University Hospitals NHS Foundation Trust Research Articles

The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis.

The role of hepatic venous pressure gradient (HVPG) measurement in risk stratification before liver resection is an ongoing area of debate. This study examines the impact of preoperative HVPG levels on overall survival (OS)/time to recurrence (TTR) and postoperative complications after hepatic resection of hepatocellular carcinoma (HCC). Thirty-eight HCC patients undergoing HVPG measurement before liver resection at Cambridge University Hospitals NHS Foundation Trust between January 2014 and April 2022 were retrospectively analysed. Statistical analysis comprised univariable/multivariable Cox/logistic regression to identify risk factors of reduced OS/TTR or 90-day post-resection complications and Kaplan-Meier estimator, log-rank, chi-squared, Fisher's exact, and Mann-Whitney U test, or Student's t-test for survival/subgroup analysis. The median HPVG was 6 (range: 0-14) mmHg. The HVPG was an independent risk factor for poorer TTR in the overall cohort (cut-off: ≥7.5 mmHg (17.18/43.81 months; P = 0.009)). In the subgroup analysis of cirrhotic patients (N = 29 (76%)), HVPG was additionally an independent risk factor for lower OS (cut-off: ≥8.5 mmHg [44.39/76.84 months; P = 0.012]). The HVPG had no impact on OS/TTR in non-cirrhotic patients (N = 9 (24%)), nor was it associated with postoperative complications in any cohort. In conclusion, preoperative HVPG levels are useful predictors for TTR and OS in cirrhotic HCC patients undergoing hepatic resection.

Effect of parental touch on relieving acute procedural pain in neonates and parental anxiety (Petal): a multicentre, randomised controlled trial in the UK

Touch interventions such as massage and skin-to-skin contact relieve neonatal pain. The Parental touch trial (Petal) aimed to assess whether parental stroking of their baby before a clinically required heel lance, at a speed of approximately 3 cm/s to optimally activate C-tactile nerve fibres, provides effective pain relief. Petal is a multicentre, randomised, parallel-group interventional superiority trial conducted in the John Radcliffe Hospital (Oxford University Hospitals NHS Foundation Trust, Oxford, UK) and the Royal Devon and Exeter Hospital (Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK). Neonates without neurological abnormalities who were born at 35 weeks gestational age or more and required a blood test via a heel lance in the first week of life were randomly assigned (1:1) to receive parental touch for 10 s either before (intervention group) or after (control group) the clinically required heel lance. Randomisation was managed at the Oxford site using a web-based minimisation algorithm with allocation concealment. The primary outcome measure was the magnitude of noxious-evoked brain activity in response to the heel lance measured with electroencephalography (EEG). Secondary outcome measures were Premature Infant Pain Profile-Revised (PIPP-R) score, development of tachycardia, and parental anxiety score. For all outcomes, the per-protocol effect was estimated via complier average causal effect analysis on the full analysis set. The trial is registered on ISRCTN (ISRCTN14135962) and ClinicalTrials.gov (NCT04901611). Between Sept 1, 2021, and Feb 7, 2023, 159 parents were approached to participate in the study, and 112 neonates were included. 56 neonates were randomly assigned to the intervention group of parental stroking before the heel lance and 56 to the control group of parental stroking after the heel lance. The mean of the magnitude of the heel lance-evoked brain activity was 0·85 arbitrary units (a.u.; SD 0·70; n=39; a scaled magnitude of 1 a.u. represents the expected mean response to a heel lance in term-aged neonates) in the intervention group and 0·91 a.u. (SD 0·76; n=43) in the control group. Therefore, the primary outcome did not differ significantly between groups, with a mean difference of -0·11 a.u. (lower in intervention group; SD 0·77; 95% CI -0·42 to 0·20; p=0·38; n=82). No significant difference was observed across secondary outcomes. The PIPP-R difference in means was 1·10 (higher in intervention group, 95% CI -0·42 to 2·61; p=0·15; n=100); the odds ratio of becoming tachycardic was 2·08 (95% CI 0·46 to 9·46; p=0·34, n=105) in the intervention group with reference to the control group; and the difference in parental State-Trait Anxiety Inventory-State score was -0·44 (higher in control group; SD 6·85; 95% CI -2·91 to 2·02; p=0·72; n=106). One serious adverse event (desaturation) occurred in a neonate randomly assigned to the control group, which was not considered to be related to the study. Parental stroking delivered at an optimal speed to activate C-tactile fibres for a duration of 10 s before the painful procedure did not significantly change neonates' magnitude of pain-related brain activity, PIPP-R score, or development of tachycardia. The trial highlighted the challenge of translating an experimental researcher-led tactile intervention into a parent-led approach, and the value of involving parents in their baby's pain management. Wellcome Trust and Bliss.

