Wessex Region Research Articles

Exploring a role for community pharmacists in the identification of alcohol-related liver disease: a qualitative interview study with professionals, patients, and the public.

To explore the views and attitudes of professionals, patients and the public to a role for community pharmacists in the identification of alcohol-related liver disease (ArLD). Semi-structured interviews were conducted with a purposive sample of patients with ArLD, members of the public, pharmacy staff, and clinicians managing patients with ArLD across the Wessex region of south England. The interviews explored experiences of alcohol, ArLD and health advice in pharmacies and elicited views of what a pharmacist role in identifying ArLD could entail and factors influencing this. Transcripts were analysed using reflexive thematic analysis. Twenty-six participants were interviewed and three themes were generated: (i) acknowledging, seeking help and engaging with a hidden problem; (ii) professional roles, boundaries and attributes; (iii) communication, relationships, collaboration and support. Participants reported key challenges to identifying people at-risk of ArLD. Offering testing for ArLD was perceived to motivate engagement but there were concerns about pharmacists performing this. A role was mostly seen to be finding people at-risk and engaging them with further care such as referral to liver services. This was perceived to require developing interprofessional collaborations, remuneration and training for pharmacy staff, and community-based liver testing. Professionals, patient and public participants recognized a role for pharmacists in the identification of ArLD. This was envisaged to incorporate educating pharmacy users about ArLD risk, and identifying and directly engaging those at-risk with liver and support services through development of interprofessional collaborations. The findings of this study support and can inform future work to develop this role.

P11.35.B STEREOTACTIC RADIOTHERAPY FOR VESTIBULAR SCHWANOMMAS: THE WESSEX EXPERIENCE

Abstract BACKGROUND Review of SRT for vestibular schwannoma (VS) within Wessex region led by University Hospital Southampton (UHS). UHS treat tumour volumes max 2.5cm in diameter without brainstem compression with 21Gy/3#. We reviewed the experience of local control and toxicity profile in our centre comparing with 1 and 5 fraction SRT schedules. We present three fraction SRT as an appropriate fractionation schedule. MATERIAL AND METHODS This is a retrospective analysis of patients treated for radiologically diagnosed vestibular schwannoma from 2019 to present. Patient notes, audiograms, imaging and radiotherapy planning system were reviewed for data collection. No patients were removed from analysis due to missing data. RESULTS 84 patients have been treated with SRT for VS. Median age 66 (39-94). 12Gy/1# (1#) in 36 patients, 21Gy/3# (3#) in 36 patients, 25Gy/5# (5#) in 12 patients. In the 1# group PTV volume 0.31cm3-4.44cm3 (median 1.12cm3), in the 3# group PTV volume from 1.03cm3 to 5.52cm3 (median 2.37cm3), in the 5# group 2.05cm3-5.44cm3 (median 4.12cm3). All patients have radiologically stable disease to date. Objective radiological response noted in 14 patients (38.9%) in 3# group this is higher than any other group and statistically significant (p=0.016). Pre-treatment serviceable hearing only in a minority of patients. Treatment related toxicity was seen in 27% in the 1# group, 19% of patients within the 3# group, and 33% in the 5# group. This was mostly mild and self-limiting. Facial nerve toxicity was seen in 8.3% of the 1# group, 16.7% of 3# group, and 33.3% of the 5# group. However, this was only persistent in 2 patients in 1# group (5.6%), 2 patients in the 3# group (5.6%), and 1 (8.3%) in the 5# group. There is no statistical difference in toxicity between any group using Chi squared test. In 3# group, when Dmax limited to <26Gy (n=15), the frequency of facial nerve toxicity reduces to 1 (2.78%). CONCLUSION Three fraction SRT provides excellent local control with high levels of objective radiological response in tumours up to 4cm3, however, long term follow-up is required. This treatment has acceptable toxicity which is not significantly different from alternative fractionation schedules and is improved by limiting Dmax to <26Gy.

