University Hospitals Of Leicester Research Articles

Prevalence, indications and demographic characteristics of Botulinum neurotoxin use in a tertiary oculoplastic centre.

Over the past 40 years, Botulinum Neurotoxin (BoNT) treatment has been used in many presentations to the hospital eye service. There is little published on its practice in an ophthalmology setting. We aim to report on the prevalence of BoNT use, indications for treatment, age, gender, socioeconomic and ethnic variations observed, and dosages used. We performed a retrospective cross sectional observation study on the use of botulinum neurotoxin treatment in the oculoplastic department of a busy tertiary centre in the University Hospitals of Leicester, United Kingdom. The prevalence of BoNT in the service was 13.7 per 100,000 people. Of the 145 cases identified, the commonest indications for treatment were hemifacial spasm (62% of cases) and blepharospasm (29% of cases). Proportionally, twice as many females than males received BoNT (χ2 = 17.3, p < 0.0001). For those >30 years of age, the prevalence increased with age with those >90 years having a seven times higher prevalence than the mean. Overall, no significant differences were found in ethnicity and median index of multiple deprivation rank between those with treatment and the general population although specific district council variations were noted. These findings would assist commissioners in providing adequate resources to meet demand based on the demographics of their local population. Further qualitative and quantitative research is required to enhance our understanding of some of these trends.

P.38 Impact of COVID-19 pandemic on anaesthetic technique for caesarean section

Introduction: COVID-19 is an international public health emergency leading to dramatic shifts in health care. The main challenges for obstetric anaesthesia have been rapidly changing theatre pathways, measures implemented to prevent spread of infection and use of personal protective equipment (PPE).1 We investigated how the pandemic and resulting measures influenced the choice of anaesthetic technique for caesarean section (CS) and compared practice to RCOA standards and pre-COVID performance at the University Hospitals of Leicester (UHL).

P185 Does BASDAI score correlate to MRI changes in ankylosing spondylarthritis?

Abstract Background/Aims The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is routinely used subjective outcome measurement of disease activity in Ankylosing Spondylitis (AS). BASDAI &amp;gt; 4 is used as a criterion for commencing anti-TNF therapy. Previous studies shown BASDAI correlation with MRI has been proven to be weak. We did this study to systemically compare clinical and radiological data of patients with AS and to look for the degree of correlation between BASDAI score and MRI changes positive for spondyloarthritis in our cohort of patients. Methods A retrospective analysis of AS patients attending Leicester spondylarthritis service at University Hospitals Leicester Trust (UHL) was carried out. Clinical characteristics such as HLA-B27 status, extra-articular features, family history of AS and CRP measurement were obtained from online systems and clinic letters. Online records were reviewed to see if patients had a MRI of the sacroiliac joints along with a BASDAI score at the time of MRI. Medcalc calculator was used for statistical analysis. Results A total of 106 patients were analysed with a mean age of 45.6 +/- 11.6 years (M = 62, F = 44) with mean BASDAI of 5.0 +/- 2.5. Mean CRP was 17.01+/- 30.4 (median CRP 6.5). 61% (n = 65) were HLA-B27 positive. 70 of 106 patients had a sacroiliac MRI scan which could be reviewed to a satisfactory level to determine whether disease is present or not. Two results were statistically significant when comparing active versus no active lesions on MRI: inflammatory back pain and anti-TNF therapy (Table 1). P185 Table 1:Comparison of clinical features in patients with active versus inactive lesions on MRI sacroiliac joint.Active lesions on MRI N = 45No active lesions on MRI N = 25P valueMean BASDAI (SD)5.0 (2.6)5.4(2.6)0.5Mean ASDAS CRP (SD)2.14(1.1)2.04(0.6)0.73Mean CRP (SD) mg/l14.7(21)17.8(33)0.645.5HLA-B2731180.Uveitis1190.3Inflammatory back pain40170.03Enthesitis820.3Peripheral Arthritis670.1Dactylitis010.2Psoriasis211Inflammatory bowel disease710.1Ethnicity: Caucasian37230.2Ethnicity: Asian820.3Age45.5 (10.2)50.5(11.3)0.06M: F26:1916:90.7Anti-TNF therapy1840.03BASDAI &amp;gt;428150.8BASDAI &amp;lt;417100.8BASDAI= Bath ankylosing spondylitis disease activity index, ASDAS= Ankylosing Spondylitis disease. CRP=C-reactive protein, HLA= human leucocyte antigen. Conclusion BASDAI score did not statistically correlate with the severity of inflammation as objectively observed on MRI. Only inflammatory back pain and anti-TNF therapy correlated with MRI disease activity. There was no difference in clinical features including HLA-B27 between patients with active and inactive MRI. Thus, BASDAI as a criterion for biologic therapy may need re-considering. Disclosure N. Jain: None. S. Byravan: None. J. Stairs: None. W. Rennie: None. M. Arumugam: Other; Speaker and Conference Fee MSD, Novartis, Abbvie.

