University Hospitals Birmingham NHS Foundation Research Articles

Diabetes Self-Management Behaviours among Adult Persons with Disabilities – A Systematic Review

International Journal of Medicine and Public Health,2023,13,1,31-36.DOI:10.5530/ijmedph.2023.1.5Published:June 2023Type:Original Article Diabetes Self-Management Behaviours among Adult Persons with Disabilities – A Systematic ReviewRajeswaran Thiagesan, Vijayaprasad Gopichandran, Sudharshini Subramaniam, Sanjai Subha, Kalpana Kosalram, and Hilaria Soundari Rajeswaran Thiagesan1,*, Vijayaprasad Gopichandran2, Sudharshini Subramaniam3, Sanjai Subha4, Kalpana Kosalram5, Hilaria Soundari1 1Centre for Applied Research, The Gandhigram Rural Institute – (Deemed to be University), Gandhigram, Dindigul, Tamil Nadu, INDIA. 2Department of Community Medicine, ESIC Medical College and PGIMSR, Ashok Pillar Main Road, KK Nagar, Chennai, Tamil Nadu, INDIA. 3Institute of Community Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, INDIA. 4Department of Neurology, Junior Specialist Doctor (Standard), Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UNITED KINGDOM. 5School of Public Health, SRM Medical College and Hospital, SRM Institute of Science and Technology, SRM Nagar, Potheri, Chengalpattu, Tamil Nadu, INDIA. Abstract:Background: Self-management of diabetes is essential for proper control of blood sugars and prevention of complications. Persons with disabilities face challenges in adopting self-management behaviours. Objectives: To assess diabetes self-management behaviours among persons with disabilities. Materials and Methods: We searched PubMed with a comprehensive search strategy to retrieve epidemiological studies that reported the diabetes self-management behaviours among persons with disabilities in English language journals between 1990 – 2022. We did a step-wise screening of the retrieved articles and synthesized the findings of the selected papers. Results: Of the 992 papers that were obtained, 981 did not meet our inclusion criteria and were excluded at the stage of title and abstract screening. Eleven papers were retrieved and read in detail, and 8 of them were excluded at this stage. Finally, three papers two from China and one from Iran were included in the review. The studies revealed poor diabetes self-management behaviours among persons with disabilities, especially in the domains of diet and physical activity. Conclusion: There is a dearth of studies exploring diabetes self-management behaviours among persons with disabilities. Even the few reported studies show low levels of self-management behaviours. Keywords:Diabetes self-management, diet, Disabilities, Exercise, Glycemic control, Medication adherence., MonitoringView:PDF (149.67 KB)

A service evaluation of the newly introduced sciatic nerve local anaesthetic infusion catheters for acute pain management of major lower limb amputations

Background: Patients who undergo lower limb amputations experience severe acute postoperative pain. Despite having no strong evidence for the efficacy of peripheral nerve blocks in reducing phantom limb pain, the reduction in acute postoperative pain and opioid-sparing effect1 make these techniques important to consider. Acute pain management has been identified as a key priority in the management of patients undergoing amputation.2 An initial audit, in October 2021, found that postoperative pain scores and opiate use were high. In April 2022, postoperative local anaesthetic nerve catheters for major lower limb amputations were introduced at our institution. The aim of this service evaluation was to ascertain the postoperative pain scores and analgesic consumption for patients having undergone a lower limb amputation and who subsequently received a continuous postoperative local anaesthetic infusion (levobupivacaine 0.125%, at 6–10 ml h−1 for up to 5 days) via a sciatic nerve catheter. Methods: A retrospective audit was undertaken between July and September 2022 at Birmingham Heartlands Hospital. We included patients having undergone a lower limb amputation with a sciatic nerve catheter placed intraoperatively by surgeons under direct vision and left along the nerve in the cut nerve sheath. Data collected included patient characteristics, postoperative pain scores days 1–5, postoperative opioid use including opioid side-effects, postoperative neuropathic pain, and block related complications. Results: We collected data for 24 patients. Compared with the period before the introduction of sciatic nerve catheters, we observed that the mean pain scores on the numeric rating scale (NRS) decreased. This was particularly evident on day 1 postoperatively when the mean pain scores decreased from the moderate to mild range. On days 1–5 of the postoperative period, the mean immediate-release opioid consumption was 16.1 mg day−1 and mean prolonged-release opioid consumption was 11.6 mg day−1. This was in comparison to the audit in October 2021 that found mean opioid use of 24.1 mg day−1 and 21 mg day−1, respectively. Opioid side-effects reported were sedation (18%), constipation (13%), and nausea or vomiting (8%). Fifty percent of patients reported neuropathic pain. Conclusion: The postoperative pain scores improved and the postoperative opioid consumption reduced slightly with the addition of a sciatic nerve catheter. Opioid side-effects and acute neuropathic pain remain an issue for this group of patients postoperatively. Overall, the introduction of a continuous local anaesthetic infusion via a sciatic nerve catheter after major lower limb amputations in our hospital has been a success and the technique is likely to play a significant future role as part of our multi-modal analgesia regimen for these patients. The Acute Pain Team at University Hospitals Birmingham NHS Foundation Trust. 1.Ilfeld BM. Anesth Analg 2011; 113: 904–252.Gough MJ, Juniper M, Freeth H, Butt A, Mason M. Lower limb amputation: Working together. A report by the National Confidential Enquiry into Patient Outcome and Death, 2014. https://www.hqip.org.uk/wp-content/uploads/2018/02/lower-limb-amputation-report.pdf (accessed 20/03/23)

Letter to the Editor: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management.

1Liver Unit, University Hospitals Birmingham, Birmingham, UK 2Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK 3Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria 4Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria Correspondence Tripathi, Dhiraj University Hospitals Birmingham NHS Foundation Trust, Liver Unit; University of Birmingham Institute of Immunology and Immunotherapy. Email: [email protected]

Privacy-Aware Early Detection of COVID-19 Through Adversarial Training.

Early detection of COVID-19 is an ongoing area of research that can help with triage, monitoring and general health assessment of potential patients and may reduce operational strain on hospitals that cope with the coronavirus pandemic. Different machine learning techniques have been used in the literature to detect potential cases of coronavirus using routine clinical data (blood tests, and vital signs measurements). Data breaches and information leakage when using these models can bring reputational damage and cause legal issues for hospitals. In spite of this, protecting healthcare models against leakage of potentially sensitive information is an understudied research area. In this study, two machine learning techniques that aim to predict a patient's COVID-19 status are examined. Using adversarial training, robust deep learning architectures are explored with the aim to protect attributes related to demographic information about the patients. The two models examined in this work are intended to preserve sensitive information against adversarial attacks and information leakage. In a series of experiments using datasets from the Oxford University Hospitals (OUH), Bedfordshire Hospitals NHS Foundation Trust (BH), University Hospitals Birmingham NHS Foundation Trust (UHB), and Portsmouth Hospitals University NHS Trust (PUH), two neural networks are trained and evaluated. These networks predict PCR test results using information from basic laboratory blood tests, and vital signs collected from a patient upon arrival to the hospital. The level of privacy each one of the models can provide is assessed and the efficacy and robustness of the proposed architectures are compared with a relevant baseline. One of the main contributions in this work is the particular focus on the development of effective COVID-19 detection models with built-in mechanisms in order to selectively protect sensitive attributes against adversarial attacks. The results on hold-out test set and external validation confirmed that there was no impact on the generalisibility of the model using adversarial learning.

Rowan Hillson Inpatient Safety Award 2022

Introduction: The annual National Diabetes Inpatient Audit (NaDIA and NaDIA-Harms) in the UK continues to show significant problems with patient care. During the COVID pandemic patient care has been even more difficult. New initiatives are urgently required to improve inpatient safety for people with diabetes. Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the seventh national Rowan Hillson Inpatient Safety Award on the theme of “the best interventions: redesigning, rebuilding and maintaining safe inpatient diabetes care during COVID”. Result: The winner was the DEKODE team, led by Dr Punith Kempegowda from University Hospitals Birmingham NHS Foundation Trust, for their innovative quality improvement project across hospitals during COVID to improve diabetes-related ketoacidosis (DKA) management and study DKA in people with COVID. Adherence to national guidance improved in some hospitals, with falls in hypoglycaemia, and overall there was a significant improvement in awareness about DKA amongst junior doctors. The King’s College NHS Foundation Trust team, led by Adrian Li and colleagues, received the highly commended award for their innovative project of remote blood glucose (BG) monitoring across healthcare boundaries. This improved diabetes control and tackled health inequalities. Summary and conclusion: These and similar schemes need to be developed, promoted and shared to improve safety for people with diabetes admitted in hospital during COVID times.