Puzzles of the Liminal Dead: St George's University Hospitals NHS Foundation Trust v Casey.

Puzzles of the Liminal Dead: St George's University Hospitals NHS Foundation Trust v Casey.

Supporting self-management for patients with Interstitial Lung Diseases: Utility and acceptability of digital devices.

Patients diagnosed with Interstitial Lung Diseases (ILD) use devices to self-monitor their health and well-being. Little is known about the range of devices, selection, frequency and terms of use and overall utility. We sought to quantify patients' usage and experiences with home digital devices, and further evaluate their perceived utility and barriers to adaptation. A team of expert clinicians and patient partners interested in self-management approaches designed a 48-question cross-sectional electronic survey; specifically targeted at individuals diagnosed with ILD. The survey was critically appraised by the interdisciplinary self-management group at Royal Devon University Hospitals NHS Foundation Trust during a 6-month validation process. The survey was open for participation between September 2021 and December 2022, and responses were collected anonymously. Data were analysed descriptively for quantitative aspects and through thematic analysis for qualitative input. 104 patients accessed the survey and 89/104 (86%) reported a diagnosis of lung fibrosis, including 46/89 (52%) idiopathic pulmonary fibrosis (IPF) with 57/89 (64%) of participants diagnosed >3 years and 59/89 (66%) female. 52/65(80%) were in the UK; 33/65 (51%) reported severe breathlessness medical research council MRC grade 3-4 and 32/65 (49%) disclosed co-morbid arthritis or joint problems. Of these, 18/83 (22%) used a hand- held spirometer, with only 6/17 (35%) advised on how to interpret the readings. Pulse oximetry devices were the most frequently used device by 35/71 (49%) and 20/64 (31%) measured their saturations more than once daily. 29/63 (46%) of respondents reported home-monitoring brought reassurance; of these, for 25/63 (40%) a feeling of control. 10/57 (18%) felt it had a negative effect, citing fluctuating readings as causing stress and 'paranoia'. The most likely help-seeking triggers were worsening breathlessness 53/65 (82%) and low oxygen saturation 43/65 (66%). Nurse specialists were the most frequent source of help 24/63 (38%). Conclusion: Patients can learn appropriate technical skills, yet perceptions of home-monitoring are variable; targeted assessment and tailored support is likely to be beneficial.

The role of medical support workers during the COVID-19 pandemic in the NHS in the UK: A qualitative service evaluation at the Oxford University Hospitals NHS Foundation Trust

We conducted a service evaluation of the medical support worker (MSW) role at Oxford University Hospitals NHS Foundation Trust following the Coronavirus 2019 (COVID-19) pandemic. The aim was to explore the roles of MSWs, their contributions to the NHS, factors influencing their career choices, and the goals of the MSW position, to inform quality improvement in relation to their integration into the Trust. The perspectives of MSWs, their supervisors and recruiters were analysed through nine semi-structured interviews and two focus group discussions involving 18 participants. Results were categorised into micro-, meso-, and macro-levels of the health system. At the micro-level, MSWs were recognised as a diverse group of highly qualified international medical graduates (IMGs) who had a crucial role during the pandemic. At the meso-level, participants emphasised the importance of a comprehensive induction by the hospital, to clarify responsibilities and familiarise MSWs with the health system. At the macro-level, the role facilitated MSW integration within the NHS, with the aim of practising as doctors. The importance of comprehensive hospital induction, with role clarity for both MSWs and their teams, supportive supervision and assistance with applying for registration with the General Medical Council, were highlighted as key quality improvement areas.

Impact of penicillin allergy labels on surgical site infections in a large UK cohort of gastrointestinal surgery patients.