Risk Factors Associated with Statin-Associated Muscle Symptoms in Patients Attending a Specialized Regional Lipid Clinic.

Background Statin-associated muscle symptoms (SAMS) are the major side effects reported for statins. Data from previous studies suggest that 7–29% of patients on statin had associated muscle symptoms. In the UK, there is a lack of corresponding data on SAMS and factors associated with the development of SAMS. Objective This analysis is aimed at establishing the prevalence of SAMS and identifying major contributory risk factors in patients attending a lipid clinic. Methods Clinical records of 535 consecutive patients, who visited the lipid clinic in the University Hospitals of Leicester, were studied retrospectively between 2009 and 2012. SAMS were defined by the presence of muscle symptoms with two or more different statins. Patients who reported muscle symptoms to statin with one or no rechallenge were excluded. The association of SAMS with clinical characteristics such as age and BMI, sex, smoking, excess alcohol, comorbidities, and medications was tested for statistical significance. A binomial logistic regression model was applied to adjust for risk factors significantly associated with SAMS. Results The prevalence of SAMS was found to be 11%. On unadjusted analysis, the mean age of patients who had SAMS was significantly higher than those without SAMS (59.4 ± 10.5 years vs. 50.3 ± 13.4 years, respectively, P < 0.001). Nonsmokers were more likely to develop SAMS in comparison to active smokers (P = 0.037). Patients taking antihypertensive medications were more likely to develop SAMS (P = 0.010). In binomial logistic regression analysis, only age was positively and significantly associated with SAMS after adjusting for other risk factors (β = 0.054, P = 0.001). Conclusion To the best of our knowledge, this study is the largest cohort of patients with SAMS in the United Kingdom. Our data suggest that the prevalence of SAMS is 11% and increased age is a risk factor associated with the development of SAMS in our cohort of patients.

Day case Mastectomy Audit: University Hospitals of Leicester (UHL) Review of Practice

Introduction: The British Association of Day Surgery (BADS) recommends a day-case target of 30% for mastectomies. This audit aimed to determine the rate of day case mastectomies at UHL and factors that are preventing it.

Revision surgery after preventative breast surgery in gene carriers and high-risk women – Risk factors and how to reduce reoperation rates.

Background: Preventative breast surgery reduces breast cancer incidence in gene carriers and high-risk individuals. Various techniques and prosthetic materials are currently used for immediate breast reconstruction. We describe single surgeon experience at University Hospitals Leicester from 2003 to 2019.

Breast surgery at University Hospitals Leicester during the Pandemic.

Breast surgery at University Hospitals Leicester during the Pandemic.