Developing the Royal College of Emergency Medicine's advanced clinical practitioners in the Wessex region: design, implementation and review of a regional training programme

Background: Since 2015, the Royal College of Emergency Medicine (RCEM) has championed an advanced clinical practitioner (ACP) credentialling process for clinicians working in advanced practice roles in the emergency department. While this process ensures a standard of advanced practice that is both governable and robust, it requires structure and support to complete successfully. This article reports the design and implementation of a regional programme aimed at supporting trainees through the RCEM ACP training process to the point of credentialling. Methods: A regional training programme was implemented and a mixed-methods approach (that included a quantitative analysis of training programme completion rates and a qualitative review of trainee feedback) was used to analyse the outcomes. The programme incorporated a structured educational programme, educational supervision and annual review, alongside integration into the deanery school board and facilitation of training time. Results: Between 2016 and 2022, a total of 46 trainee RCEM ACPs were recruited to the programme. Of these, 19 had credentialled by spring 2022 and 20 were in ongoing training, aiming for credentialling. During this time, these participants accounted for 19% of the nationally credentialled ACP workforce (19 of 99). Since 2020, the first pass rate for programme trainees has been 71%, compared to the national average of 38%. Credentialled ACPs, when asked how well the programme prepared them to credential with the RCEM, responded positively, with most scoring the programme between 4 and 5, with 5 being marked as ‘excellent’. Free text comments in feedback on the programme were collated and reviewed for common themes resulting in key themes of ‘supportive’, ‘excellence’ and ‘adequate preparation for credentialling’. Conclusion: Meeting the criteria for RCEM credentialling as an ACP is a demanding process that requires support and structure. The development and implementation of a regional training programme not only meets these requirements but yields higher credentialling success rates and creates trainee satisfaction in the process.

Dental core trainees’ experience of vasovagal episodes while attending the operating theatre

Vasovagal presyncope and syncope while attending operating theatres have been reported among medical trainees. However, no such studies are available in relation to dental trainees. The aim of this study was to investigate the prevalence, preventative measures and attitudes towards these events among dental trainees. An anonymised online questionnaire was sent to all dental core trainees in the Thames Valley and Wessex regions (n = 34). Nineteen of these participated (56% response rate). Ten (53%) had experienced a presyncopal or syncopal episode. The majority had experienced an episode during a major operation. High operating room temperatures and needing to stand for a long time were reported as the most common predisposing factors (60%). Several different actions were taken to prevent further episodes, with 90% of respondents reporting that these helped. Seven trainees expressed their desire to pursue a surgical career; five of these had experienced a vasovagal event. Most (78%) felt that this would not discourage them from following a career in surgery. Seven respondents felt that there was a perceived stigma about trainees who experienced such an episode. This study revealed that operating theatre related syncope is common among dental trainees. We highlight the importance of educating trainees on preventative strategies.

Unexpected benefits: reflections on virtual relationship building within public involvement during the Covid-19 pandemic

The Covid-19 pandemic reduced research collaborations with public contributors and prevented face-to-face interaction. The formation of Researcher Coffee Mornings within the Wessex region aimed to continue relationships between the research community and public through the pandemic. Researcher Coffee Mornings were regular Zoom meetings run by public involvement staff at University Hospital Southampton NHS Foundation Trust, UK. They were created to provide pastoral support and ‘check-ins’ between staff and public contributors during the Covid-19 pandemic. Reorganisation, implemented by public involvement staff but led by public contributors, meant that the events evolved over time. The Researcher Coffee Mornings were a means to share updates about research with the public. They were a safe space for involvement staff, researchers and the public to exchange knowledge and share experiences. This article highlights the intended and unexpected benefits of investing in relationships. We reflect on these benefits through the perspectives of the public involvement staff, public contributors and researchers. Investing in relationships has brought value to everyone involved. By demonstrating the benefits of providing regular, inclusive spaces for relationship building between the research community and public contributors, we hope to encourage others to invest in relationship building in their settings, to improve public involvement practices.

