West Of Scotland Research Articles

#5533 DOES AV FISTULA FORMATION DELAY TIMING OF INITIATION OF KIDNEY REPLACEMENT THERAPY IN PATIENTS WITH STAGE 5 CHRONIC KIDNEY DISEASE?

Abstract Background and Aims Several retrospective observational studies have supported kidney protective effects of arteriovenous fistula (AVF) formation. However, these studies were limited by immortal time and selection biases. We investigated whether AVF formation delays the initiation of kidney replacement therapy (KRT) in patients with stage 5 CKD by applying target trial emulation methods, which do not suffer from these biases. Method We included adult patients who had an eGFR ≤15 mL/min/1.73m2, attended the ‘low clearance’ nephrology clinic in the West of Scotland between January 1st 2010 and May 1st 2022, and had no prior AVF or AV graft formation. Available data were obtained from the Strathclyde Electronic Renal Patient Record. The target trial would randomize patients to either receive an AVF immediately or to not receive an AVF. To emulate this trial, we matched each patient who underwent AVF formation to patients who had not undergone AVF formation but remained eligible to participate in the trial, and were matched in sex, age (within 5 years) and eGFR (within 0.5 ml/min/1.73m2). Inverse probability of treatment weighting was used to adjust for baseline confounders, including age, sex, comorbidities, medication use, serum and urine biochemical measurements (eGFR CKD-EPI, eGFR CKD-EPI slope for 6 months preceding trial, haemoglobin, C-reactive protein, albumin, phosphate, adjusted calcium, ferritin, urine protein:creatinine ratio), and blood pressure. The primary outcome was kidney replacement therapy. The eGFR slope closest to the time of AVF creation was estimated as a co-primary endpoint. We estimated hazard ratios using Cox regression and estimated restricted mean survival time (RMST) from the Kaplan-Meier curves. The eGFR slope co-primary endpoint was analysed with a mixed-effects model. Results Among 2,988 included patients (55% men; mean [SD] age 64 [15] years), AVF formation was associated with a higher risk of KRT (HR 1.45; CI 1.20–1.49, p <0.001, Figure 1) and a lower risk of death (HR 0.68; (0.64–0.80, p = 0.001). The AVF group had a lower KRT-free survival with an estimated RMST difference of 265 days (95% CI −331 to −199, p <0.001) and higher overall survival (RMST difference of 191 days; 95% CI 57 to 326, p = 0.005). Finally, we used a mixed-effects model to analyse the association between eGFR CKD-EPI, time, and AVF formation. AVF formation and time were both associated with a negative slope in the model (estimates −1.28; 95% CI −1.36 to −1.19, p<0.001 and −0.01; 95% CI −0.01 to −0.01, p<0.001, respectively, Figure 2). Their interaction was also associated with a negative slope (estimate −0.001; 95% CI −0.0022 to −0.0004, p <0.001), suggesting those undergoing AVF formation had a more rapid eGFR decline compared to the control group. Conclusion Unlike what was observed in previously published work, we did not identify a kidney protective effect of AVF formation. The estimated time of dialysis initiation remains the main determinant for timing of access surgery. These findings illustrate the usefulness of target trial emulation in approaching research questions where randomised controlled trials would be impractical.