Access to secondary care services for patients with established inflammatory bowel disease

Background: Standards of care for inflammatory bowel disease (IBD) recommend the introduction of pathways for rapid assessment or direct admission of patients with Crohn's disease or ulcerative colitis to specialist gastroenterology services. In 2017, services provided at University Hospitals of Leicester consisted of traditional outpatient services, a dedicated gastroenterology ward and access to specialist advice via a telephone helpline, which was available Monday to Friday at 09:00–13:00. The trust did not have a dedicated service for rapid-access clinics or direct admission. Aim: A study was conducted to explore how patients with an established diagnosis of IBD accessed secondary care services, when having an acute exacerbation. Methods: A questionnaire was provided to patients over 12 months, just before their discharge from the gastroenterology ward to identify what took place during their admission. Findings: The study recruited 50 participants. The majority of these patients had been admitted to secondary care via emergency or urgent care (60%), with 22% admitted from medical admissions units, 14% directly to gastroenterology ward and 2% via other departments. For 58% of patients, the pathway to the gastroenterology ward involved being transferred to a total of three different wards. Most patients waited for many hours before entering the gastroenterology ward, and around a quarter waited for 2 days or more. Conclusions: It was found that 16% of patients had been admitted to hospital unnecessarily. Following patient feedback, a rapid-access hot clinic should be piloted to improve access pathways for patients with acute exacerbations of IBD.

Impact of COVID-19 pandemic and lockdown on eye emergencies.

Background:To characterise and compare ocular pathologies presenting to an emergency eye department (EED) during the COVID-19 pandemic in 2020 against an equivalent period in 2019.Methods:Electronic patient records of 852 patients in 2020 and 1818 patients in 2019, attending the EED at a tertiary eye centre (University Hospitals of Leicester, UK) were analysed. Data was extracted over a 31-day period during: (study period 1 (SP1)) COVID-19 pandemic lockdown in UK (24th March 2020–23rd April 2020) and (study period 2 (SP2)) the equivalent 2019 period (24th March 2019–23rd April 2019).Results:A 53% reduction in EED attendance was noted during lockdown. The top three pathologies accounting for >30% of the caseload were trauma-related, keratitis and uveitis in SP1 in comparison to conjunctivitis, trauma-related and blepharitis in SP2. The overall number of retinal tears and retinal detachments (RD) were lower in SP1, the proportion of macula-off RD’s (84.6%) was significantly (p = 0.0099) higher in SP1 (vs 42.9% in SP2).Conclusion:COVID-19 pandemic related lockdown has had a significant impact on the range of presenting conditions to the EED. Measures to stop spread of COVID-19 such as awareness of hand hygiene practices, social distancing measures and school closures could have an indirect role in reducing spread of infective conjunctivitis. The higher proportion of macula-off RD and lower number of retinal tears raises possibility of delayed presentation in these cases. Going forward, we anticipate additional pressures on EED and other subspecialty services due to complications and associated morbidity from delayed presentations.

Demographic and occupational determinants of anti-SARS-CoV-2 IgG seropositivity in hospital staff.

BackgroundAlthough evidence suggests that demographic characteristics including minority ethnicity increase the risk of infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), it is unclear whether these characteristics, together with occupational factors, influence anti-SARS-CoV-2 IgG seroprevalence in hospital staff.MethodsWe conducted cross-sectional surveillance examining seroprevalence of anti-SARS-CoV-2 IgG amongst staff at University Hospitals of Leicester (UHL) NHS Trust. We quantified seroprevalence stratified by ethnicity, occupation and seniority of practitioner and used logistic regression to examine demographic and occupational factors associated with seropositivity.ResultsA total of 1148/10662 (10.8%) hospital staff members were seropositive. Compared to White staff (seroprevalence 9.1%), seroprevalence was higher in South Asian (12.3%) and Black (21.2%) staff. The occupations and department with the highest seroprevalence were nurses/healthcare assistants (13.7%) and the Emergency Department (ED)/Acute Medicine (17.5%), respectively. Seroprevalence decreased with seniority in medical/nursing practitioners. Minority ethnicity was associated with seropositivity on an adjusted analysis (South Asian: aOR 1.26; 95%CI: 1.07–1.49 and Black: 2.42; 1.90–3.09). Anaesthetics/ICU staff members were less likely to be seropositive than ED/Acute medicine staff (0.41; 0.27–0.61).ConclusionsEthnicity and occupational factors, including specialty and seniority, are associated with seropositivity for anti-SARS-Cov-2 IgG. These findings could be used to inform occupational risk assessments for front-line healthcare workers.