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

524 Infective Endocarditis Timings and Indications for Intervention in Neurological Complications

Abstract Background Infective endocarditis (IE) is the inflammation of the endocardium. Cardiac surgery is reserved for patients that deteriorate despite best medical therapy. Neurological complications are a serious IE complication. There is still not a clear consensus on how and when IE should be treated when neurological complications occur. Identifying in which patients to intervene and when can help improve patient management. Aim To evaluate the management and outcomes of patients that presented with IE in the Wessex region of England with a particular focus on treatment of patients with neurological complications. Method Patient records were accessed to collect data on patient demographics, infection status and clinical management of patients between 2019–2020. Results 147 patients with IE were included, 19 patients with neurological complications underwent early surgery (n=15) or late surgery (n=4). The mean ages were 54 (30–76) and 55 (22–82) respectively. There was no statistical association between timing of surgery, early (within 14 days of CT) or late, and mortality (p=0.53). The median stay in hospital for early and late surgery was 28 days and 47 days respectively. The only significant indicator for having early surgery was the presence of staph aureus (p=0.008). The 6-month survival for early and late surgery was 73.3% and 100% (p=0.212). Conclusions Early surgery was not shown to be significantly associated with 6-month mortality but did lead to earlier discharge from hospital. Neurological complications in endocarditis significantly affects survival. Due to the limited number of patients considered further data is needed to draw more conclusive results.

GP trainees' experiences of training.

Understanding the experience of training in an authentic and rich way can be a powerful driver to reviewing teaching and learning practice. GP educators in the Health Education England Wessex region decided to take this a step further and examine the equity of the experience of training, including trainees' thoughts and views about how that experience could be improved. An online questionnaire survey was developed covering topics such as the perceived support needs of IMG (international medical graduate) trainees, trainees' experiences of discrimination, and their ideas for improvement. The survey focused on areas that were within the power of local educators to change, thereby enabling the results to drive improvement. The survey link was emailed to all trainees in our deanery via their training patches. Responses were anonymous. One hundred and eighty-seven responses were received from a cohort of approximately 530 trainees-a response rate of 35%. Responses ranged from a limited awareness of additional support needs for trainees from different backgrounds, through to those who had experienced uncomfortable situations and those with clear ideas about improvements. The data have been used to trigger improvement discussions within patch teams and facilitate changes in practice. The outcome of the work has led to change-from providing additional courses and support to raising awareness of trainees' experiences. The results have also been fed back to senior educators who manage training across the region.

MO048PATHOGENIC VARIANTS IN CHLORIDE VOLTAGE-GATED CHANNEL 5 (CLCN5), ASSOCIATED WITH DENT DISEASE TYPE 1, SHOULD BE CONSIDERED IN END-STAGE KIDNEY DISEASE OF UNKNOWN AETIOLOGY