Studies in the USA, Canada and France have reported higher surgical site infection (SSI) risk in patients with a penicillin allergy label (PAL). Here, we investigate the association between PALs and SSI in the UK, a country with distinct epidemiology of infecting pathogens and range of antimicrobial regimens in routine use. Electronic health records and national SSI surveillance data were collated for a retrospective cohort of gastrointestinal surgery patients at Cambridge University Hospitals NHS Foundation Trust from 1 January 2015 to 31 December 2021. Univariable and multivariable logistic regression were used to examine the effects of PALs and the use of non-β-lactam-based prophylaxis on likelihood of SSI, 30 day post-operative mortality, 7 day post-operative acute kidney injury and 60 day post-operative infection/colonization with antimicrobial-resistant bacteria or Clostridioides difficile. Our data comprised 3644 patients and 4085 operations; 461 were undertaken in the presence of PALs (11.3%). SSI was detected after 435/4085 (10.7%) operations. Neither the presence of PALs, nor the use of non-β-lactam-based prophylaxis were found to be associated with SSI: adjusted OR (aOR) 0.90 (95% CI 0.65-1.25) and 1.20 (0.88-1.62), respectively. PALs were independently associated with increased odds of newly identified MRSA infection/colonization in the 60 days after surgery: aOR 2.71 (95% CI 1.13-6.49). Negative association was observed for newly identified infection/colonization with third-generation cephalosporin-resistant Gram-negative bacteria: aOR 0.38 (95% CI 0.16-0.89). No evidence was found for an association between PALs and the likelihood of SSI in this large UK cohort, suggesting significant international variation in the impact of PALs on surgical patients.

An audit of a general practices compliance with national recommendations for the avoidance of complications for type 2 diabetic patients

Abstract Introduction Each week, diabetes leads to more than 700 strokes, almost 600 heart attacks and more than 2000 instances of heart failure, in addition to being the single most common cause of chronic kidney disease in the UK.1 The NHS spends 10% of its annual budget on diabetes with 80% of that treating the complications of diabetes.2 Pharmacists have a crucial role to optimise the medication of diabetic patients and prevent future problems. Aim To assess a general practices (GP) compliance with national recommendations and the Quality and Outcomes Framework for the avoidance of complications for Type 2 Diabetes Mellitus (T2DM) patients. Methods This single-centre, retrospective audit was conducted at a GP in the London Borough of Southwark. Six standards were measured focusing on the prevention of the complications of diabetes. Each standard incorporated an exclusion and inclusion criteria. Standard 1 and 2 reviewed the appropriate management of nephropathy and hypertension respectively. Standard 3 and 4 relate to statin use for primary and secondary prevention. The final standards assess how many patients have documented QRISK2 scores and initiated on a Sodium-Glucose Co-Transporter 2 (SGLT2) inhibitor as per the new NICE guidelines.3 Ethical approval was not deemed necessary for this clinical audit in agreement with the Hurley Group and King’s College Hospital NHS Foundation Trust guidelines. Results Half (50%, n=153/304) of all included T2DM patients at the practice have a blood pressure reading defined as hypertensive. Out of all diabetic patients, 25 of them had clinical proteinuria, micro-albuminuria, or a diagnosis of nephropathy. Of these 25 patients, 19 (76%) were prescribed an angiotensin-converting enzyme inhibitor or angiotensin-receptor blockers. A small portion (7%, n=28/374) of the diagnosed T2DM patients have a documented QRISK2 score. Subsequently, only 32 diabetic patients (9%, n=32/374) are prescribed an SGLT2 inhibitor. For standards 3 and 4, there were 122 patients (73%) who were prescribed a statin for primary prevention and 89 patients (87%) who were prescribed a statin for secondary prevention. Discussion/Conclusion The microvascular and macrovascular complications of diabetes are well documented. The incidence of these complications can be reduced by pharmacological management. Although none of the standards were met, the results are similar to other practices across the country. However, in comparison to the local average, the audited GP underperformed with no standards being better than the average of GPs in the area. Sub-analysis emphasises the disparities in health between various racial and ethnic groups. The results of the two largest demographic groups audited, Caucasian and Caribbean patients, show that the former is more likely to meet the standards. These findings indicate that the processes of the practice require change to meet the needs of our diabetic patients. In particular, work is required to understand the disparities in care for our patients categorised as ethnic minorities. The recommendations fall under 5 main categories – feedback, learn, templates, analyse, and review.

