c. 960–920 Ma. The newly named Loch Ness Supergroup consists of the Glenfinnan, Loch Eil and Badenoch groups of the Scottish mainland, deposited c. 900–870 Ma and are assigned to Megasequence 2. These units record Knoydartian orogenesis c. 820–725 Ma. The regionally extensive Dalradian Supergroup belongs to Megasequence 3; it was deposited c. &lt;725–500 Ma and records the opening of the Iapetus Ocean, ultimately leading to deposition of the passive margin Cambrian–Ordovician Ardvreck and Durness groups.

Long admission waiting list at the Orchard clinic-why?

AimsThe Orchard clinic is one of the three medium secure units in Scotland. This project was completed: To gain an understanding of the causes of the Orchard clinic's long admission waiting list.To use this information to improve current clinical pathways, service development and further research and development.MethodTo study the longitudinal traffic flow through the clinic from January 2017 to December 2019, data were collected for this time retrospectively from electronic minutes of fortnightly bed management meetings at the Orchard clinic.This was cross checked with the Orchard clinic's record of admissions and discharges during this time and approved by the Forensic Research and Audit Group, NHS Lothian.ResultNovember 2018 onwards, a surge of 90% was observed in the admission waiting list.Looking at the trends of traffic flow through the clinic during this time, the following observations were made:1. More admissions than discharges, especially November 2018 onwards.2. New referrals for medium secure care at the Orchard clinic peaked twice during this time.3. Delayed discharges peaked in July 2018 and further in January 2019 running parallel to the surge in admission waiting list thereafter.4. 42% patients on the delayed discharge list belonged to other health boards awaiting local low secure/community placements.ConclusionDelayed discharges were identified as a constant parallel to the long waiting list and hence identified as the main factor contributing to it. Out of area (non-NHS Lothian) admissions were noted to be linked to these delayed discharges.Regular peaks in new referrals was also noted to be contributory.

Influence of socioeconomic deprivation on interventions and outcomes for patients admitted with COVID-19 to critical care units in Scotland: A national cohort study.

BackgroundCoronavirus disease 2019 (COVID-19) can lead to significant respiratory failure with between 14% and 18% of hospitalised patients requiring critical care admission. This study describes the impact of socioeconomic deprivation on 30-day survival following critical care admission for COVID-19, and the impact of the COVID-19 pandemic on critical care capacity in Scotland.MethodsThis cohort study used linked national hospital records including ICU, virology testing and national death records to identify and describe patients with COVID-19 admitted to critical care units in Scotland. Multivariable logistic regression was used to assess the impact of deprivation on 30-day mortality. Critical care capacity was described by reporting the percentage of baseline ICU bed utilisation required.FindingsThere were 735 patients with COVID-19 admitted to critical care units across Scotland from 1/3/2020 to 20/6/2020. There was a higher proportion of patients from more deprived areas, with 183 admissions (24.9%) from the most deprived quintile and 100 (13.6%) from the least deprived quintile. Overall, 30-day mortality was 34.8%. After adjusting for age, sex and ethnicity, mortality was significantly higher in patients from the most deprived quintile (OR 1.97, 95%CI 1.13, 3.41, p=0.016). ICUs serving populations with higher levels of deprivation spent a greater amount of time over their baseline ICU bed capacity.InterpretationPatients with COVID-19 living in areas with greatest socioeconomic deprivation had a higher frequency of critical care admission and a higher adjusted 30-day mortality. ICUs in health boards with higher levels of socioeconomic deprivation had both higher peak occupancy and longer duration of occupancy over normal maximum capacity.FundingNone.

Evaluating the impact of Minimum Unit Pricing on population alcohol consumption in Scotland

Abstract Background Scotland experiences high levels of alcohol consumption and related harm. The relationship between alcohol price and consumption is well established. Minimum unit pricing (MUP), introduced in Scotland in 2018, sets a minimum price at which a unit of alcohol can be sold. The intention of MUP is to prevent alcohol being sold at below 50 pence per unit, thereby reducing alcohol consumption and in turn related harm to health. Scotland is the first country to implement this form of MUP; the evaluation of the impact of MUP is therefore of international importance. Methods Using commercial alcohol retail sales data, we use a natural experiment design with interrupted time series analysis to assess for changes in the level or trend of the volume of pure alcohol sold in Scotland associated with MUP implementation. Data for England and Wales will be used as a control. Results Descriptive analysis shows per adult off-trade sales of pure alcohol in Scotland fell by 3.6% in the year following MUP implementation. An increase in the average price of alcohol of 5 pence per unit in Scotland was also observed. There were reductions in per adult sales in all major drink categories with cider having the greatest relative decline (18.6%); cider also had the greatest increase in average price. Results of the interrupted time series analysis have yet to be reported but will be available for the conference. Conclusions The early indication of a reduction in total per adult off-trade sales of pure alcohol is an encouraging sign that MUP is having its intended impact. However, the full impact of MUP can only be judged across a range of outcome areas and over a longer time period. Key messages Minimum unit pricing appears to be having its intended impact on alcohol consumption at a population level in Scotland in the short term. Further work is ongoing to assess the impact of MUP on a wide range of outcomes and over a longer time period.