#3140 THE WEST OF SCOTLAND AND THROMBOTIC MICROANGIOPATHY

Abstract Background and Aims Thrombotic microangiopathy (TMA) is a diagnosis made on tissue biopsy manifesting as acute organ dysfunction. It has a variety of causes broadly categorised as: primary hereditary/genetic, primary acquired, secondary, and infection-related [1]. On blood testing there is evidence of microangiopathic haemolytic anaemia (MAHA) –, thrombocytopenia, raised lactate dehydrogenase (LDH), reduced haptoglobin and fragments on blood film. Renal involvement with acute injury is evidenced by an elevation in creatinine; together with MAHA this is haemolytic uraemic syndrome (HUS). We sought to examine the TMA/MAHA population as it presented to nephrology in the West of Scotland and evaluate if there was differences in presentation between TMA with and without MAHA. Method This is a retrospective case series of adult nephrology patients. We extracted health data from the west of Scotland renal electronic patient records database Strathclyde Electronic Renal Patient Record (“SERPR”) provided by VitalDataClient. We ran a query to identify patients in whom TMA and/or MAHA and/or HUS was inputted as a diagnosis. 363 patients were identified. Each was manually inspected. Patients were excluded who were not suitable for inclusion (e.g. paediatric data, incomplete records, patients without relevant diagnoses). Non-parametric Kruskal Wallis testing was used via R statistical software. Results 134 patients were identified. The underlying diagnoses were: hypertension (n = 34), the atypical HUS (aHUS, n = 22), drug-induced (n = 17), autoimmune (n = 12,), thrombotic thrombocytopenic purpura (n = 12), malignancy (n = 10), inflammatory (n = 10), peri-partum (n = 9). Others included: transplant-related, unknown, Ecoli 0157, diarrhoea-related, IgA, AAV, MPGN, and essential thrombocythaemia. Note: many patients had multiple possible contributors to their diagnosis. The average biochemical levels at presentation were: creatinine 591umol/L; haemoglobin 82; platelet count 98.7; LDH 1674.2; bilirubin 34.5. Renal recovery was observed in n = 27 (19%); CKD3 n = 32 (24%); CKD4 n = 10(7%); CKD5 n = 7(5%); those who have progressed to ESRF (requiring renal replacement therapy) n = 40(31%); persisting transplant function n = 5(4%). 15 patients died (10%). We categorised patients into 3 groups. 1 – presence of TMA on biopsy without MAHA (n = 28). 2 – TMA on biopsy plus evidence of MAHA (n = 41). And 3 – MAHA in those not biopsied (n = 62). 3 patients with MAHA did not have TMA on biopsy. Those in group 1 had on average a lower serum creatinine at 331umol/L compared with group 2 (634 umol/L) and group 3 (666 umol/L). This result was significant p <0.05. Hypertension was a leading cause in groups 1 and 2. aHUS was not present in group 1 - all patients presented with MAHA. All peri-partum patients were in group 3 i.e. not biopsied. Conclusion It is evident from the dataset that hypertension is a major contributor to acute and chronic renal impairment. With aHUS contributing to a significant number of cases, given the advances in testing and therapeutics, early liaison with national services in complement disorders is paramount to protecting the kidneys. With 19% of patients regaining an eGFR >60ml/min prompt investigation is crucial to reducing the burden of disease. Long term renal follow-up should be offered. 21% of patients had no evidence of MAHA –we should be wary of excluding a TMA process in the absence of MAHA.

Editor’s Note

Editor’s Note

P318 Weight and vitamin D changes in adults with cystic fibrosis in the West of Scotland post induction of triple therapy during a global pandemic

The aim of this audit is to assess weight and vitamin D uptake before and after commencement of Kaftrio in 212 individuals in the West of Scotland Adult CF Unit (WOSACF).

Survival following breast conserving therapy vs. mastectomy in the west of Scotland

Survival following breast conserving therapy vs. mastectomy in the west of Scotland

Trends in the diagnosis and management of breast cancer across the West of Scotland 2010-2018

Trends in the diagnosis and management of breast cancer across the West of Scotland 2010-2018

ESOL classes as trauma-sensitive physical spaces

Abstract I have worked in ESOL for the best part of 15 years now in the west of Scotland in a number of educational contexts engaging learners with ESOL needs from a variety of backgrounds. I have often thought of working in ESOL as akin to completing a 1000-piece jigsaw; having to work with an infinite number of variables, fitting together all the parts, coping with the continuous stream of missing pieces, and needing the emotional strength to withstand the occasional knocks to the table.

Adverse Tumour and Host Biology May Explain the Poorer Outcomes Seen in Emergency Presentations of Colon Cancer.

To examine the association between tumor/host factors (including the systemic inflammatory response), mode of presentation, and short/long-term outcomes in patients undergoing curative resectional surgery for TNM I to III colon cancer. Emergency presentations of colon cancer are associated with worse long-term outcomes than elective presentations despite adjustment for TNM stage. A number of differences in tumor and host factors have been identified between elective and emergency presentations and it may be these factors that are associated with adverse outcomes. Patients undergoing curative surgery for TNM I to III colon cancer in the West of Scotland from 2011 to 2014 were identified. Tumor/host factors independently associated with the emergency presentation were identified and entered into a subsequent survival model to determine those that were independently associated with overall survival/cancer-specific survival (OS/CSS). A total of 2705 patients were identified. The emergency presentation was associated with a worse 3-year OS and CSS compared with elective presentations (70% vs 86% and 91% vs 75%). T stage, age, systemic inflammatory grade, anemia (all P < 0.001), N stage ( P = 0.077), extramural venous invasion ( P = 0.003), body mass index ( P = 0.001), and American Society of Anesthesiologists Classification classification ( P = 0.021) were independently associated with emergency presentation. Of these, body mass index [hazard ratio (HR), 0.82], American Society of Anesthesiologists Classification (HR, 1.45), anemia (HR, 1.29), systemic inflammatory grade (HR. 1.11), T stage (HR, 1.57), N stage (HR, 1.80), and adjuvant chemotherapy (HR, 0.47) were independently associated with OS. Similar results were observed for CSS. Within patients undergoing curative surgery for colon cancer, the emergency presentation was not independently associated with worse OS/CSS. Rather, a combination of tumor and host factors account for the worse outcomes observed.