Quantifying the variability in the assessment of reproductive hormone levels

To quantify how representative a single measure of reproductive hormone level is of the daily hormonal profile using data from detailed hormonal sampling in the saline placebo-treated arm conducted over several hours. Retrospective analysis of data from previous interventional research studies evaluating reproductive hormones. Clinical Research Facility at a tertiary reproductive endocrinology centre at Imperial College Hospital NHS Foundation Trust. Overall, 266 individuals, including healthy men and women (n = 142) and those with reproductive disorders and states (n = 124 [11 with functional hypothalamic amenorrhoea, 6 with polycystic ovary syndrome, 62 women and 32 men with hypoactive sexual desire disorder, and 13 postmenopausal women]), were included in the analysis. Data from 266 individuals who had undergone detailed hormonal sampling in the saline placebo-treated arms of previous research studies was used to quantify the variability in reproductive hormones because of pulsatile secretion, diurnal variation, and feeding using coefficient of variation (CV) and entropy. The ability of a single measure of reproductive hormone level to quantify the variability in reproductive hormone levels because of pulsatile secretion, diurnal variation, and nutrient intake. The initial morning value of reproductive hormone levels was typically higher than the mean value throughout the day (percentage decrease from initial morning measure to daily mean: luteinizing hormone level 18.4%, follicle-stimulating hormone level 9.7%, testosterone level 9.2%, and estradiol level 2.1%). Luteinizing hormone level was the most variable (CV 28%), followed by sex-steroid hormone levels (testosterone level 12% and estradiol level 13%), whereas follicle-stimulating hormone level was the least variable reproductive hormone (CV 8%). In healthy men, testosterone levels fell between 9:00 am and 5:00 pm by 14.9% (95% confidence interval 4.2, 25.5%), although morning levels correlated with (and could be predicted from) late afternoon levels in the same individual (r2 = 0.53, P<.0001). Testosterone levels were reduced more after a mixed meal (by 34.3%) than during ad libitum feeding (9.5%), after an oral glucose load (6.0%), or an intravenous glucose load (7.4%). Quantification of the variability of a single measure of reproductive hormone levels informs the reliability of reproductive hormone assessment.

Using Artificial Intelligence to Stratify Normal versus Abnormal Chest X-rays: External Validation of a Deep Learning Algorithm at East Kent Hospitals University NHS Foundation Trust.

Background: The chest radiograph (CXR) is the most frequently performed radiological examination worldwide. The increasing volume of CXRs performed in hospitals causes reporting backlogs and increased waiting times for patients, potentially compromising timely clinical intervention and patient safety. Implementing computer-aided detection (CAD) artificial intelligence (AI) algorithms capable of accurate and rapid CXR reporting could help address such limitations. A novel use for AI reporting is the classification of CXRs as 'abnormal' or 'normal'. This classification could help optimize resource allocation and aid radiologists in managing their time efficiently. Methods: qXR is a CE-marked computer-aided detection (CAD) software trained on over 4.4 million CXRs. In this retrospective cross-sectional pre-deployment study, we evaluated the performance of qXR in stratifying normal and abnormal CXRs. We analyzed 1040 CXRs from various referral sources, including general practices (GP), Accident and Emergency (A&E) departments, and inpatient (IP) and outpatient (OP) settings at East Kent Hospitals University NHS Foundation Trust. The ground truth for the CXRs was established by assessing the agreement between two senior radiologists. Results: The CAD software had a sensitivity of 99.7% and a specificity of 67.4%. The sub-group analysis showed no statistically significant difference in performance across healthcare settings, age, gender, and X-ray manufacturer. Conclusions: The study showed that qXR can accurately stratify CXRs as normal versus abnormal, potentially reducing reporting backlogs and resulting in early patient intervention, which may result in better patient outcomes.

A casemix classification for those receiving specialist palliative care during their last year of life across England: the C-CHANGE research programme