COVID-19 and anatomy: Stimulus and initial response.

The outbreak of COVID-19, resulting from widespread transmission of the SARS-CoV-2 virus, represents one of the foremost current challenges to societies across the globe, with few areas of life remaining untouched. Here, we detail the immediate impact that COVID-19 has had on the teaching and practice of anatomy, providing specific examples of the varied responses from several UK, Irish and German universities and medical schools. Alongside significant issues for, and suspension of, body donation programmes, the widespread closure of university campuses has led to challenges in delivering anatomy education via online methods, a particular problem for a practical, experience-based subject such as anatomy. We discuss the short-term consequences of COVID-19 for body donation programmes and anatomical education, and highlight issues and challenges that will need to be addressed in the medium to long term in order to restore anatomy education and practice throughout the world.

P0209PRESENTATION AND OUTCOMES OF ANCA ASSOCIATED VASCULITIS: THE SCOTTISH EXPERIENCE

Abstract Background and Aims This is a national project undertaken on behalf of the Scottish Renal Biopsy Registry describing the presentation, biopsy appearances, management and outcomes of patients presenting with a new diagnosis of renal biopsy proven ANCA associated vasculitis (AAV) to all units in Scotland. Method The Scottish Renal Biopsy Registry collects data annually on all renal biopsies performed across Scotland. From the Registry, all patients with a possible diagnosis of AAV found on renal biopsy performed between1/1/2014 and 31/12/2017 were identified. Individual units searched the electronic patient records of each patient and identified all those with a new diagnosis of AAV. Those undergoing repeat biopsy or who were not felt to have AAV on biopsy were excluded. Demographic data including immunological and outcome data were recorded and statistical analysis was undertaken in SPSS (v22). Results 267 patients were identified as having AAV across 8 centres and followed up for an average of 989 (IQR 610-1247) days. In 52% (n= 140) the biopsy indication was acute kidney injury. 38% (n=101) had a diagnosis of granulomatosis with polyangiitis (GPA). 52% (n=140) were female and the mean age at biopsy was 66.6±12.1 years. 38% (n=100) were PR3 positive. The average number of glomeruli on biopsy was 14 (IQR 11-21) with 3 (IQR 2-7 crescents. 28% (IQR 7-51) of viable glomeruli contained crescents. 41% (n=110) had at more than 10% interstitial fibrosis on biopsy. Creatinine at biopsy was 208µmol/L (IQR 141-380 µmol/L) and at 90 days 141 µmol/L (IQR 101-222 µmol/L). Most patients received standard induction therapy of cyclophosphamide and steroid. 24% (n=65) had plasma exchange at presentation and 11% (n=30) renal replacement therapy (RRT). 15% (n=39) patients relapsed with an average time to relapse of 511 (IQR 223-11127) days. 62% (n=24) of relapses were treated with rituximab. Those with GPA relapsed earlier. 12% (n= 31) developed end stage renal disease (ESRD). 18% (n=49) died with 14 patients (5%) dying within 90 days of biopsy. Average time to death was 246 (IQR 89-321) days. There was a trend towards an increased risk of death with those who developed ESRD. Patients who received PEX or RRT during initial admission were no more likely to relapse or die than those who did not. Conclusion This study accurately describes the presentation, management and outcomes of patients with AAV and renal involvement in Scotland. This allows comparison between centres within Scotland and other countries. The cohort will added to and followed to look at longer term outcomes.

UK stillbirth trends in over 11 million births provide no evidence to support effectiveness of Growth Assessment Protocol program.