Evaluating Actions to Improve Air Quality at University Hospitals Birmingham NHS Foundation Trust

Air pollution is the single largest environmental risk to human health in the UK, exerting a major healthcare sector burden and exacerbating health and social inequalities. The NHS Long Term Plan commits the healthcare sector to reducing emissions from all sources, however, to date few Acute NHS Trusts have implemented air quality focused sustainability plans. In this case study, we assess potential air quality improvement actions at University Hospitals Birmingham NHS Foundation Trust’s, Queen Elizabeth Hospital in Birmingham, UK as a test case for NHS sustainability actions. We generate an evidenced based, prioritized shortlist of actions to mitigate emissions and protect patients, staff, and local communities from air pollution exposure. The project supports adoption of an evidence-based, contextually relevant, approach to air quality management within healthcare provision. The methodology used could be employed by organizations with similar goals to address environmental concerns.

Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention

BackgroundVenous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action—here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers.MethodsAll admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach).ResultsData from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90–95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis.DiscussionAn EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8–5% despite this mandated system. Further research is needed to assess the potential reasons for this.

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

On 11th March 2020 the World Health Organization declared the international spread of the SARS-CoV-2 virus to represent a pandemic.(1World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19 [Internet]. WHO Director-General’s opening remarks at the media briefing on COVID-19. 2020. p. 1. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020Google Scholar) Thus far more than 160 million cases has been confirmed worldwide with nearly 4.5 million cases of SARS-CoV-2 infection have been confirmed in the UK and with high numbers of patients requiring respiratory support, the outbreak converted the entire UK healthcare system into the Critical Care without walls.(2Johns Hopkins Coronavirus Resource Center. Johns Hopkins University. New Cases of COVID-19 in World Countries [Internet]. Johns Hopkins Coronavirus Resource Center. 2021 [cited 2021 May 23]. Available from: https://coronavirus.jhu.edu/Google Scholar,3GOV.UK. Coronavirus (COVID-19) in the UK [Internet]. Coronavirus (COVID-19) in the UK. 2021 [cited 2021 May 23]. Available from: https://coronavirus.data.gov.uk/details/casesGoogle Scholar) The mortality in patients with COVID varies between countries and healthcare systems and has been reported between 0.1% and 19,6%.(4Johns Hopkins Coronavirus Resource Center. Cases and mortality by country [Internet]. 2021. [cited 2021 May 23]. Available from: https://coronavirus.jhu.edu/data/mortalityGoogle Scholar) Our local Intensive Care Unit (ICU) audit indicates that once the patient requires organ support, the mortality is as high as 30% which is similar to the 25% overall mortality in a recently published systematic review.(5Quah P. Li A. Phua J. Mortality rates of patients with COVID-19 in the intensive care unit: a systematic review of the emerging literature.Crit Care [Internet]. 2020; 24 (Available from:): 285https://doi.org/10.1186/s13054-020-03006-1Google Scholar) There is evidence that the underlying patho-mechanism of COVID-19 is related to hypercoagulable state and endothelial dysfunction which results in pan-vascular events: thrombosis within small and large vessels, resulting in deep vein thrombosis(DVT), pulmonary embolisms, strokes and myocardial infarctions.(6Page EM, Ariëns RAS. Mechanisms of thrombosis and cardiovascular complications in COVID-19. Thromb Res [Internet]. 2021;200:1–8. Available from: https://www.sciencedirect.com/science/article/pii/S0049384821000141Google Scholar) There have been reports of thrombosis within other vascular beds including upper and lower limbs as well as visceral circulation. This is likely to be a result of sepsis-induced coagulopathy (associated with the cytokine storm, not the cytokine storm itself) and viral replication leading to endothelial injury.(7Magro G. Cytokine Storm: Is it the only major death factor in COVID-19 patients? Coagulation role.Med Hypotheses [Internet]. 2020; 142 (Available from): 109829https://doi.org/10.1016/j.mehy.2020.109829Google Scholar, 8Ortega-Paz L. Capodanno D. Montalescot G. Angiolillo D.J. COVID-19 Associated Thrombosis and Coagulopathy: Review of the Pathophysiology and Implications for Antithrombotic Management.J Am Hear Assoc. 2020 Nov; e019650Google Scholar, 9Karna S.T. Panda R. Maurya A.P. Kumari S. Superior Mesenteric Artery Thrombosis in COVID-19 Pneumonia: an Underestimated Diagnosis-First Case Report in Asia.Indian J Surg. 2020 Oct; : 1-3Google Scholar, 10Avila J. Long B. Holladay D. Gottlieb M. Thrombotic complications of COVID-19.Am J Emerg Med. 2021 Jan; 39: 213-218Google Scholar) The incidence of arterial/venous thromboembolism has been recently reported but the rates have been compared with non-COVID-19 patients or historical populations in only a few papers and therefore, we believe that the scale of the problem is not sufficiently defined.(11Smilowitz N.R. Subashchandran V. Yuriditsky E. Horowitz J.M. Reynolds H.R. Hochman J.S. et al.Thrombosis in hospitalized patients with viral respiratory infections versus COVID-19.Am Hear J. 2021 Jan; 231: 93-95Google Scholar,12Etkin Y. Conway A.M. Silpe J. Qato K. Carroccio A. Manvar-Singh P. et al.Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.Ann Vasc Surg. 2021 Jan; 70: 290-294Google Scholar) However, recent reports indicate that the incidence of thromboembolic events in patients with SARS-CoV-2 infection might be higher than expected and would require adjusted thromboprophylaxis.(13Bikdeli B. Talasaz A.H. Rashidi F. Sharif-Kashani B. Farrokhpour M. Bakhshandeh H. et al.Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies.Thromb Res. 2020 Dec; 196: 382-394Google Scholar, 14Lee E. Krajewski A. Clarke C. O’Sullivan D. Herbst T. Lee S. Arterial and venous thromboembolic complications of COVID-19 detected by CT angiogram and venous duplex ultrasound.Emerg Radiol [Internet]. 2021 Jan; (Available from:): 1-8http://www.ncbi.nlm.nih.gov/pubmed/33428043Google Scholar, 15Nadeem R, Thomas SJ, Fathima Z, Palathinkal AS, Alkilani YE, Dejan EA, et al. Pattern of anticoagulation prescription for patients with Covid-19 acute respiratory distress syndrome admitted to ICU. Does it impact outcome? Hear Lung. 2021;50(1):1–5.Google Scholar) However, thus far there are significant uncertainties regarding prevention and management of thromboembolic events in patients with COVID-19. We considered this project to be a hypothesis generating study. The main objective of was to establish the incidence of acute vascular events and identify potential associations with clinical and demographic factors in a cohort of ICU patients with confirmed, severe SARS-CoV-2 infection. The secondary objectives were to provide a basis necessary for ad hoc adjustment of clinical practice and to highlight areas for potential research studies aiming to optimise thromboprophylaxis and medical management of thromboembolic events. We followed STROBE Statement for cross-sectional studies in preparation of this manuscript.(16von Elm E. Altman D.G. Egger M. Pocock S.J. Gøtzsche P.C. Vandenbroucke J.P. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.Lancet (London, England) [Internet]. 2007 Oct; 370 (7. Available from:): 1453https://www.equator-network.org/reporting-guidelines/strobe/Google Scholar) This was a retrospective, single-centre (University Hospitals Birmingham NHS Foundation Trust; UHB), multi-site cohort study using routinely collected data, conducted within the clinical audit framework (Audit numbers); no intervention was performed, and patients were not contacted outside their routine clinical care. Therefore, a specific ethical approval was not required, and patient consent was not sought in line with guidance from the UK Health Research Authority and UK Policy Framework for Health and Social Care Research. We collated the data from three hospitals in Birmingham Metropolitan area for all consecutive patients admitted to ITU during the peak of COVID-19 pandemic in the UK, between 01/04/2020 and 30/04/2020. We also collected data from the corresponding pre-COVID period in 2019 (01/04/2019 – 30/04/2019) and used it to estimate excess events. Definitions and type of data collected are detailed in the supplementary file. The primary outcome was defined as a composite outcome of acute arterial and venous events, which included: 1) upper and/or lower limb arterial thrombosis or embolus, 2) exacerbation of peripheral arterial occlusive disease (PAOD) with progression to critical limb ischaemia (CLI), 3) stroke or transient ischaemic attack (TIA), 4) visceral malperfusion, 5) thrombosis of AV fistula, 6) venous thrombotic events (DVT); pulmonary embolism (PE), visceral veins thrombosis, thrombophlebitis). The secondary outcome was 30-day mortality. We also studied associations of demographic and clinical factors with the primary and secondary outcome, and temporal changes in the biochemical and clotting parameters. Primary outcome was validated manually by the direct clinical care team members. Cases where the outcome was not certain were verified by senior clinicians. Survival status was verified by cross-referencing local electronic patient record with the NHS-wide mortality database (Primary Care Mortality Database, Spine, NHS Digital) derived from death records from the Office for National Statistics. The statistical analysis was performed in R environment (R version 4.0.3, The R Foundation for Statistical Computing, Vienna, Austria; https://www.r-project.org) using pre-specified data analysis plan. Data characteristics were assessed using dplyr package and data missingness was assessed using naniar package. Missing data were treated by pairwise deletion. Continuous variables were presented as median [interquartile range; IQR] unless stipulated otherwise; categorical data were presented as frequencies (%) with 95% confidence intervals (95%CI) if required. Student’s t-test and Wilcoxon rank-sum test were used to compare continuous data. Pearson’s chi-squared test and Fisher’s exact test with continuity correction were used to analyse categorical data. Haldane-Anscombe correction was used when appropriate. Multi-variate explanatory model was built using purposeful, manual selection of covariates with univariate p<0.1, taking into consideration the quality of the data and clinical judgement. Effect size was presented as odds ratio (OR) with 95%CI and categorised as “small” (OR<1.5), “medium” (1.5=<OR<5.0) and “large” (OR>=5.0). During April 2020 the peak of the pandemic in the UK, 317 patients were treated and discharged (alive or deceased) from ITU at three sites of the University Hospitals Birmingham NHS Foundation Trust. The median age was 56 years [47, 66], and 94 of them (29%) were female. Patients with white Caucasian ethnic background constituted a majority (170; 53.8%) of patients in whom ethnicity was declared (268; 84.5%), followed by Asian (79; 29.55%) and Black (19; 7.1%) ethnic background. Over a half of patients (51.4%) came from the 20% most deprived households, and only 8.9% from the 20% least deprived households in England based on Index of Multiple Deprivations 2019.(17Ministry of Housing C& LG. English indices of deprivation 2019 [Internet]. English indices of deprivation 2019. 2019 [cited 2021 Jun 5]. Available from: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019Google Scholar) Detailed characteristics of comorbid status of patients in the study is shown in <u>Table 1</u>. Hypertension (128/317; 40.4%), diabetes (86/317; 27.1%) and chronic lung disease (46/317; 14.5%) were the most prevalent comorbidities in patients admitted to ITU in April 2020. Smoking status was recorded in 47.5% of patients: 20.7% declared as non-smokers, 24.0% as ex-smokers and 55.3% declared non-smoking status.Table 1Cohort characteristics stratified by YEAR. Comparison on ITU cohorts between March/April 2019 and April 2020. All patients irrespective of COVID-19 status. ACEi – angiotensin converting enzyme inhibitor; aPTT – activated partial thromboplastin time; ARB – angiotensin receptor blocker; IQR – interquartile range; PT – prothrombin time; SD – standard deviation; VTE – venous thrombo-embolism.VariableLevel2019 (n=555)2020 (n=317)p-valueCOVID19StatusGRPNegative555 (100.0)119 (37.5)Positive0 (0.0)198 (62.5)< 0.0001DEATH0455 (82.0)212 (66.9)1100 (18.0)105 (33.1)< 0.0001AGEmedian [iqr]62 [48, 73]56 [47, 66]< 0.0001SEXFemale215 (38.7)94 (29.7)EthnicityMale340 (61.3)223 (70.3)0.008677White400 (81.3)170 (63.4)Asian70 (14.2)79 (29.5)Black22 (4.5)19 (7.1)< 0.0001missing6349IMD_QUINTQ1227 (42.9)161 (51.4)Q2100 (18.9)44 (14.1)Q382 (15.5)46 (14.7)Q467 (12.7)34 (10.9)Q553 (10.0)28 (8.9)0.155293missing264Heightmedian [iqr]170 [161, 177]170 [164, 178]0.023621missing5850Weightmedian [iqr]76 [65, 90]81.2 [70.7, 95.0]< 0.0001missing5551Body Mass Indexmedian [iqr]26.4 [23.4, 30.3]27.8 [24.9, 31.6]0.000230missing6051IHDNo465 (83.8)287 (90.5)Yes90 (16.2)30 (9.5)0.007318Atrial FibrillationNo511 (92.1)295 (93.1)Yes44 (7.9)22 (6.9)0.691055CCFNo519 (93.5)309 (97.5)Yes36 (6.5)8 (2.5)0.015920VTENo520 (93.7)300 (94.6)Yes35 (6.3)17 (5.4)0.676454HypertensionNo354 (63.8)189 (59.6)Yes201 (36.2)128 (40.4)0.251326CVANo523 (94.2)300 (94.6)Yes32 (5.8)17 (5.4)0.923753Diabetes MellitusNo454 (81.8)231 (72.9)Yes101 (18.2)86 (27.1)0.002655CLDNo486 (87.6)271 (85.5)Yes69 (12.4)46 (14.5)0.442156MALIGNANCYNo381 (69.0)281 (88.6)Not confirmed16 (2.9)8 (2.5)Yes155 (28.1)28 (8.8)< 0.0001missing30SMOKINGNon-smoker111 (39.4)83 (55.3)Current smoker94 (33.3)31 (20.7)Ex-smoker77 (27.3)36 (24.0)0.003345missing273167APANo372 (71.3)257 (85.1)Yes150 (28.7)45 (14.9)< 0.0001missing3315DOACNo481 (92.1)276 (91.4)Yes41 (7.9)26 (8.6)0.802775missing3315WARFARINNo498 (95.4)292 (96.7)Yes24 (4.6)10 (3.3)0.475923missing3315STATINNo338 (64.8)212 (70.2)Yes184 (35.2)90 (29.8)0.127838missing3315ACENo375 (71.8)239 (79.1)Yes147 (28.2)63 (20.9)0.025478missing3315Beta BlockerNo411 (78.7)246 (81.5)Yes111 (21.3)56 (18.5)0.397312missing3315SURG_GRPNo163 (29.7)223 (70.3)Yes385 (70.3)94 (29.7)< 0.0001missing70Haematocritmedian [iqr]0.3 [0.3, 0.4]0.4 [0.3, 0.4]< 0.0001missing07Plateletmedian [iqr]210 [155.5, 278.5]242.5 [175.5, 320.0]< 0.0001missing01Activated partial thromboplastin timemedian [iqr]27.4 [25.2, 31.2]30.4 [27.4, 33.4]< 0.0001missing285Prothrombin timemedian [iqr]13.6 [12.5, 15.7]14.4 [13.2, 15.6]0.380160missing641D Dimermedian [iqr]1,136 [ 558, 3,445]874 [ 449, 3,538]0.820550missing530128Neutrophilsmedian [iqr]9.4 [ 5.6, 13.7]8.5 [ 5.9, 11.7]0.041200missing03Lymphocytesmedian [iqr]1 [0.6, 1.6]1 [0.7, 1.6]0.226872missing05Creatininemedian [iqr]79 [ 62, 108]80 [ 62, 115]0.568150missing01Ureamedian [iqr]5.8 [4.1, 8.9]6 [ 4.4, 10.1]0.309157missing02RRT_GRPNo502 (90.5)248 (78.5)Yes53 (9.5)68 (21.5)< 0.0001missing01ABG