Abstract Background and Aims Hemizygous variants in chloride voltage-gated channel 5 (CLCN5) on chromosome Xp11.22 cause Dent disease type 1, characterised by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, nephrolithiasis, and progressive renal failure. We describe a truncating pathogenic variant in two brothers presenting with end-stage kidney disease (ESKD) and no evidence of nephrolithiasis or nephrocalcinosis. Method Two white British brothers presented to a different regional centre over 20 years ago with ESKD of unknown aetiology. The UK 100,000 Genomes Project provided a unique opportunity to make a molecular diagnosis using whole-genome sequencing linked to clinical records. Results The older brother presented with ESKD aged 23 with bilateral small kidneys and no evidence of nephrolithiasis or nephrocalcinosis on ultrasound. He had various musculoskeletal pains, 'cutaneous ectopic calcification' and secondary hyperparathyroidism, all of which improved post parathyroidectomy. Investigation of his 17-year-old brother for consideration of kidney transplant donation revealed progressive chronic kidney disease (CKD), microscopic haematuria, proteinuria (3g/24hours) and hypokalaemia. There was no nephrocalcinosis or renal calculi on ultrasound or cystoscopy. Renal biopsy showed tubulointerstitial changes with patchy fibrosis and marked chronic inflammatory cell infiltrates. He had a history of enuresis, polydipsia, delayed bone age and general developmental delay. ESKD by the age of 22 was complicated by hypertension and hyperparathyroidism requiring parathyroidectomy. Right knee pain with 'unusual osteochondral abnormality' on MRI resulted in a supracondylar femoral osteotomy. Early serum and urine biochemistry results were not available. A hemizygous nonsense variant p.Arg417Ter in CLCN5 was identified by whole-genome sequencing via the 100,000 Genomes Project. Sanger sequencing at the Wessex Regional Genetics Laboratory confirmed this. This variant was predicted to be protein-truncating, was absent in the genome aggregation database (gnomAD) and equivalent to a variant associated with Dent disease in other patients therefore classified as a class 5 pathogenic variant according to ACMG guidelines. Three male children with Dent disease have previously been reported with the pathogenic variant p.Arg347Ter. A seven and a twelve year old from two different families in Japan had microscopic haematuria, proteinuria, elevated β2-microglobulin and normal renal function. The twelve-year-old had mild hypercalciuria, but neither had a history of nephrolithiasis or nephrocalcinosis. A four-year-old Turkish boy manifested hypophosphataemia, nephrolithiasis and nephrocalcinosis. Unusually for Dent disease, he also had hypokalaemic hypochloraemic metabolic alkalosis and hyper-reninaemic hyperaldosteronism more characteristic of Bartter syndrome, but with elevated β2-microglobulin more typical of Dent disease. None of these cases had CKD but were all reported at a very young age. Conclusion Approximately 15% of patients with ESKD in Europe have an unknown aetiology. Dent disease has a variable phenotype and screening of patients for low molecular weight proteinuria such as β2-microglobulin is not routinely performed. Dent disease type 1 should be considered in patients presenting with unexplained renal failure even without typical clinical features.

The Wessex Dementia Friendly Pharmacy Framework.

To develop and launch a dementia friendly framework for community pharmacies in the Wessex region of England. A framework consisting of essential (mandatory) and additional (non-mandatory) criteria were devised by local stakeholders and external scrutiny from the Alzheimer's Society. The framework was designed to allow pharmacy teams to achieve essential criteria without the need for approval by others (e.g. authorisation from internal company management structures). In total, 38 essential criteria across seven domains were devised. All essential criteria had to be met for pharmacies to be awarded dementia friendly status. Engagement events were organised to launch the framework detailing what it was and how pharmacies could meet each criterion. Pharmacies self-certified compliance with the framework criteria via an online platform, and validation activity was subsequently undertaken to see if pharmacies had appropriately self-certified against all essential criteria. Three hundred and fifty-five pharmacies (n = 504, 70%) engaged with the initiative, of which 330 uploaded self-certifications met all essential criteria of the framework. Validation visits showed self-certification to be appropriate in all but one visit (n = 11/12). Staff comments revealed that engaging with the framework had allowed them to be more aware of how better to support people with dementia. A dementia friendly framework was devised and implemented with a subsequent high level of uptake by community pharmacy.

A simulation modelling toolkit for organising outpatient dialysis services during the COVID-19 pandemic.

This study presents two simulation modelling tools to support the organisation of networks of dialysis services during the COVID-19 pandemic. These tools were developed to support renal services in the South of England (the Wessex region caring for 650 dialysis patients), but are applicable elsewhere. A discrete-event simulation was used to model a worst case spread of COVID-19, to stress-test plans for dialysis provision throughout the COVID-19 outbreak. We investigated the ability of the system to manage the mix of COVID-19 positive and negative patients, the likely effects on patients, outpatient workloads across all units, and inpatient workload at the centralised COVID-positive inpatient unit. A second Monte-Carlo vehicle routing model estimated the feasibility of patient transport plans. If current outpatient capacity is maintained there is sufficient capacity in the South of England to keep COVID-19 negative/recovered and positive patients in separate sessions, but rapid reallocation of patients may be needed. Outpatient COVID-19 cases will spillover to a secondary site while other sites will experience a reduction in workload. The primary site chosen to manage infected patients will experience a significant increase in outpatients and inpatients. At the peak of infection, it is predicted there will be up to 140 COVID-19 positive patients with 40 to 90 of these as inpatients, likely breaching current inpatient capacity. Patient transport services will also come under considerable pressure. If patient transport operates on a policy of one positive patient at a time, and two-way transport is needed, a likely scenario estimates 80 ambulance drive time hours per day (not including fixed drop-off and ambulance cleaning times). Relaxing policies on individual patient transport to 2-4 patients per trip can save 40-60% of drive time. In mixed urban/rural geographies steps may need to be taken to temporarily accommodate renal COVID-19 positive patients closer to treatment facilities.