73 Is There A Real Relationship Between Body Mass Index and Vasovagal Syncope or is it Just Anecdote?

Abstract Introduction Syncope is characterised by global cerebral hypoperfusion rapidly causing a transient loss of consciousness with loss of voluntary muscle tone and a subsequent spontaneous, prompt and complete recovery. It is often caused by Neurally mediated reflex syncope syndromes of which Vasovagal syncope (VVS) is the commonest form. The prodromal symptoms of VVS are explained by circulatory alterations (vasodilatation and bradycardia) and autonomic activation. Whilst many triggers and risk factors for such alterations are recognised, they are incompletely understood. Anecdotally, being “young and thin” is a risk factor but there is little published data evaluating the relationship between body weight and VVS. Whilst VVS can often be diagnosed on clinical history alone, further evaluation is warranted in some patients. The validated test to assess susceptibility to VVS is the head-up-tilt table (HUT) test. We set out to evaluate the relationship between Body Mass Index (BMI) and the outcome of HUT testing. Methods We reviewed the outcomes of 1193 patients attending for HUT testing at the University Hospitals of Leicester between December 2014 and October 2017. The protocol used was a 40 minute passive HUT (70 degree) followed by sublingual nitroglyserin. The parameters of height, weight, gender and test outcome were recorded prospectively and interrogated retrospectively. Results Of the 1193 patients, the passive HUT test was positive for VVS in 293 patients. These patients were then sub-grouped by BMI as set out in the table. The chances of VVS, as diagnosed by HUT testing are almost doubled in those with a (clinically underweight) BMI range 16-20. (p value 0.002-0.001) Discussion The presented data supports the anecdotal experience of many clinicians: that low BMI may be associated with an increased tendency to VVS. The physiological basis for this (if it is real) is not understood and requires further evaluation since it may have implications for future management strategies. Larger studies are required to further analyse this relationship to determine if BMI is an independent predictor or risk factor for VVS.

Comedones and carbapenems: hydradenitis suppurativa in the OPAT clinic

Background Hydradenitis suppurativa (HS) is a chronic inflammatory skin disease. The UK prevalence is estimated at between 1-4%. There is an approximate 3:1 female: male preponderance and it is associated with smoking, obesity, type 2 diabetes mellitus. The pathogenesis of HS is poorly understood. Clinical features vary in extent and the axillae, inguinal and anogenital areas are typically affected. It has a significant impact on quality of life, with high rates of depression amongst sufferers. Current UK treatment guidelines focus on lifestyle interventions, as well as targeted use of oral antibiotics, however microbiological sampling is usually not helpful. Where these are unsuccessful anti-TNF agents and surgical intervention may be indicated. Despite their absence from these guidelines, there is growing evidence to support the role of intravenous (IV) antibiotics in treating HS. It is not known whether the treatment response seen with IV antibiotics is due to their antibacterial or an anti-inflammatory effect. We present a series of HS patients managed under the OPAT team at University Hospitals of Leicester. Cases To date 8 patients have completed treatment (7F/1M). All received at least 6 weeks of therapy with IV ertapenem (+/- teicoplanin). Significant improvement in both clinical signs and symptoms was achieved in all cases. However, disease relapse was seen in three cases after cessation of IVs, requiring additional courses of treatment. Antibiotics were well tolerated with one adverse drug reaction secondary to teicoplanin. Conclusion Intravenous antibiotics are an effective adjunctive treatment in selected cases of hidradenitis suppurativa.