Lactatemedian [iqr]1.6 [1.1, 2.7]1.4 [1.1, 2.1]0.018191missing42ABG PaO2median [iqr]15.7 [11.1, 24.2]10.5 [ 8.4, 14.6]< 0.0001missing43ABG FiO2median [iqr]0.2 [0.2, 0.4]0.4 [0.2, 0.7]< 0.0001missing43VTE Prophylaxis GroupMechanical18 (3.3)0 (0.0)No69 (12.5)19 (6.1)Treatment0 (0.0)0 (0.0)Yes466 (84.3)295 (93.9)NAmissing23EVENTNo493 (88.8)242 (76.3)Yes62 (11.2)75 (23.7)< 0.0001Arterial Event GroupNo517 (93.2)291 (91.8)Yes38 (6.8)26 (8.2)0.546455DVTGroupNo539 (97.1)297 (93.7)Yes16 (2.9)20 (6.3)0.023249Pulmonary Embolism GroupNo538 (96.9)283 (89.3)Yes17 (3.1)34 (10.7)< 0.0001Arteriovenous Access thrombosis GroupNo549 (98.9)310 (97.8)Yes6 (1.1)7 (2.2)0.302713Abbreviations : IHD: Ischemic Heart Disease, IMD_Quint: Index Of Multiple Deprivation Quintiles, CCF: Congestive Cardiac Failure, VTE: Venous Thromboembolism , DOAC : Direct Oral Anticoagulant, APA: Antiplatelet Agents, BB : Beta Blocker, CVA: Cerebrovascular Accident, CLD: Chronic Lung Disease, ACE: Angiotensin-Converting Enzyme Inhibitors, RRT: Renal Replacement Therapy, ABG: Arterial Blood Gases, Pao2: Partial Pressure Of Oxygen, Fio2: Fraction Of Inspired Oxygen Open table in a new tab Abbreviations : IHD: Ischemic Heart Disease, IMD_Quint: Index Of Multiple Deprivation Quintiles, CCF: Congestive Cardiac Failure, VTE: Venous Thromboembolism , DOAC : Direct Oral Anticoagulant, APA: Antiplatelet Agents, BB : Beta Blocker, CVA: Cerebrovascular Accident, CLD: Chronic Lung Disease, ACE: Angiotensin-Converting Enzyme Inhibitors, RRT: Renal Replacement Therapy, ABG: Arterial Blood Gases, Pao2: Partial Pressure Of Oxygen, Fio2: Fraction Of Inspired Oxygen Data on VTE prophylaxis was missing in 3 cases (0.9%). VTE prophylaxis was in prescribed in 294 (93.6%) patients; one patient was on bridging therapy (0.3%); VTE prophylaxis was not prescribed in 19 patients (death shortly after admission to ITU or clearly documented contraindications). The DVT prophylaxis regimen was the standard hospital protocol of 40mg of enoxaparin once a day. Data characteristics are detailed in the supplemtary file. During April 2020, 198 out of 317 ITU patients were diagnosed with COVID-19 resulting in the period prevalence of 62.5% (56.9-67.8). The D-Dimer levels were measured in 189 patients (59.6%) in whom there was a clinical suspicion of VTE. The levels were similar in COVID and non-COVID patients (849 [ 438.0, 3472.5] v. 947 [ 535.8, 5931.2, p=.589) and were significantly higher in patients who had a thromboembolic event (1,656 [IQR 577.8, 9172.5] v. 826 [IQR 426.5, 2836.5]). The difference in D-Dimer levels between patients with different COVID status and thromboembolic events were not statistically significant (ANOVA, df=5, F=0.893, p=.487). Arterial and venous thromboembolic events occurred in 75 patients treated on ITU in April 2020 (event rate 23.7% (19.1-28.7)). Detailed distribution of thromboembolic events is shown in <u>Table 2</u>.Table 2Cohort stratified by COVID status, Analysis for 2020 only.VariableLevelNegative (n=119)Positive (n=198)p-valueAGEmedian [iqr]55 [44, 65]58 [49, 66]0.0454785SEXFemale39 (32.8)55 (27.8)Male80 (67.2)143 (72.2)0.4145237EthnicityBlack6 (5.9)13 (7.8)White79 (78.2)91 (54.5)Asian16 (15.8)63 (37.7)0.0003173missing1831IMD_QUINTQ155 (47.4)106 (53.8)Q320 (17.2)26 (13.2)Q512 (10.3)16 (8.1)Q216 (13.8)28 (14.2)Q413 (11.2)21 (10.7)0.7679140missing31HEIGHTmedian [iqr]170.5 [164.2, 178.0]170 [163, 178]0.9231268missing1337WEIGHTmedian [iqr]80 [70.0, 90.8]85 [74, 98]0.0229065missing1437BODY MASS INDEXmedian [iqr]27.1 [24.2, 30.7]28.3 [25.9, 32.7]0.0113599missing1437DEATHNo87 (73.1)125 (63.1)Yes32 (26.9)73 (36.9)0.0882851IHDNo109 (91.6)178 (89.9)Yes10 (8.4)20 (10.1)0.7627410ATRIAL FIBRILLATION (AF)No109 (91.6)186 (93.9)Yes10 (8.4)12 (6.1)0.5710131CCFNo112 (94.1)197 (99.5)Yes7 (5.9)1 (0.5)0.0097086VTENo109 (91.6)191 (96.5)Yes10 (8.4)7 (3.5)0.1083799HYPERTENSIONNo81 (68.1)108 (54.5)Yes38 (31.9)90 (45.5)0.0239626CVANo109 (91.6)191 (96.5)Yes10 (8.4)7 (3.5)0.1083799DIABETES MELLITUSNo97 (81.5)134 (67.7)Yes22 (18.5)64 (32.3)0.0106999CLDNo100 (84.0)171 (86.4)Yes19 (16.0)27 (13.6)0.6849795MALIGNANCYNo101 (84.9)180 (90.9)Not confirmed4 (3.4)4 (2.0)Yes14 (11.8)14 (7.1)0.2606323SMOKINGEx-smoker11 (18.0)25 (28.1)Non-smoker24 (39.3)59 (66.3)Current smoker26 (42.6)5 (5.6)< 0.0001missing58109APANo95 (84.1)162 (85.7)Yes18 (15.9)27 (14.3)0.8249742missing69DOACNo100 (88.5)176 (93.1)Yes13 (11.5)13 (6.9)0.2400167missing69WARFARINNo106 (93.8)186 (98.4)Yes7 (6.2)3 (1.6)0.0667872missing69STATINNo83 (73.5)129 (68.3)Yes30 (26.5)60 (31.7)0.4090385missing69ACENo97 (85.8)142 (75.1)Yes16 (14.2)47 (24.9)0.0384546missing69BETA BLOCKERNo95 (84.1)151 (79.9)Yes18 (15.9)38 (20.1)0.4528087missing69SURGICAL GROUPNo49 (41.2)174 (87.9)Yes70 (58.8)24 (12.1)< 0.0001HAEMATOCRITmedian [iqr]0.4 [0.3, 0.4]0.4 [0.3, 0.4]0.2066641missing25PLATELETmedian [iqr]243 [163, 316]242 [180, 323]0.3215948missing01ACTIVATED PARTIAL THROMBOPLASTIN TIMEmedian [iqr]30.4 [27.4, 33.4]30.4 [27.4, 33.4]0.2827159missing14PROTHROMBIN TIMEmedian [iqr]13.2 [12.0, 14.4]14.4 [13.2, 15.6]0.0001996missing01D-DIMERmedian [iqr]947 [ 535.8, 5,931.2]849 [ 438.0, 3,472.5]0.5888318missing7751FERRITINmedian [iqr]413 [154.5, 939.0]992 [ 428.0, 1,963.5]0.0023882missing8795FIBRINOGENmedian [iqr]4.2 [2.7, 5.0]5.2 [4.3, 5.9]< 0.0001missing6092NEUTROPHILSmedian [iqr]9.1 [ 5.4, 12.1]8.2 [ 6.0, 11.4]0.4857807missing03LYMPHmedian [iqr]1.3 [0.8, 2.2]0.9 [0.6, 1.3]< 0.0001missing14CREATININEmedian [iqr]79 [ 64.5, 108.5]81 [ 62, 116]0.9003825missing01UREAmedian [iqr]5.7 [4.1, 9.0]6.3 [ 4.5, 10.2]0.2059393missing11RRT_GROUPNo102 (85.7)146 (74.1)Yes17 (14.3)51 (25.9)0.0219907missing01ABG LACTATEmedian [iqr]1.6 [1.1, 2.7]1.4 [1.1, 1.9]0.0261479missing11ABG PA02median [iqr]13.8 [ 9.2, 22.2]9.7 [ 8, 12]< 0.0001missing12ABG FIO2median [iqr]0.3 [0.2, 0.5]0.6 [0.2, 0.8]< 0.0001missing12VTE PROPHYLAXIS GROUPYes105 (89.7)190 (96.4)No12 (10.3)7 (3.6)0.0304708missing21ARTERIAL EVENT GROUPNo110 (92.4)181 (91.4)Yes9 (7.6)17 (8.6)0.9123990DVT GROUPNo114 (95.8)183 (92.4)Yes5 (4.2)15 (7.6)0.3381037PULMONARY EMBOLISM GROUPNo114 (95.8)169 (85.4)Yes5 (4.2)29 (14.6)0.0064762ARTERIOVENOUS ACCESS THROMBOSIS GROUPNo115 (96.6)195 (98.5)Yes4 (3.4)3 (1.5)0.4911531EVENTNo99 (83.2)143 (72.2)Yes20 (16.8)55 (27.8)0.0366960Abbreviations : IHD: Ischemic Heart Disease, IMD_Quint: Index Of Multiple Deprivation Quintiles, CCF: Congestive Cardiac Failure, VTE: Venous Thromboembolism , DOAC : Direct Oral Anticoagulant, APA: Antiplatelet Agents, BB : Beta Blocker, CVA: Cerebrovascular Accident, CLD: Chronic Lung Disease, ACE: Angiotensin-Converting Enzyme Inhibitors, RRT: Renal Replacement Therapy, ABG: Arterial Blood Gases, Pao2: Partial Pressure Of Oxygen, Fio2: Fraction Of Inspired Oxygen Open table in a new tab Abbreviations : IHD: Ischemic Heart Disease, IMD_Quint: Index Of Multiple Deprivation Quintiles, CCF: Congestive Cardiac Failure, VTE: Venous Thromboembolism , DOAC : Direct Oral Anticoagulant, APA: Antiplatelet Agents, BB : Beta Blocker, CVA: Cerebrovascular Accident, CLD: Chronic Lung Disease, ACE: Angiotensin-Converting Enzyme Inhibitors, RRT: Renal Replacement Therapy, ABG: Arterial Blood Gases, Pao2: Partial Pressure Of Oxygen, Fio2: Fraction Of Inspired Oxygen Arterial events occurred in 26 out of 317 patients (8.2%). This rate was higher than in comparable months of 2019, however, the difference was not statistically significant (OR 1.22, 0.69-2.10, p=.546). In seven patients' arterial events coincided with 3 deep and 2 superficial vein thrombosis, and 3 pulmonary embolisms. COVID-19 status was not associated with arterial events, and neither was the best medical therapy. However, arterial events were associated with increased 30-day