Exomphalos without other prenatally detected anomalies: Perinatal outcomes from 22 years of population-based data.

To ascertain the perinatal outcomes for an apparently isolated exomphalos detected by prenatal ultrasound. Our dataset captures cases from 614 321 births in the Wessex region of England and the Channel Isles on all cases of pre- or postnatally diagnosed exomphalos from 1994 to 2015. Ascertainment was >95%. Three hundred and thirty five cases were reported to the register: 28 (8%) were not detected prenatally, 18 (6%) had already died in utero, 169 (55%) cases were found to have additional anomalies on first tertiary ultrasound scan and one case was lost to follow-up. Therefore 119 (39%) cases had an apparently isolated exomphalos. Of the 119 cases with only an exomphalos detected on first tertiary ultrasound scan, 25 (21%) had a chromosome abnormality. Of those with a normal or untested karyotype, 61% were confirmed to be an isolated anomaly after birth, 13% had an additional heart abnormality, 9% had Beckwith-Wiedemann syndrome and 11% had additional problems diagnosed postnatally. Our large population-based dataset with an average of 1 year's postnatal follow-up suggests that more than one-third of apparently isolated prenatal cases of exomphalos will have an additional finding detected after birth. These data should help assist clinicians in their prenatal counseling.

The FRAXA and FRAXE allele repeat size of boys from the Avon Longitudinal Study of Parents and Children (ALSPAC).

The FRAXA and FRAXE alleles of the FMR1 and FMR2 genes located on the X chromosome contain varying numbers of trinucleotide repeats. Large numbers of repeats at FRAXA (full mutations) manifest as Fragile X syndrome, associated with mental impairment that affects males more severely. In this paper, we present the dataset of frequencies of FRAXA and FRAXE repeat size extracted from DNA samples collected from boys enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC). DNA data were extracted from samples collected in ALSPAC clinics from several types of samples: cord blood, venepuncture blood taken at 43 months, 61 months, seven years or nine years. The DNA was amplified at FRAXA and FRAXE using fluorescent PCR in the Wessex Regional Genetics Laboratory, Salisbury District Hospital. The mean repeat size for FRAXA is 28.92 (S.D. 5.44), the median 30 and the range 8 to 68. There were particularly high numbers of boys with repeat sizes of 20 (10.67%) and 23 (7.35%). The mean repeat size for FRAXE is 17.41 (S.D. 3.94), with median of 16 and range of 0 to 61. There is a relatively high degree of variation of the FRAXA repeat size particularly and we suggest the extensive data available from the ALSPAC study opens up areas of research into understanding phenotypes associated with relatively unexplored repeat sizes. This could be particularly interesting for the lower repeat sizes occurring with high frequency at FRAXA in this population. As the data can be linked to exposures and phenotypes, it will provide a resource for researchers worldwide.

The stratigraphy of the Cretaceous (Albian stage) Gault and Upper Greensand formations: Dorset to Buckinghamshire and the western Weald, UK

The present account is a review of the successions in the Albian Gault and Upper Greensand formations, their lithology and their ammonite biostratigraphy, proved at outcrop between Dorset and Buckinghamshire, in the western Weald and that recorded in boreholes in the intervening area. It is concluded that the Wessex and Weald regions formed a single sedimentary basin during the Albian Stage. The lithostratigraphy and biostratigraphy are described area by area and are combined with recent accounts of the Albian sediments of the adjacent regions to describe lateral and stratigraphical variations in the depositional environments and sources of sediment. We conclude that although the steady overall rise in sea level in the Albian had an important effect on the local depositional environments and in the distribution of Albian sediments in England and adjacent areas, the influence of intermittent tectonic phases on the development of transgressive erosion surfaces was such that individual pulses in global eustatic sea-level rise cannot be correlated with confidence with most of the transgressions in the Albian.