Use of the Growth Assessment Protocol (GAP) has increased internationally under the assumption that it reduces the stillbirth rate. The evidence for this is limited and based largely on an ecological time-trend study. Discordance in the uptake of the GAP program between Scotland and England/Wales enabled us to assess the assertion that implementation of GAP leads to a reduced stillbirth rate. We analyzed data from the National Records for Scotland and the Office for National Statistics on the number of singleton maternities and stillbirths in Scotland and in England and Wales, respectively, from 1 January 2000 to 31 December 2015. National uptake of the GAP program over time in each of the regions was recorded. Stillbirth rate per 1000 maternities was calculated, according to year of delivery, and compared between Scotland and England/Wales. During the study period, there were 870 632 singleton maternities in Scotland, of which 4243 were stillbirths, and there were 10 469 120 singleton maternities in England and Wales, of which 51 562 were stillbirths. There was a marked difference in uptake of the GAP program between the two regions, with substantially fewer maternity units in Scotland implementing the program. Stillbirth rates were static up to 2010, with a decline thereafter in both regions, to 3.75 (95% CI, 3.25-4.30) per 1000 maternities in Scotland and 4.30 (95% CI, 4.15-4.46) per 1000 maternities in England and Wales in 2015. From 2010 onwards, the decline in Scotland was faster, equating to 48 (95% CI, 47.9-48.1) fewer stillbirths per 100 000 maternities in Scotland than in England and Wales from 2010 to 2015 compared with 2000 to 2009. We observed a decline in stillbirth rate in England and Wales, which coincided with implementation of the GAP program. However, a concurrent decline in stillbirth rate was observed in Scotland in the absence of increased implementation of GAP. The secular rates of change in stillbirth rate in England and Wales cannot be used to infer efficacy of the GAP program. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

P191 Real life experience of tocilizumab for the management of giant cell arteritis in Fife, Scotland

Abstract Background Tocilizumab was accepted by the Scottish Medicines Consortium for use in the management of Giant Cell Arteritis (GCA) on 10.09.18. The Fife Rheumatic Diseases Unit is the first Rheumatology unit in Scotland to introduce a structured process for the management of GCA patients with tocilizumab. We describe here our experience of this new service for NHS Fife. Methods All GCA patients considered for tocilizumab are discussed at our weekly Medication Review Meeting by the Consultant Rheumatologists (JSM &amp; SJH) and Rheumatology Pharmacist (SH). By consensus decision, GCA patients deemed appropriate for tocilizumab treatment are then referred to the Vasculitis Nurse Specialist (VNS; PA) for counselling. We have prospectively recorded data on all GCA patients counselled on tocilizumab from 08.11.18 onwards. Patients are followed up closely in a structured manner by the VNS on a fortnightly basis, with both clinical and laboratory assessment at each visit. The VNS ensures that GCA patients follow a rapid steroid taper in line with that used in the GiACTA Trial. Patients also have laboratory assessments performed between each VNS visit at their GP's surgery (to monitor the ESR) to assist in decision making in view of the rapid steroid taper. The VNS also records the cumulative steroid dose along with drug-related side effects (both from steroids and tocilizumab). Results 14 GCA patients have been counselled and commenced on tocilizumab between 08.11.18 and 18.09.19. We have another 2 GCA patients awaiting counselling and due to start tocilizumab soon. Twelve patients have newly diagnosed GCA (5 with unilateral visual loss), 5 with Large vessel vasculitis and 3 patients have refractory GCA. Of the newly diagnosed patients, the reasons for initiating tocilizumab were as follows: poor control of diabetes mellitus on high dose steroids; large vessel vasculitis confirmed on PET scan; previous long-term steroid exposure due to past history of polymyositis; high osteoporotic risk. Conclusion We have successfully introduced a structured process for the use of tocilizumab in Fife GCA patients via a VNS-led GCA clinic. This ensures robust clinical governance around the issues of safety, efficacy and cost. In addition, by collecting real life prospective data, we will add to the existing information available regarding use of this new therapeutic advance for GCA management in routine clinical practice. This initiative is the first of its kind in Scotland and a new service development for NHS Fife. Disclosures P. Allcoat None. S. Hart None. S.J. Hailwood None. J.S. McLaren Honoraria; J.S.M. has received Speaker fees from Roche.

Equity of access to critical care services in Scotland: A Bayesian spatial analysis.

There is increasing evidence that access to critical care services is not equitable. We aimed to investigate whether location of residence in Scotland impacts on the risk of admission to an Intensive Care Unit and on outcomes. This was a population-based Bayesian spatial analysis of adult patients admitted to Intensive Care Units in Scotland between January 2011 and December 2015. We used a Besag-York-Mollié model that allows us to make direct probabilistic comparisons between areas regarding risk of admission to Intensive Care Units and on outcomes. A total of 17,596 patients were included. The five-year age- and sex-standardised admission rate was 352 per 100,000 residents. There was a cluster of Council Areas in the North-East of the country which had lower adjusted admission rates than the Scottish average. Midlothian, in South East Scotland had higher spatially adjusted admission rates than the Scottish average. There was no evidence of geographical variation in mortality. Access to critical care services in Scotland varies with location of residence. Possible reasons include differential co-morbidity burden, service provision and access to critical care services. In contrast, the probability of surviving an Intensive Care Unit admission, if admitted, does not show geographical variation.