mortality. This was significant irrespective of COVID-19 status (all patients: 65.4% v. 30.2%; OR 4.34, 1.75-11.49, p<.001; COVID-19 positive only: 64.7% v. 34.3%; OR 3.49, 1.12-12.08, p=.018). DVT occurred in 20 patients (6.3%). This rate was significantly higher than in corresponding months of 2019 (16/555, 2.88%; OR 2.27, 1.10-4.75, p=.020). Amongst patients with DVT, 3 had simultaneous arterial events, 4 had simultaneous PEs and two had thrombophlebitis (one coinciding with arterial event). In the studied cohort of patients, DVT was not associated with COVID-19 status, demographic factors, comorbid status, or best medical therapy or thirty-day mortality. However, we observed an association of DVT rate with personal history of VTE (OR 5.41, 1.15-20.34, p=.016), and regular prescription for DOAC (OR 5.19, 1.31-17.81, p=.010), but not warfarin, before index admission. Thirty-four pulmonary embolisms occurred during the observation period (10.7%). Pulmonary embolisms occurred almost 4 times more often than in 2019 (OR 3.80, 2.02-7.38, p<.001). In patients with diagnosis of PE, 7 events coexisted with 3 arterial events and 4 DVT. There was an association between the diagnosis of pulmonary embolisms, and diagnosis of COVID-19 (OR 3.80, 1.54-11.64, p=.004), personal history of VTE (OR 7.03, 2.34-20.15, p<.001), lactate on admission to ITU (Cohen's d = -0.19 (effect negligible), p=.023). Pulmonary embolism was also associated with a higher risk of 30-day mortality (OR 3.30, 1.60-7.01, p=.002). Univariate analysis demonstrated that age, but not ethnicity or social deprivation, was the demographic factor associated with development of arterial and venous thromboembolic events. Smoking status was associated with thromboembolic events (non-smokers and ex-smokers v. current smokers: OR 5.3, 1.22-48.3, p=.015) but there was a substantial missingness within this variable and this factor was not used in multivariate model. A diagnosis of COVID-19 (clinical or laboratory-based) and personal history of VTE, but none of the recorded comorbidities were associated with development of thrombotic events. A new onset renal failure requiring acute dialysis was also associated with the diagnosis of VTE, but the direction of this association could not be ascertained using our data. Amongst regular medication, only antiplatelet agents and direct oral anticoagulants were associated with the diagnosis of arterial and venous thromboembolism. VTE prophylaxis was uniformly applied and was not associated with the risk of VTE. Multivariate analysis showed that only personal history of VTE (OR 14.0, 3.98-54.34, p<.001), pre-admission regular antiplatelet agent (OR 0.25, 95%CI 0.07-0.71, p=0.018), COVID19 status (OR 2.64, 1.29-5.77, p=.011), a need for renal replacement therapy (OR 2.40, 1.21-4.72, p=.011) and lactate level on admission to ITU (OR 1.17, 1.03-1.33, p=.013) were independently associated with the diagnosis of arterial and venous thromboembolic events figure 1 and figure 2 . Tables and figures detailing the multivariate analysis are included in the supplementary file.Figure 2Multi-variate analysis for composite outcome (EVENTS). The analysis includes only COVID-positive patients from April 2020.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We observed increased rates of DVT and PE, with no excess arterial events or thrombophlebitis in patients admitted to ITU in 2020 compared with 2019. When we compared the non COVID patients in the 2020 cohort versus the 2019 cohort there was no statistically significant difference in the incidence of the VTE. In patients with positive COVID-19 status, 30-day mortality was associated with arterial events and pulmonary embolism, but not DVT or thrombophlebitis. There was no association of arterial events with COVID-19 status. Similarly, the rates of deep and superficial venous thrombosis were not associated with COVID-19 in our cohort. However, there was a significant association of pulmonary embolism with COVID-19 status (OR 3.90 1.43-13.29, p=.006). This can be explained by under diagnosis of asymptomatic of deep and superficial venous thrombosis. The incidence of acute arterial events is notoriously difficult to establish, since it is often not recognised and not treated promptly in particular if the symptoms are mild. Using a large prospective cohort Howard et al. demonstrated the incidence of acute arterial events of around 0.4%.(18Howard D.P.J. Banerjee A. Fairhead J.F. Hands L. Silver L.E. Rothwell P.M. Population-Based Study of Incidence, Risk Factors, Outcome, and Prognosis of Ischemic Peripheral Arterial Events.Circulation [Internet]. 2015 Nov 10; 132 (15. Available from:): 1805https://doi.org/10.1161/CIRCULATIONAHA.115.016424Google Scholar) A large retrospective analysis of patients with COVID-19 from New York involving over 12 thousand patients failed to explicitly provide the point prevalence of acute arterial events, but the number of patients presenting during observation period represents the rate of ∼0.36%.(12Etkin Y. Conway A.M. Silpe J. Qato K. Carroccio A. Manvar-Singh P. et al.Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.Ann Vasc Surg. 2021 Jan; 70: 290-294Google Scholar)Although done in different geographical locations, encompassing different populations, and different healthcare systems, the results look suspiciously similar, and point towards absence of excess events. We believe that the perceived increase in acute arterial events is caused by the high number of COVID-19 cases and increased attentiveness of vascular surgeons, and may represent observer bias. The increased incidence of VTE (mainly PE) in patients with COVID-19 has been demonstrated previously.(19Malas M.B. Naazie I.N. Elsayed N. Mathlouthi A. Marmor R. Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis.EClinicalMedicine. 2020 Dec; 29: 100639Google Scholar, 20Boonyawat K. Chantrathammachart P. Numthavej P. Nanthatanti N. Phusanti S. Phuphuakrat A. et al.Incidence of thromboembolism in patients with COVID-19: a systematic review and meta-analysis.Thromb J. 2020 Nov; 18: 34Google Scholar, 21Wu T. Zuo Z. Yang D. Luo X. Jiang L. Xia Z. et al.Venous thromboembolic events in patients with COVID-19: A systematic review and meta-analysis.Age Ageing. 2020 Nov; Google Scholar) However, the rates vary considerably depending on the cohort studied. A recent meta-analysis demonstrated a considerable geographical variability with reports from Germany showing the incidence of around 20% and countries like France and Netherlands reporting the incidence of VTE of up to 40%.(20Boonyawat K. Chantrathammachart P. Numthavej P. Nanthatanti N. Phusanti S. Phuphuakrat A. et al.Incidence of thromboembolism in patients with COVID-19: a systematic review and meta-analysis.Thromb J. 2020 Nov; 18: 34Google Scholar) The incidence was higher in critically ill patients than in patients not requiring higher level of care, or patients not requiring hospitalisation.(22Rashidi F. Barco S. Kamangar F. Heresi G.A. Emadi A. Kaymaz C. et al.Incidence of symptomatic venous thromboembolism following hospitalization for coronavirus disease 2019: Prospective results from a multi-center study.Thromb Res [Internet]. 2021 Dec; (November 2020):135–8. Available from:: 198https://doi.org/10.1016/j.thromres.2020.12.001Google Scholar) The post-discharge incidence of VTE was also low, but the baseline incidence of VTE in the studied ethnic group is generally low.(23Miri M. Goharani R. Sistanizad M. Deep Vein Thrombosis among Intensive Care Unit Patients; an Epidemiologic Study.Emerg (Tehran, Iran) [Internet]. 2017; 5 (Available from:): e13http://www.ncbi.nlm.nih.gov/pubmed/28286820%0Ahttp://www.pubmedcentral.nih.g