Background The hospice movement has provided an excellent model of specialist palliative care for those with advanced illness approaching the end of life. However, there are marked inequities in provision of this care, and major geographical variations in the resourcing of palliative care, often resulting in a poor match between the needs of a patient/family and resources provided to meet those needs. Objective To develop/test a casemix classification to accurately capture the complex needs of patients with advanced disease, better quantify those needs and more fairly allocate resources to meet them. A ‘casemix classification’ groups patients into classes according to differing care needs to help inform the resources needed to meet those care needs. Design Workstream 1 comprised the validating and refining of patient-centred measures of health status and well-being. In workstream 2, stakeholder interviews with patients, families, policy-makers, service providers and commissioners were carried out to understand complexity/casemix and models of specialist palliative care. In workstream 2 the casemix classification was developed through a multicentre cohort study. Workstream 4 comprised a longitudinal mixed-methods study to test the casemix classification, with a nested qualitative study to explore experiences of transitions between care settings. Setting Voluntary sector and NHS specialist palliative care services across England. Participants Patients ≥ 18 years receiving specialist palliative care, their families and the professionals delivering this care. Results For the Integrated Palliative care Outcome Scale validation: data from 376 patient participants and 161 clinicians showed this measure has a strong ability to distinguish between clinically relevant groups, good internal consistency (α = 0.77), and acceptable-to-good test–retest reliability (60% of items kw &gt; 0.60). The Phase of Illness measure showed function and symptoms/concerns varied significantly by Phase of Illness, but Phase of Illness reflected additional construct(s) and so is important for casemix (workstream 1 conducted 2013–15). To gain stakeholder perspectives, 65 participants were interviewed. Based on emergent themes, we developed a theoretical framework to conceptualise complexity in specialist palliative care. This framework emphasises that considering physical, psychological and social needs is not enough to characterise complexity. Number, severity and range of needs all need to be considered in the development of a meaningful casemix classification. To understand models of care, semistructured interviews were conducted with 14 participants, 54 further participants took part in a two-round Delphi survey and interviews were conducted with 21 service leads. Twenty criteria were adopted to define/distinguish models of specialist palliative care (workstream 2 conducted 2014–16). For the development of the casemix classification, a total of 2469 patients were recruited, providing data on 2968 episodes of specialist palliative care. The mean age was 71.6 years, 51% of patients were male, 74% were white and 25% were non-cancer patients. Episodes of care lasted a median of 8 days (range 1–402 days) in hospital advisory care, 12 days (range 1–140 days) in inpatient units, 30 days (range 1–313 days) in the community. The median costs per day (lower–upper quartiles) were: £56 (£31–£100) in hospital advisory, £365 (£176–£698) for inpatient, and £21 (£6–£49) in community care. Seven hospital advisory, six inpatient and six community casemix classes for specialist palliative care were developed, based on levels of pain, other physical symptoms, psychological symptoms, functional status, palliative Phase of Illness, living alone and family distress (workstream 3 conducted 2016–18). For the testing of the casemix classification, a total of 309 patients (mean age 66.9 years, 55% female, 85% white) provided data on 751 episodes of specialist palliative care. The casemix classification was able to accurately predict the actual cost-per-day of care, especially for hospital advisory and community care. The actual costs of inpatient hospice care were consistently higher than predicted class costs, although cost weights remained consistent. Interviews to understand transitions between care settings were conducted with 26 participants (mean age 68 years, range 36–91 years). Four themes emerged: uncertainty about the new care setting, biographical disruption, the importance of continuity of care and the need for emotional/practical support during transition (workstream 4 conducted 2018–19). Limitations Recruitment was challenging but adding new sites helped to overcome this. Models of palliative care proved more diverse and harder to categorise than expected. This casemix classification needs broader testing among those with non-cancer conditions, especially those with multiple conditions. Conclusions The Integrated Palliative care Outcome Scale is a valid, reliable outcome measure for use in advanced illness. We have developed (1) an evidence-based framework to conceptualise complexity of palliative care needs, (2) defined criteria to characterise/differentiate models of specialist palliative care and (3) a casemix classification for specialist palliative care. Each person needing specialist palliative care is different, with varying degrees of complex needs. We now have the casemix classification to understand and capture this, systematically and at scale, for practice, policy and research. This has the potential to help address inequities and provide more equitable specialist palliative care to all who need it. Future research is needed, including further validation of measures, more detailed research into models of care, and further testing of the casemix classification. Study registration This trial is registered as ISRCTN90752212. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and is published in full in Programme Grants for Applied Research; Vol. 11, No. 7. See the NIHR Funding and Awards website for further award information. It was also supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London, previously Collaboration for Leadership in Applied Health Research and Care) at King’s College Hospital NHS Foundation Trust.

Pathway for post-prostatectomy urinary incontinence: impact on patient confidence and satisfaction.

Between 8 and 87% of prostatectomies result in urinary incontinence, with around half of patients using incontinence pads daily at 6 months. Specialist urology continence nurses at the Norfolk and Norwich University Hospitals (NNUH) NHS Foundation Trust created a pre- and post-surgical care pathway formalising support for these patients, which involves the provision of TENA Men (Essity) male incontinence pads. This audit aimed to assess patient satisfaction with this pathway and TENA Men pads. Patients who underwent a radical prostatectomy at NNUH between 27 April and 9 November 2021 and who required continence pads were invited to fill out an online anonymous mixed-method (mainly qualitative) survey. Of 28 respondents, 71% reported incontinence after their surgical catheter was removed. Most (89%) were satisfied with the preoperative advice. Of 19 respondents to questions on confidence and satisfaction, 16 were confident that the pads they had been prescribed were helping them to manage urinary leakage, and 16 were confident or very confident that they could manage their incontinence themselves. Generally, respondents were confident that their overall and mental health had improved, and most were confident or very confident that they had less anxiety. However, less than a quarter of respondents were 'very confident' about going out, meeting people or exercising. All but one respondent found TENA Men pads easy to fit, and the most used words in the free-text explanations of what they most liked, included 'easy', 'discreet', 'comfortable' and 'unobtrusive'. The clinical pathway helped give patients undergoing radical prostatectomy confidence in their ability to manage post-surgery incontinence themselves and could be of value in other hospitals. Easy access to incontinence pads designed for the male anatomy has an important part in this.