The FRAXA and FRAXE allele repeat size of boys from the Avon Longitudinal Study of Parents and Children (ALSPAC)

The FRAXA and FRAXE alleles of the FMR1 and FMR2 genes located on the X chromosome contain varying numbers of trinucleotide repeats. Large numbers of repeats at FRAXA (full mutations) manifest as Fragile X syndrome, associated with mental impairment that affects males more severely. In this paper, we present the dataset of frequencies of FRAXA and FRAXE repeat size extracted from DNA samples collected from boys enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC). DNA data were extracted from samples collected in ALSPAC clinics from several types of samples: cord blood, venepuncture blood taken at 43 months, 61 months, seven years or nine years. The DNA was amplified at FRAXA and FRAXE using fluorescent PCR in the Wessex Regional Genetics Laboratory, Salisbury District Hospital. The mean repeat size for FRAXA is 28.92 (S.D. 5.44), the median 30 and the range 8 to 68. There were particularly high numbers of boys with repeat sizes of 20 (10.67%) and 23 (7.35%). The mean repeat size for FRAXE is 17.41 (S.D. 3.94), with median of 16 and range of 0 to 61. There is a relatively high degree of variation of the FRAXA repeat size particularly and we suggest the extensive data available from the ALSPAC study opens up areas of research into understanding phenotypes associated with relatively unexplored repeat sizes. This could be particularly interesting for the lower repeat sizes occurring with high frequency at FRAXA in this population. As the data can be linked to exposures and phenotypes, it will provide a resource for researchers worldwide.

Population-based observational study of acute pancreatitis in southern England.

Acute pancreatitis is a common surgical emergency. Identifying variations in presentation, incidence and management may assist standardisation and optimisation of care. The objective of the study was to document the current incidence management and outcomes of acute pancreatitis against international guidelines, and to assess temporal trends over the past 20 years. A prospective four-month audit of patients with acute pancreatitis was performed across the Wessex region. The Atlanta 2012 classifications were used to define cases, severity and complications. Outcomes were recorded using validated systems and correlated against guideline standards. Case ascertainment was validated with clinical coding and hospital episode statistics data. A total of 283 patient admissions with acute pancreatitis were identified. Aetiology included 153 gallstones (54%), 65 idiopathic (23%), 29 alcohol (10%), 9 endoscopic retrograde cholangiopancreatography (3%), 6 drug related (2%), 5 tumour (2%) and 16 other (6%). Compliance with guidelines had improved compared with our previous regional audit. Results were 6.5% mortality, 74% severity stratification, 23% idiopathic cases, 65% definitive treatment of gallstones within 2 weeks, 39% computed tomography within 6-10 days of severe pancreatitis presentation and 82% severe pancreatitis critical care admission. The Atlanta 2012 severity criteria significantly correlated with critical care stay, length of stay, development of complications and mortality (2% vs 6% vs 36%, P < 0.0001). The incidence of acute pancreatitis in southern England has risen substantially. The Atlanta 2012 classification identifies patients with severe pancreatitis who have a high risk of fatal outcome. Acute pancreatitis management is seen to have evolved in keeping with new evidence and updated clinical guidelines.

Help seeking for antibiotics; is the influence of a personal social network relevant?