757 ASSESSING THE READMISSION RATES OF THE OLDER PERSON’S ASSESSMENT AND LIAISON ACUTE FRAILTY TEAM AT GOOD HOPE HOSPITAL

IntroductionThe Older Person’s Assessment and Liaison (OPAL) team at Good Hope Hospital (GHH), part of the University Hospitals Birmingham NHS Foundation Trust, provides multidisciplinary, patient-centred comprehensive assessment to patients presenting to the hospital front door. The team takes a ‘home first’ approach and where possible aims to discharge patients home with support by community teams. The service is part of the Birmingham wide Early Intervention programme. A front door OPAL service therefore enables early discharge for frail patients who would otherwise be likely to have a prolonged hospital admission. This has to be balanced against ensuring readmission rates do not exceed that of a comparable hospital inpatient population.MethodWe measured the 7 and 28-day readmission rate of all patients who received OPAL input and were discharged from A&E, the Medical Admissions Unit or the Acute Medical unit from July 2020—January 2021. This was compared with an inpatient short stay frailty unit however data was not available beyond November 2020 due to changes in response to the Covid-19 pandemic.Results2096 patients were discharged by OPAL with a 7-day readmission rate of 9.2% (95% CI 4.6–13.7%) and a 28-day readmission rate of 20.2% (95% CI 14.0–26.4%). From July—October 2020 the short stay frailty unit at GHH had a 7-day readmission rate of 9.7% (95% CI 3.1–16.3%) and a 28-day readmission rate of 25.2% (95% CI 8.2–42.2%). In the same period OPAL had a 7-day readmission rate of 8.7% (95% CI 3.2–14.2%) and a 28-day readmission rate of 19.9% (95% CI 13.3–26.5%).ConclusionThe OPAL service enabled the early discharge of patients without compromising readmission rates. The readmission rates for patients discharged by the OPAL team were better than the inpatient frailty unit with over 20% fewer 28 day readmissions.

75 - Evaluation of the use of next generation sequencing for directing treatment for patients with advanced non-small cell lung cancer (NSCLC): a single centre experience from University Hospitals Birmingham NHS Foundation Trust (UHB)

75 - Evaluation of the use of next generation sequencing for directing treatment for patients with advanced non-small cell lung cancer (NSCLC): a single centre experience from University Hospitals Birmingham NHS Foundation Trust (UHB)

Introduction of Systematized Nomenclature of Medicine–Clinical Terms Coding Into an Electronic Health Record and Evaluation of its Impact: Qualitative and Quantitative Study

BackgroundThis study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations.ObjectiveThe aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable remodeling of medical pathways.MethodsThe study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes toward the new tool, and the future use of the tool.ResultsThe new coding system (tool) was well received and immediately widely used in all specialties. This resulted in increased, accurate, and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and provided extensive feedback for further development.ConclusionsSuccessful implementation of the new system aligned the University Hospitals Birmingham NHS Foundation Trust with national strategy and can be used as a blueprint for similar projects in other health care settings.

There is still time to save the NHS, but time is running out

The NHS is falling over. Not everywhere, but in some places and in some services the signs of extreme stress are manifest. These signs are the result of the irresistible...

‘Fast-track’ pathway for resectable pancreatic cancer: barriers and facilitators to implementation across a regional network

The National Institute for Health and Care Excellence guidelines recommend a 'fast-track' approach to avoid preoperative biliary drainage (PBD) when treating resectable pancreatic cancer. For reasons not yet known, there is variable uptake of this approach across the UK. A 'fast-track' pathway which avoids PBD was introduced in University Hospitals Birmingham NHS Foundation Trust (UHB) and referring centres in 2015. Eleven semi-structured interviews were conducted with members of the hepatobiliary multidisciplinary team (MDT) in UHB and referring centres. Barriers and facilitators to pathway implementation were assessed. Facilitators underpinning implementation were collaboration between stakeholders, clinical leadership and careful coordination of referrals. Barriers to implementation included clinician opposition and increased workload. Barriers were mitigated through phased implementation and the appointment of dedicated staff. Future work may focus on exploring contextual factors in other tertiary centres and evaluating the emotional impact of 'fast-tracked' versus delayed surgery in patients with resectable pancreatic cancer.

Spatiotemporal analysis of the first wave of COVID-19 hospitalisations in Birmingham, UK

ObjectivesTo evaluate the spatiotemporal distribution of the incidence of COVID-19 hospitalisations in Birmingham, UK during the first wave of the pandemic to support the design of public health disease control...

EP.TH.449Routine G&amp;S in elective laparoscopic cholecystectomy and the impact on NHS resources

Abstract Aim Current guidelines for routine pre-operative tests for elective surgery, don’t mention routine Group &amp; Save (G&amp;S). At present the need for G&amp;S sample is dependent on the operative severity and the likelihood of blood loss. However, despite consistently low major bleeding rates in elective laparoscopic cholecystectomy (ELC) (0.1 – 0.46%) many hospitals, including ours, still hold local policies to have routine G&amp;S pre-operatively and/or on the day of surgery. Our aim is to audit our hospitals local policy regarding G&amp;S samples in ELC and establish its necessity and financial impact. Methods Retrospective study looking at adult patients undergoing ELC at University Hospitals Birmingham NHS Foundation Trust in 2020. Results 344 ELC procedures were carried out in 2020. Of those 82 had no G&amp;S, 137 had pre-op sample taken with no following samples, with a total of 182 samples sent on the day of surgery. Antibodies were identified in 5 patients (1,45%) however none were cross-matched before surgery. Only 1 patient needed transfusion in the peri-operative period and was cross-matched from sample sent after surgery. Conclusion Based on our results the likelihood of having peri-operative bleeding in ELC requiring blood transfusion is minimal (0.29%), therefore the need for routine G&amp;S in this context is questionable. Arguably, diagnosing antibodies in itself would justify one G&amp;S sample. In agreement with this our results show that in 2020 our Trust spent unnecessarily more that 2’431£, additionally adding workload to already stretched staff and delaying theatres.