P852 Introduction of Entamoeba histolytica serology testing in the management of inflammatory bowel disease patients at University Hospitals of Leicester, UK

Abstract Background Amoebic colitis can mimic inflammatory bowel disease (IBD) in clinical presentation, endoscopic and (to some extent) histological findings. Four patients with amoebic colitis were misdiagnosed with IBD or an IBD flare at University Hospitals of Leicester (UHL), UK in 2018. This prompted a change in practise in our department and we began screening for Entamoeba histolytica in patients with newly-diagnosed IBD, a flare or those being considered for biologics. We analysed cases of possible amoebic colitis after this change by reviewing IBD patients with a positive E. histolytica immunofluorescence antibody test (IFAT). Methods We conducted a retrospective electronic and case note review of patients with IBD and positive amoeba IFAT serology &amp;gt;1:80 from April 2019 through September 2019. We collected information including Crohn’s disease (CD), ulcerative colitis (UC), IBD treatment, histological findings, travel history, stool E. histolytica DNA polymerase chain reaction (PCR) and amoebic serology including IFAT and Cellulose Acetate Precipitin test (CAP). The histology of endoscopic biopsies for 16 of the IFAT positive patients was reviewed specifically for amoebic trophozoites. Results During the study period we identified 26 IFAT positive patients, excluded 3 patients that were felt to be non-IBD; 23 were included in the study. The median age was 37.8 (range 16–86); 43.5% were male. Four had a diagnosis of UC; 19 had CD. 12 were new IBD presentations. Seven patients had a relevant travel history (Jamaica, Thailand, Turkey, Italy, Greece, and Spain). Four did not have a travel history. Travel history was unknown for 12. Three patients were on biologics, one on biologics and thiopurines. Five were on thiopurines, three on thiopurines and steroids. Four were on steroids only, four on 5-ASAs. Three were on no treatment. Two out of 16 patients reviewed had amoebic trophozoites on endoscopic biopsy, unfortunately stool PCR was not sent on these two patients. Stool E. histolytica DNA PCR, was sent for 19 patients and was negative in those cases. All 24 patients were negative for CAP. Conclusion While IFAT is helpful in detecting past exposure it is only 75% sensitive for amoebic colitis. Even if IFAT and CAP are combined it is difficult to differentiate amoebic colitis from IBD. It is not clear if these cases represent past infections, early infections that precipitated an IBD flare, early infections that arose in the setting of immunosuppression, or false positive IFATs. The risk of infection in the immunosuppressed patient is high and the consequences of misdiagnosis are significant therefore a comprehensive screening method is merited; this may encompass IFAT ± CAP, stool E. histolytica DNA PCR, and possibly histological review.

P853 Amoebic colitis mimicking inflammatory bowel disease: a report of four cases

Abstract Background Amoebic colitis, caused by Entamoeba histolytica is an emerging diagnostic challenge for gastroenterologists in developed countries. Due to the similarity of symptoms and endoscopic findings, it can be easily misdiagnosed as inflammatory bowel disease (IBD) with a potentially devastating outcome especially if patient receives immunosuppression. The aim of this study is to look into the misdiagnosed cases to identify the challenges in differentiating amoebic colitis from IBD and to outline strategies to avoid this Methods Clinical and electronic case notes for the 4 patients, who were misdiagnosed as IBD between September 2015 to February 2019 at University Hospitals of Leicester U.K. were reviewed. The histology of resected colon specimens and endoscopic colonic biopsies were re-reviewed specifically for amoebic trophozoites. Results Three were male and 1 female. 1 patient was Caucasian while 3 patients were British Asian. Their mean age was 47.75 years (range 28–71). 3 cases were new IBD presentations while 1 patient was misdiagnosed as IBD since 2015. Two patients had a travel history to India and travelled to South East Asia 12 months prior to presentation. The travel history for 1 patient was not available. All 4 cases presented with bloody diarrhoea and had an endoscopic examination around the time of diagnosis which suggested acute inflammation likely IBD. Three were treated as ulcerative colitis while 1 patient was treated as Crohn’s disease. One patient required rescue therapy with cyclosporin while on intravenous steroids. As clinical symptoms worsened with rescue therapy, the patient required a subtotal colectomy. Similarly the patient who was treated for Crohn’s disease with Azathioprine and intravenous steroids, required subtotal colectomy due to recurrent flare ups. The other two cases were successfully treated with antimicrobial after the diagnosis of amoebic colitis although one of them received adalimumab prior to the correct diagnosis. The diagnosis of amoebic colitis was made through histological examination of the resected colon in 2 patients, colonic biopsy in 1 patient and stool E. histolytica DNA polymerase chain reaction (PCR) in 1 patient. Conclusion All 4 cases who were misdiagnosed as IBD had the diagnostic challenge of differentiating IBD from amoebic colitis due to similarity of symptoms and the endoscopic findings. Travel history is an important clue and should be considered for any patient presenting with colitis. New local guidelines were introduced to screen all patient with colitis for E. histolytica with serology and stool PCR. Patients requiring immunosuppression for suspected IBD are commenced on antimicrobial cover until E. histolytica results are available.