A single centre service evaluation of degenerative cervical and thoracic myelopathy

BackgroundDegenerative cervical myelopathy (DCM) and degenerative thoracic myelopathy (DTM) present with leg, bladder and bowel symptoms. If imaging confirms spinal cord compression both conditions are usually managed surgically. Surgical timing is important in patient management as it affects post-operative recovery and long-term outcomes. This service evaluation aims to explore whether that patients with DTM are more likely to be treated urgently than those with DCM and to examine whether any differences in management are justified. MethodsA retrospective service evaluation was registered and approved by the Cambridge University Hospitals NHS Foundation Trust (CUH) Clinical Audit Department (Clinical Project ID4455 PRN10455). All patients who had undergone surgery for DTM at CUH from January 2015 until April 2022 were included. Comparison was made to a cohort of DCM patients who underwent surgery at CUH from June 2016 to January 2019. Data analysis was conducted in R. ResultsA total of 130 DCM patients and 78 DTM patients were included. Our DCM and DTM patient cohorts had comparable demographics, but DTM patients had fewer spinal levels affected. Despite equivalent disease severity, DTM patients had a shorter time to diagnosis, shorter wait for surgery and were more likely to be operated on as an emergency case. ConclusionsDespite comparable demographics and pathophysiology, DTM was diagnosed and managed more quickly than DCM. Better defined diagnostic pathways for degenerative spinal myelopathy may hold opportunities to optimise diagnosis and management, ensuring consistent high quality, efficient and equitable care.

Improved Computer-Aided Diagnosis System for Nonerosive Reflux Disease Using Contrastive Self-Supervised Learning with Transfer Learning

Article Improved Computer-Aided Diagnosis System for Nonerosive Reflux Disease Using Contrastive Self-Supervised Learning with Transfer Learning Junkai Liao 1, Hak-Keung Lam 1,*, Shraddha Gulati 2, and Bu Hayee 2 1 Department of Engineering, King’s College London, London, United Kingdom 2 King’s Institute of Therapeutic Endoscopy, King’s College Hospital NHS Foundation Trust, London, United Kingdom * Correspondence: hak-keung.lam@kcl.ac.uk     Received: 5 February 2023 Accepted: 21 July 2023 Published: 26 September 2023   Abstract: The nonerosive reflux disease (NERD) is a common condition, the symptoms of which mainly include heartburn, regurgitation, dysphagia and odynophagia. The conventional diagnosis of NERD needs the endoscopic examination, biopsy of the lining of the esophagus (mucosa), and ambulatory pH testing over 24 to 96 hours, which is complex and time-consuming. To address this problem, a computer-aided diagnosis system for NERD (named NERD-CADS) has been proposed in our previous paper. The NERD-CADS offers a more convenient and efficient approach to diagnosing NERD, which only requires the input of endoscopic images into the computer to produce a nearly instant diagnostic result. The NERD-CADS uses a convolutional neural network (CNN) as a classifier and can classify the endoscopic images captured in the esophagus of both healthy people and NERD patients. This is, in fact, a classification problem of two classes: non-NERD and NERD. We conduct ten-fold cross-validation to verify the classification accuracy of the NERD-CADS. The experiment shows that the mean of ten-fold classification accuracy of the NERD-CADS test reaches 77.8%. In this paper, we aim to improve the classification accuracy of the NERD-CADS. We add the contrastive self-supervised learning as an additional component to the NERD-CADS (named NERD-CADS-CSSL), and investigate whether it can learn the capability of extracting representations to improve the classification accuracy. This paper combines the contrastive self-supervised learning with transfer learning, which first employs massive public image data to train the CNN by the contrastive self-supervised learning, and then uses the endoscopic images to fine-tune the CNN. In this way, the capability of extracting representations (learned by the contrastive self-supervised learning) can be transferred into the downstream task (NERD diagnosis). The experiment shows that the NERD-CADS-CSSL can obtain a higher mean (80.6%) in tests than the NERD-CADS (77.8%).

Percutaneous Cholecystostomy to Manage a Hot Gallbladder: A Single Center Experience.