Tre-O2-01 - Assessing the efficacy of mogamulizumab: a novel tool for the management of mycosis fungoides and Sézary syndrome

<h3>Introduction:</h3> A novel monoclonal antibody therapy termed mogamulizumab is currently seeking approval for treatment of mycosis fungoides and Sézary syndrome. Mogamulizumab is a humanized IgG1 κ monoclonal antibody which targets C-C chemokine receptor type 4 (CCR4), a transmembrane chemokine receptor which promotes T cell migration to the skin and is expressed at high levels on the surface of the malignant cells which drive cutaneous lymphomas. <h3>Methods:</h3> We performed a multi-centre clinical audit using data from 16 patients who have received mogamulizumab through a patient access programme at The Christie (8) and University Hospitals Birmingham (8) NHS Foundation Trusts. Our cohort had a median age of 68.1 (57.1–71.5) years at initiation of treatment, with a male to female sex ratio of 1.67 and varied diagnoses including Sézary syndrome (62.5%), classical mycosis fungoides (18.8%) and folliculotropic mycosis fungoides (12.5%). We assessed objective measures of disease response in the skin (mSWAT scores) and blood (flow cytometry), progression free survival (PFS) and the incidence of adverse events with the aim to further assess the efficacy and safety of mogamulizumab in this setting. <h3>Results:</h3> The patients in our cohort showed significant responses to mogamulizumab with median mSWAT score falling from 108 (53.8–139.1) to 23.1 (8.8–75.0) at peak response which was achieved at a median of 202 (115.5–328) days. 31.3% of our patients achieved a complete skin response whilst 37.5% achieved a partial skin response. The flow cytometry results of our cohort showed a marked improvement after initiation of mogamulizumab with median CD4/CD8 ratio, median number of circulating CD4+CD7– and CD4+CD26–being reduced by 89.0%, 96.8% and 95.8% respectively with median time to peak response being 193 (139.75–305.25) days. 62.5% of patients achieved a complete blood response with a further 25% achieving a partial blood response. Mogamulizumab was generally well tolerated with a median number of CTCAE events of 1.5 (0–4.25), which were predominantly grade 1 (62.9%) followed by grade 2 (22.9%) and grade 3 (14.3%) with no higher-grade adverse events being reported by any of the patients who had received mogamulizumab. One patient did discontinue treatment due to toxicity. Progression was only seen in 2 of the 16 with a medium follow up of 267 days (194.3–462.8) The median PFS has not been reached. 3 of the 16 patients have died, causes of death were CTCL (1), squamous cell carcinoma (1) and upper gastrointestinal haemorrhage (1). <h3>Conclusion:</h3> Mogamulizumab treatment resulted in marked improvements in skin and blood disease activity for patients across both centres whilst being generally well tolerated. The median PFS has not been reached after a median FU of 8.9 months. This compares favourably with the PFS of 7.7 months seen in the MAVORIC study. This observational study confirmed a high response rate in blood and skin in this group of diseases.

COVID-19 rapid antigen testing strategies require careful evaluation

Throughout the Covid-19 pandemic, testing for SARS-CoV-2 to allow early identification and isolation of those likely to be infectious has been a cornerstone of public health strategies to interrupt transmission of infection. An early reliance on reverse transcription polymerase chain reaction (RT-PCR) to confirm infection in those showing ‘typical’ signs and symptoms associated with Covid-19 was quickly supplemented with the use of rapid antigen detection tests (RDTs), particularly as the use case scenarios for testing changed from a focus on containment to a situation where testing has a much wider role as part of efforts to ease societal restrictions [[1]Boehme C Hannay E Sampath R. SARS-CoV-2 testing for public health use: core principles and considerations for defined use settings.Lancet Global Health. 2021; 9 (e247-e9)Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. The need for specialist laboratory facilities and worldwide demand for reagents limited countries’ ability to quickly scale up RT-PCR testing [[2]Peeling RW Olliaro PL Boeras DI Fongwen N. Scaling up COVID-19 rapid antigen tests: promises and challenges.Lancet Infect Dis. 2021; Summary Full Text Full Text PDF PubMed Scopus (147) Google Scholar]. RDTs conversely, are less expensive, provide results significantly more quickly, and do not require the same technical expertise or specialist facilities making them attractive for wide scale deployment [[1]Boehme C Hannay E Sampath R. SARS-CoV-2 testing for public health use: core principles and considerations for defined use settings.Lancet Global Health. 2021; 9 (e247-e9)Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. The advantages of RDTs come at a cost of lower and more variable sensitivity. Rt-PCR (able to detect even the smallest amount of viral RNA) is highly sensitive for detection of SARS-CoV-2, but has been criticised for its continued detection of the virus long after an individual is likely to remain infectious [[3]Mina MJ Peto TE García-Fiñana M Semple MG Buchan IE. Clarifying the evidence on SARS-CoV-2 antigen rapid tests in public health responses to COVID-19.Lancet. 2021; Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar]. RDTs use antibodies to capture SARS-CoV-2 proteins and accuracy is strongly affected by viral load. Indeed, test manufacturers have typically validated RDTs for use in symptomatic populations during the first five to seven days after symptom onset when viral load is expected to be highest and, by corollary, individuals are more likely to be infectious. A Cochrane review has shown RDT sensitivity of 78% on average during the first week after onset of symptoms (based on 2,320 RT-PCR positive cases), however observed sensitivities varied considerably, in part because of differences between assays, but also likely to reflect differences in sample types and storage, the adequacy of sampling and test interpretation [[4]Dinnes J Deeks JJ Berhane S et al.Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection.Cochrane Database Syst Rev. 2021; 3 (Cd013705)Google Scholar]. The same review highlighted the need for more information about how well RDTs perform in those who do not show typical signs and symptoms of Covid-19, and the lack of evidence for mass testing of asymptomatic individuals with no epidemiological indication for testing, for example to allow return to work or school, facilitate travel, or allow resumption of mass gatherings [[4]Dinnes J Deeks JJ Berhane S et al.Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection.Cochrane Database Syst Rev. 2021; 3 (Cd013705)Google Scholar]. In this article of EBioMedicine [[5]Wagenhäuser I Knies K Rauschenberger V et al.Clinical performance evaluation of SARS-CoV-2 rapid antigen testing in point of care usage in comparison to RT-qPCR.EBioMedicine. 2021; 69https://doi.org/10.1016/j.ebiom.2021.103455Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar], Isabell Wagenhäuser and colleagues provide a significant contribution to the evidence base for targeted community-based screening with RDTs. The ‘community’ consisted of over 5000 participants at a tertiary care hospital facility including all admitted patients or those accompanying patients, and hospital employees with respiratory symptoms or close contact with confirmed cases. The observed sensitivity of the RDT testing strategy was low – 42% overall and rising only to 49% in those with a ‘typical’ Covid-19 symptom profile. Almost all false positive results (15/16) occurred in those with no or with atypical Covid-19 symptoms, so that nearly three quarters of positive RDT results in this group were falsely positive (positive predictive value of 29%). As expected, the tests performed better in those with higher viral load and the authors point to the ability of the tests to detect all samples from individuals who may be considered ‘super spreaders’ of infection (detecting all 8 samples with SARS-CoV-2 RNA copies/mL of 10^8 or above), a claim that is supported by empirical studies of transmission risks [[6]Marks M Millat-Martinez P Ouchi D et al.Transmission of COVID-19 in 282 clusters in Catalonia, Spain: a cohort study.Lancet Infect Dis. 2021; 21: 629-636Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. However, transmission of infection does not stop at any specific viral load cut-off but operates on a continuum, with transmission also occurring in those with much lower viral loads [[6]Marks M Millat-Martinez P Ouchi D et al.Transmission of COVID-19 in 282 clusters in Catalonia, Spain: a cohort study.Lancet Infect Dis. 2021; 21: 629-636Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar]. Considering samples with viral loads above the commonly advocated cut-off for ‘infectiousness’ of 106 RNA copies/mL [[7]Corman VM Haage VC Bleicker T et al.Comparison of seven commercial SARS-CoV-2 rapid point-of-care antigen tests: a single-centre laboratory evaluation study.Lancet Microbe. 2021; Summary Full Text Full Text PDF Scopus (141) Google Scholar], 6 of 32 likely infectious cases in this study were missed. Wagenhäuser and colleagues[[5]Wagenhäuser I Knies K Rauschenberger V et al.Clinical performance evaluation of SARS-CoV-2 rapid antigen testing in point of care usage in comparison to RT-qPCR.EBioMedicine. 2021; 69https://doi.org/10.1016/j.ebiom.2021.103455Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar] reported RDT sensitivity at the lower end of that observed in other recent large-scale studies of RDT testing strategies which also included large proportions of asymptomatic people [[8]Pollock NR Jacobs JR Tran K et al.Performance and implementation evaluation of the Abbott BinaxNOW rapid antigen test in a high-throughput drive-through community testing site in Massachusetts.J Clin Microbiol. 2021; 59 (e00083-21)Crossref Scopus (73) Google Scholar,[9]Jakobsen KK Jensen JS Todsen T et al.Detection of SARS-CoV-2 infection by rapid antigen test in comparison with RT-PCR in a public setting.medRxiv. 2021; (2021.01.22.21250042)Google Scholar], so what are the possible explanations? Between-assay variations in sensitivity and the use of possibly less sensitive oropharyngeal samples may well have contributed [[10]Tsang NNY So HC Ng KY Cowling BJ Leung GM Ip DKM. Diagnostic performance of different sampling approaches for SARS-CoV-2 RT-PCR testing: a systematic review and meta-analysis.Lancet Infect Dis. 2021; Summary Full Text Full Text PDF PubMed Scopus (105) Google Scholar], however the low prevalence of SARS-CoV-2 and differences in the case-mix of participants, particularly in terms of the distribution of viral loads are likely to be a driving factor. While this study applied a blanket testing policy regardless of indication for SARS-CoV-2 testing, studies conducted at freely available Covid-19 testing sites will include those sufficiently motivated to attend and a greater proportion of people with epidemiological indications for testing [[8]Pollock NR Jacobs JR Tran K et al.Performance and implementation evaluation of the Abbott BinaxNOW rapid antigen test in a high-throughput drive-through community testing site in Massachusetts.J Clin Microbiol. 2021; 59 (e00083-21)Crossref Scopus (73) Google Scholar,[9]Jakobsen KK Jensen JS Todsen T et al.Detection of SARS-CoV-2 infection by rapid antigen test in comparison with RT-PCR in a public setting.medRxiv. 2021; (2021.01.22.21250042)Google Scholar]. The study period also overlapped a strict lockdown with declining prevalence of infection, and consequently lower proportions of people with the highest viral loads. The ability of RDTs to quickly pick up the majority of individuals with high levels of virus is undeniable but these tests do still miss people who are likely to be infectious and also risk falsely classifying uninfected individuals as positive. RDTs alone cannot be relied on to prevent outbreaks but, used in combination with Covid-19 symptom profiles and as triage to RT-PCR, can be a useful component of strategies to allow routine hospital procedures to continue. This study clearly emphasises the need for careful evaluation of RDT testing strategies for any given use case scenario prior to widespread roll-out. JD was solely responsible for the writing of the commentary. The author declares no conflict of interest. The author is supported by the NIHR Birmingham Biomedical Research Centre. This paper presents independent work supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Clinical performance evaluation of SARS-CoV-2 rapid antigen testing in point of care usage in comparison to RT-qPCRBackground: Antigen rapid diagnostic tests (RDT) for SARS-CoV-2 are fast, broadly available, and inexpensive. Despite this, reliable clinical performance data from large field studies is sparse.Methods: In a prospective performance evaluation study, RDT from three manufacturers (NADAL®, Panbio™, MEDsan®, conducted on different samples) were compared to quantitative reverse transcription polymerase chain reaction (RT-qPCR) in 5 068 oropharyngeal swabs for detection of SARS-CoV-2 in a hospital setting. Full-Text PDF Open Access