Clinical outcomes of patients discharged from the Rapid Access Chest Pain Clinic with non-anginal chest pain: A retrospective cohort study

BackgroundThe Rapid Access Chest Pain Clinic (RACPC) has become an important means of assessing patients who present with ischaemic or ischaemia-like symptoms of recent onset. Observations have shown that up to 70% are discharged with a diagnosis of non-anginal chest pain (NACP) and accordingly “reassured”. This study aims to describe the actual clinical outcomes of this cohort of patients discharged from the RACPC. MethodsWe undertook a single centre retrospective cohort study at a tertiary cardiac hospital. The outcomes of unselected patients diagnosed with NACP and discharged from the RACPC between April 2010 and March 2013 at University Hospitals of Leicester (UHL) were recorded. Re-referrals to cardiology outpatient clinic and emergency hospital admissions for cardiovascular disease within 6 months, and the mortality rate at 12 months, were determined. Results7066 patients were seen in the UHL RACPC during the 36-month period. 3253 (46.0%) were diagnosed with NACP and discharged. 7 (0.2%) were diagnosed with coronary artery disease (CAD) and 8 (0.25%) cases of acute coronary syndrome (ACS) identified during the review period. 11 (0.3%) patients died within 12 months of discharge from RACPC. No deaths were attributable to CAD. ConclusionsComprehensive assessment using risk-stratification criteria in a nurse practitioner-led RACPC can accurately identify patients who are at low-risk for subsequent CAD. Despite contemporary National Institute for Health and Care Excellence (NICE) guidelines that shift focus away from a clinical judgement based approach, this strategy appears to robustly predict favourable outcomes in patients diagnosed with NACP.

Audit of premature ovarian insufficiency management at University Hospitals Leicester NHS Trust

Audit of premature ovarian insufficiency management at University Hospitals Leicester NHS Trust

Estimation of post-surgical hypoparathyroidism incidence following total thyroidectomy in University Hospitals Leicester NHS Trust

Estimation of post-surgical hypoparathyroidism incidence following total thyroidectomy in University Hospitals Leicester NHS Trust

Audit of adrenal crisis management at University Hospitals Leicester NHS Trust

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Legibility of The Operative Notes According To The Royal College of Surgeons Guidelines After Introducing Electronic Forms at University Hospitals of Leicester : A Prospective Quality Improvement Study

Background: Proper documentation of the operative notes is one of the pillars of good surgical practice. It ensures safety and maintains communication between MDT members involved in post-op care. Complete and clear operation notes provide a medico legal record to use as evidence when required. Based on 2 previous audits done on hand-written operative notes at UHL, legibility continued to be a problem. Therefore, we introduced an e-template to compare against RCS guidelines. Our aim was to maintain accurate and legible records of surgical procedures.

Listening to junior doctors: exploring morale in a large NHS trust

To explore the morale of junior doctors at University Hospitals of Leicester (UHL) NHS Trust, and improve our understanding of the major contributory factors. In November 2017, an online survey was sent to 943 junior doctors working at UHL. We designed this survey to capture a comprehensive picture of junior doctor morale in several domains. Respondents used an ordinal scale of zero (low) to 10 (high) …