Objective A percutaneous cholecystostomy (PC) is a suitable option for treating acutely inflamed gallbladders. Its use has been postulated before for treating acute cholecystitis (AC), especially in elderly populations. The primary aim of our study is to analyze and present the positive results of PC as a bridge to laparoscopic cholecystectomy. Methods All patients who underwent PC at our hospital, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR, from October 2020were reviewed using a retrospective approach. Results Our study comprises 123 patients, with 72 females (58.5%) and 51 males (41.4%). In our study, many patients had significant comorbidities, and some of them were categorized as high-risk due to their frailty and medical conditions. The majority of the patients were in American Society of Anaesthesiologists' (ASA) groups II and III (45, 61), respectively. Though hospital stays can depend on variable factors, in our experience, the mean hospital length ofstay was 12.7 days. In our study, 119 patients (96.8%) had the procedure through the interventional radiological approach, while only four patients had it through the laparoscopic approach. The transhepatic route for drainage was more commonly practiced at our center and was used in 108 patients. At the time of writing this article, 54 patients have already had a laparoscopic cholecystectomy (LC) done as an interval procedure after surpassing the acute attack of cholecystitis, while 42 patients are still awaiting their surgical procedure. Conclusion Our results show that PC is a viable option, especially in cases of AC that are not responding to conservative treatments. Our study has shown low complications and conversion rates after PC. We believe PC is a safe and effective tool for managing severe and refractory cases of AC.

690 Quality Improvement Project: Improving Engagement with Smoking Cessation Services Among Emergency Surgical Admissions

Abstract Aim Smoking status has a significant impact on surgical patient outcomes, with significantly increased rates of intra- and post-operative complications. Within Liverpool University Hospitals NHS Foundation Trust (LUHFT), the CURE team is a dedicated smoking cessation service that uses an electronic proforma to identify smokers and offer support. We assessed smoking cessation efforts among emergency surgical admissions pre- and post-teaching intervention. Method Two rounds of audit were completed: a baseline audit of emergency surgical admissions from 01/01/21 to 31/01/21(n = 202); and a reaudit of emergency surgical admissions from 01/11/22 to 30/11/22 (n = 163), following a structured teaching session on smoking cessation, delivered to incoming doctors in August 2022. We assessed documentation of smoking status within patient notes, completion of the smoking status proforma, prescription of nicotine replacement therapy (NRT), and assessment/follow up from CURE. Results Following intervention, smoking status documentation improved from 83% (n = 166) to 96% (n = 157), and proforma completion from 55% (n = 112) to 91% (n = 148). Among documented smokers (cycle 1 n = 49; cycle 2 n = 47), NRT prescription improved from 29% to 40%, and CURE involvement increased from 31% to 64%. Overall, following intervention, 21% of smokers accepted ongoing support from CURE during and post-admission, compared to 10% at baseline. Conclusions Use of electronic smoking status proforma and a dedicated inpatient smoking cessation team has high rates of engagement among emergency surgical inpatients. The use of structured teaching sessions to highlight the importance of smoking cessation among these patients has led to improved rates of smoking cessation support, benefiting surgical outcomes.

1058 Jejunal or Ileal Exocrine Drainage in Pancreas Transplantation?

Abstract Aim Pancreas transplantation (PT) is performed for restoration of endocrine function in type 1 diabetes mellitus with amelioration of diabetic complications. However, PT can have serious complications requiring salvage pancreatectomy and surgical approaches should be carefully considered. Anastomoses to jejunum or ileum are most often employed. We compare outcomes between these techniques. Method A retrospective analysis was performed on simultaneous pancreas and kidney transplants (SPK) at Manchester University Hospitals NHS Foundation Trust between 2013 and 2015. Follow up was completed until 2020. Results 86 SPK were performed. 59.2% were male with mean age of 41.5yo (SD±8.4). 72.4% (n = 55) were donors after brain death and 98.7% (n = 75) were receiving first PT. 43 SPK were performed with ileal anastomosis, 33 jejunal. There were no significant differences in demographics of recipients, donors, immunosuppression regimens, overall patient and graft survival and frequency of GI complications. Length of hospital stay was higher with ileal anastomosis (median 14 v 19 days, p&amp;lt;0.05), as was cold ischaemic time (median 8:48 v 9:31 hours, p&amp;lt;0.05). Three patients required salvage pancreatectomy and loop ileostomy formation with multi-organ support and prolonged ITU stay. Conclusions Long term outcomes between groups were comparable in this cohort. Catastrophic complications occur in the minority requiring salvage surgery. Here more occurred with ileal anastomosis, but this approach allows graft pancreatectomy and formation of loop ileostomy, avoiding a more proximal stoma in a clinically unstable patient. Further powered studies are required to rigorously examine the impact of enteric anastomosis site.

Characterizing Antibiotic Allergy Labels in a Large UK Hospital Population to Inform Antimicrobial Stewardship and Delabeling Assessment Strategy.

Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described. To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate. Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels. Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%). Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment.

POTENTIAL IMPACT OF THE IMPLEMENTATION OF AN ELECTRONIC HEALTH RECORD ON NATIONAL JOINT REGISTRY OUTLIER ANALYSES

Electronic Health Records (EHRs) have benefits for hospitals and uptake in the UK is increasing. The National Joint Registry (NJR) monitors implant and surgeon performance and relies on accuracy of data. NJR data are used for identification of potential outliers for both mortality and revision; analyses are adjusted for age, sex, and American Society of Anaesthesiologists score (ASA) and cases with some indications are excluded from analyses. In October 2020, the Royal Devon University Hospitals NHS Foundation Trust “went live” on an EHR, almost eradicating paper from the Trust. This included stopping use of paper NJR forms by creating a bespoke electronic template. We sought to identify discrepancies between operation notes and data input to the NJR in variables that may influence potential outlier analyses.Data input to the NJR from 15/10/2020 to 18/10/2022 for hip procedures were provided by NEC Software Solutions. NJR data were compared to those recorded on operation notes.There were 1067 hip procedures recorded in the NJR (946 primary THRs). Of the primary THRs, discrepancies in indication between NJR and operation note were identified in 139 (15%) cases. Common discrepancies included cases being recorded as osteoarthritis where the true indication was acute trauma (n=63), avascular necrosis (n=14), metastatic cancer/malignancy (n=6) and 21 cases with no recorded indication. We identified 88 cases where the ASA recorded in the NJR differed from the anaesthetic chart. Other inaccuracies were identified including 23 cases missing type of procedure (e.g., primary or revision) and one where revision surgery had been recorded as primary.We identified at least 83 cases that should have been excluded from NJR mortality analyses but were not. Given the low incidence of mortality following primary THR, these cases (with increased risk of death) have the potential to incorrectly identify the hospital as a potential outlier. Discrepancies in ASA may also impact on both revision and mortality outlier calculations. We urge caution to hospitals in the implementation of EHRs and advise regular audit of data sent to the NJR.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum. An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text. All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound. Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

Covid-19 associated coagulopathy (CAC): Global research output, 2020-2022

Objective. This study examined the Covid-19 associated coagulopathy (CAC) publication and citation trends, focusing on the top authors, countries, organizations, journals, collaboration, subject areas, keywords, and high-cited articles.&#x0D; Design/Methodology/Approach. Publications data on Covid-19 associated coagulopathy (CAC) were identified and extracted from the Scopus database. Data analysis has been performed using VOS viewer software, Biblioshiny, and MS Excel Software.&#x0D; Results/Discussion. The study identified 1740 articles on Covid-19 associated coagulopathy from the Scopus database, which received 47,502 citations, averaging 27.3 citations per paper. In all, 905 authors from 601 organizations originating in 96 countries participated in research and published in 776 journals. United States, Italy, and China contributed the most publications (498, 258, and 164 papers). While China (73.43 and 2.69), France (57.60 and 2.11,) and Germany (50.13 and 1.84) registered the highest citation impact by CPP and RCI. Harvard Medical School, USA, Huazhong University of S&amp;T, China, and Tongji Medical College, China, lead with most of the publications (4,4, 41, and 39 papers). In contrast, Tongji Medical College, China (198.31 and 7.26), Huazhong University of S&amp;T, China (198.15 and 7.26), and University College Hospital NHS Foundation Trust, U.K (129.23 and 4.73) lead in citation impact. J.H. Levy, T. Iba and M. Levy contributed to most of the publications (27, 25, and 20), while N. Tag (804.75 and 29.48), A. Tripodi (157.83 and 5.78), and J. Thachil (154.17 and 5.65) registered the highest citation impact by CPP and RCI. Journal of Thrombosis and Haemostasis, Journal of Thrombosis and Thrombolysis, and Thrombosis Research were the most productive ones (with 55, 51, and 46 publications). At the same time, Medical Hypotheses (1222), Blood (355.71) and Thrombosis Journal (233.86) were the most impactful journals. The top 9 keywords were Covid-19 (1681 occurrences), Blood Clotting (952), D Dimer (652), C (628), Coagulopathy (628), Thrombosis (584), blood (506), Anticoagulants (499), Blood Coagulation (426) and Fibrinogen (376).&#x0D; Conclusions. Global research on Covid-19 associated coagulopathy since the pandemic was considered for scientometric assessment for the first time, combining the productivity and citation measures to present an overall picture of the literature in this area. Such an analysis will provide scholars and policy-makers with a meaningful reference for further exploration of topical issues and research trends in the field.