An evaluation of the potential to improve perinatal outcomes by improving antenatal detection of small for gestational age babies in Scotland: a retrospective population cohort study

Background: Small for gestational age (SGA) babies are at high risk of perinatal mortality. We aimed to determine the potential to reduce perinatal mortality by improving antenatal detection of SGA babies in Scotland. Methods: We conducted a retrospective population study of all singleton SGA babies born in the 15 Consultant-led maternity units in Scotland in a 3-month period (1st Dec 2014 to 28th Feb 2015 inclusive). Demographic and pregnancy outcome data were extracted from Scottish birth records for all pregnancies; case note review was performed for all SGA cases [defined as birthweight less than the 10th centile for their gestational age at delivery as defined by the appropriate sex-specific UK-WHO Child Growth Standards]. Results: The SGA rate in Scotland was 5.5% (673/12218; 95% confidence interval [CI] 5.1, 5.9) and 27.6% (186/673; 95% CI 24.3, 31.2) of SGA cases were identified prior to delivery. SGA was associated with 18.2% (12/66; 95% CI [10.1%, 30.0%) of all perinatal deaths. The majority (10/12, 83.3%) of SGA babies who died had been identified as SGA in the antenatal period. There was no difference in perinatal mortality whether SGA was detected or not (5.4% [10/186; 95% CI 2.8, 10.0] in the SGA detected group vs 0.4% [2/487 [95% CI 0.3, 2.2] in the non-detected group after adjusting for risk factors for SGA, gestation at delivery and birthweight centile (Adjusted odds ratio [AOR] 0.85 [95% CI 0.5, 1.5], p=0.556). Conclusions: Despite only around a quarter of SGA babies being identified antenatally, the potential to reduce perinatal mortality in the Scottish population by improving SGA detection is limited. Only a minority of perinatal deaths occurred in SGA babies; and in the majority of these SGA was detected antenatally.

Influence of Socioeconomic Deprivation on Interventions and Outcomes for Patients Admitted with COVID-19 to Critical Care Units in Scotland: A National Cohort Study

Background: Coronavirus disease 2019 (COVID-19) can lead to significant respiratory failure with between 14% and 18% of hospitalised patients requiring critical care admission. This study describes the impact of socioeconomic deprivation on 30-day survival following critical care admission for COVID-19, and the impact of the COVID-19 pandemic on critical care capacity in Scotland.Methods: This cohort study used linked national hospital records including ICU, virology testing and national death records to identify and describe patients with COVID-19 admitted to a critical care unit in Scotland. Multivariable logistic regression was used to assess the impact of deprivation on 30-day mortality. Critical care capacity was described by reporting the percentage of baseline ICU bed utilisation required.Results: There were 735 patients with COVID-19 admitted to critical care units across Scotland from 1/3/2020 to 20/6/2020. There was a higher proportion of patients from more deprived areas, with 183 admissions (24.9%) from the most deprived quintile and 100 (13.6%) from the least deprived quintile. 30-day mortality was 34.8%. After adjusting for age, sex and ethnicity, mortality was significantly higher in patients from the most deprived quintile (OR 1.97, 95%CI 1.13, 3.41, p=0.016). ICUs serving populations with higher levels of deprivation spent a greater amount of time over their baseline ICU bed capacity.Conclusion: Patients with COVID-19 living in areas with greater socioeconomic deprivation had a higher frequency of critical care admission and a higher adjusted 30-day mortality. ICUs in health boards with higher levels of socioeconomic deprivation had both higher peak occupancy and longer duration of occupancy over normal maximum capacity.Funding Statement: None.Declaration of Interests: All authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; NL is Director of Research, Intensive Care Society; JM is funded by a THIS.Institute (University of Cambridge) Research Fellowship (PD-2019-02-16). Ethics Approval Statement: The Scottish Intensive Care Society Audit Group in Public Health Scotland has a legislative remit to process personal data in relation to public health. Linkage to additional datasets was approved following scrutiny by the Public Benefit and Privacy Panel for Health and Social Care (ref 1920-0093). Access and use of the data for the purpose of this work were approved following a Public Health Scotland information governance review of linking additional internal datasets to identify patients with COVID-19. Only analysts working in Public Health Scotland had access to the linked patient data which could only be accessed via an NHS secure network.