Antinociceptive and Discriminative Stimulus Effects of Six Novel Psychoactive Opioid Substances in Male Rats.

Compounds with novel or fentanyl-like structures continue to appear on the illicit drug market and have been responsible for fatalities, yet there are limited preclinical pharmacological data available to evaluate the risk of these compounds to public health. The purpose of the present study was to examine acetyl fentanyl, butyryl fentanyl, 3,4-dichloro-N-[[1-(dimethylamino)cyclohexyl]methyl]benzamide (AH-7921), 1-cyclohexyl-4-(1,2-diphenylethyl)piperazine (MT-45), 4-chloro-N-[1-(2-phenylethyl)-2-piperidinylidene]-benzenesulfonamide (W-15), and 4-chloro-N-[1-[2-(4-nitrophenyl)ethyl]-2-piperidinylidene]-benzenesulfonamide (W-18) for their relative potency to reference opioids and their susceptibility to naltrexone antagonism using the 55oC warm-water, tail-withdrawal assay of antinociception and a morphine drug discrimination assay in male, Sprague-Dawley rats. In the antinociception assay, groups of 8 rats per drug were placed into restraining tubes, their tails were immersed into 40o or 55oC water, and the latency for tail withdrawal was measured with a cutoff time of 15 seconds. In the drug discrimination assay, rats (n = 11) were trained to discriminate between 3.2 mg/kg morphine and saline, subcutaneously, in a two-choice, drug discrimination procedure under a fixed ratio-5 schedule of sucrose pellet delivery. Morphine, fentanyl, and four of the synthetic opioids dose dependently produced antinociception and fully substituted for morphine in the drug discrimination assay with the following rank order of potency: fentanyl > butyryl fentanyl > acetyl fentanyl > AH-7921 > MT45 > morphine. All drugs that produced antinociception or morphine-like discriminative stimulus effects were blocked by naltrexone. W-15 and W-18 did not show antinociceptive or morphine-like discriminative stimulus effects at the doses tested supporting a lack of opioid activity for these two compounds. These findings suggest that butyryl fentanyl, acetyl fentanyl, AH-7941, and MT-45 have abuse liability like other opioid agonists. SIGNIFICANCE STATEMENT: As novel psychoactive substances appear on the illicit drug market, preclinical pharmacological testing is required to assist law enforcement, medical professionals, and legal regulators with decisions about potential public health risks. In this study, four synthetic opioids, acetyl fentanyl, butyryl fentanyl, AH-7921, and MT-45 produced effects similar to fentanyl and morphine and were blocked by naltrexone. These data suggest the four synthetic opioids possess similar abuse liability risks as typical opioid agonists.

Is it safe to perform elective orthopaedic surgery with high community rates of COVID-19? An observational cohort study.

During the first wave of the COVID-19 pandemic, University Hospitals Birmingham NHS Foundation trust was able to recommence elective orthopaedic surgery using private hospitals procured by the NHS as COVID-19 free 'green' sites. We report on the safety of elective orthopaedic surgery with high rates of community transmission. We conducted an observational cohort study on consecutive NHS patients attending three private hospitals between 4 May 2020 and 16 June 2020. Patients attended preoperative assessment, including coronavirus disease (COVID-19) symptom screening, were instructed to self-isolate for 14 days and had a negative COVID-19 swab within 72 hours of surgery. Patient age, American Society of Anesthesiologists (ASA) grade, body mass index, surgery performed, type of anaesthetic and length of stay were collected. Our primary outcome was a positive COVID-19 swab, secondary outcomes were COVID-19 symptoms, readmission, surgical complications and mortality. Between 4 May 2020 and 16 June 2020, 191 patients were admitted to three private hospitals for elective surgery; 121 (67%) patients underwent general or regional anaesthetic, 179 patients were ASA grades 1 or 2 (94%) and 12 (6%) were ASA 3. In total, 187 (98%) patients were successfully contacted at 30 days postoperative and no COVID-19 symptoms, positive COVID-19 swabs or mortality or were recorded. One patient was readmitted following a pulmonary embolism and two patients were treated as outpatients for a deep vein thrombosis and a superficial infection. With 'green pathways' elective orthopaedic surgery can safely be performed while rates of COVID-19 in the community are high.

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave

Background: This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus. Methods: All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days. Results: Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions. Conclusion: Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.