BackgroundHealth policy focuses on reducing antibiotic prescribing that in order to succeed requires the public to hold similar attitudes towards judicious use. Social network influences on health behaviour and attitudes are well established and yet these influences are not sufficiently acknowledged in the UK’s antibiotic stewardship programmes. Therefore, the aim of this study was to evaluate individuals’ attitudes and behaviours towards antibiotics and also identify the social network influences on these in the process of help seeking for self-limiting illnesses.MethodsFrom a social network approach the methods used were a personal community mapping exercise which was carried out ahead of a semi-structured interview. A purposive sample was drawn from across the Wessex region and participants were recruited via GP practices and pharmacists. In total 14 adults, and 10 parents of children, who had received a prescription for antibiotics for a self-limiting illness within the 3 months preceding the interview were recruited and interviewed.ResultsThree network types were identified; diverse, family and friend and restricted. The type of network an individual has appears to have an influence on antibiotic attitudes and behaviours. Most notably, the more diverse a network the more likely the individual will delay in help seeking from healthcare professionals as they draw upon self-care strategies advised by network members. The role of the GP varies according to network type too. Individuals’ with diverse networks draw upon GP network members to provide clarity and certainty following a period of self-care. People with restricted networks are more reliant upon the GP, seek help quicker and also more likely to prioritise the GPs advice over other sources of information.ConclusionThe understanding a social network approach brings to help seeking behaviour for antibiotics could help practitioners modify their consultation approach to mitigate some uncertainties and perceptions around prescribing behaviour.

GP retention in the UK: a worsening crisis. Findings from a cross-sectional survey

ObjectiveTo investigate how recent national policy-led workforce interventions are affecting intentions to remain working as a general practitioner (GP).DesignOnline questionnaire survey with qualitative and quantitative questions.Setting and participantsAll GPs (1697)...

Diagnosis and outcome in nonhydropic fetal pleural effusions.

To determine the outcome of all pregnancies with nonhydropic fetal pleural effusions in the Wessex region. Data were extracted from the Wessex congenital anomaly database for the years 1994-2015 inclusive. Sixty-two fetuses and babies were identified giving a total prevalence of 1:9500. Eight fetuses had bilateral effusions with additional, nonhydrops anomalies, and 54 had isolated effusions. Of the isolated cases, 36 presented before 24-week gestation: 12 were unilateral and 24 bilateral. All of the unilateral effusions resolved before or soon after birth with no other diagnosis but of the bilateral cases, four (17%) had a trisomy and three (13%) a genetic or syndrome diagnosis. Eighteen isolated cases presented after 24-week gestation, six were unilateral of which one had trisomy 21 (17%), and three (50%) Noonan's or another lymphoedema syndrome. Twelve were bilateral: One had trisomy 21, one an unbalanced translocation (17%), three had Noonan's or another lymphoedema syndrome, and two an unspecified syndrome (42%) at birth. These data suggest that a chromosomal microarray should be offered to all fetuses presenting with a pleural effusion in the absence of hydrops, and Noonan's syndrome testing should be considered for those that develop after 24weeks. To determine the outcome of all pregnancies with nonhydropic fetal pleural effusions in the Wessex region from 1994-2015.

From a small local audit to a regional quality improvement project - Improving lung protective ventilation.

Lung protective ventilation with tidal volumes (VT) of 6-8 ml per kg ideal body weight have been shown to reduce mortality in patients with acute respiratory distress syndrome and reduce post-operative pulmonary complications in major abdominal surgery. Following a local audit on weight recording, the Southcoast Perioperative Audit and Research Collaboration (SPARC) conducted a regional multi-disciplinary survey on the current practice in lung protective ventilation in the Wessex region. This resulted in a quality improvement project improving lung protective ventilation across these intensive care units. Over one-week period in January over two consecutive years, lung protective ventilation parameters of mandatory ventilated patients (above the age of 18 years) were audited in intensive care units in the Wessex region. A total 1843 hours of mandatory ventilation were audited. The quality improvement project led to an improvement of lung protective ventilation with an average of 30% higher duration of ventilation with VT < 8 ml/kg ideal body weight. There was a suggestion that documentation of height and weight on admission to intensive care units improved compliance with lung protective ventilation. Adherence to lung protective ventilation is variable across intensive care units but can be improved by recording patient's weight and height accurately and using simple chart to help calculate the appropriate tidal volume. Additionally, this project demonstrates how a regional audit and quality improvement network can help to facilitate regional quality improvement.