Impact of regional multi-disciplinary team on the management of complex urogynaecology conditions

Introduction and hypothesisFollowing the publication of the National Institute for Health and Care Excellence guidelines on the management of pelvic floor dysfunction, articles speculating on the benefits and costs of local and regional multi-disciplinary teams (MDTs) have been in circulation. To date, there has been no formal assessment of the impact of a regional MDT on the management of women with complex urogynaecological conditions.MethodsThroughout the existence of the West of Scotland (WoS) Regional Urogynaecology MDT, from May 2010 to December 2015, 60 patients with complex Urogynaecology conditions were discussed. Data were collected on presenting condition, pre- and post-MDT management plans, and treatment outcomes.ResultsThe average age was 52.6 years (range 21–91 years). All meetings had at least 1 urogynaecologist, 1 gynaecologist, 1 reconstructive female urologists, 1 urodynamicist and, on average, 3 continence nurses, 4 physiotherapists, as well as 1 clinical librarian to conduct a literature search and 1 secretary for administrative support. The majority of the referrals dealt with urinary incontinence (n=34) and 8 patients presented with mesh complications alongside other pelvic floor disorders. The MDT made changes to the original referrer’s management plan in at least 25 (41.7%) patient presentations. Twenty-two out of all the patients discussed (36.7%) were reported as cured or improved in their condition following the MDT-recommended management.ConclusionThe WoS Regional Urogynaecology MDT had a positive impact on the management of women presenting with complex condition(s). Cross-sharing of resources between hospitals within the region provided a wider range of management plans, better tailored to each individual.

Abundance of Atlantic white-sided dolphin (Lagenorhynchus acutus) during summer off northwest Scotland

A shipboard cetacean survey was conducted in July/August 1998 within an area to the west of Scotland, UK, commonly known as the Atlantic Frontier. The aim of the survey was to document the distribution and abundance of cetaceans to provide baseline population data for an area that is being increasingly explored and developed by oil companies. A double platform ‘independent observer’ (IO) method was used to estimate the abundance of the Atlantic white-sided dolphin (Lagenorhynchus acutus) using standard line-transect and distance sampling methodology. Previously, uncorrected Atlantic white-sided dolphin abundance was estimated as 27,194 (CV = 0.29) from this survey. This paper presents abundance estimates corrected for g(0) &lt; 1 using a direct duplicate method. The value of g(0) was estimated to be 0.61 (CV = 0.09). The abundance in two strata was estimated as 21,371 (CV = 0.54) to the west of the Outer Hebrides and 74,626 (CV = 0.72) in the Faroe Shetland Channel. The high CVs are the result of small sample sizes, particularly of the duplicate data set. However, the abundance estimates represent the first for this species to the northwest of Scotland and adds to existing baseline abundance estimates for small cetaceans in UK waters. The results could be useful for planning future surveys that aim to calculate more precise abundance estimates. These results, together with opportunistic sightings data collected during other surveys, suggest that the waters to the west of Scotland are an important habitat for the Atlantic white-sided dolphin. Presently, threats to this species in the area are relatively unknown but a baseline population estimate will be an integral part of any management regime should there become a need in future.

Real-world effectiveness of systemic anticancer therapy for advanced melanoma in the west of Scotland from 2010 to 2018.

Aim: Assess the real-world effectiveness of systemic anticancer therapy in advanced (unresectable or metastatic) melanoma. Methods: This was a retrospective cohort study linking routine healthcare data with systemic anticancer therapy prescriptions for patients starting immunotherapy or targeted treatments between 1 November 2010 and 31 December 2017 in the west of Scotland. Results: Among 362 patients identified, median overall survival varied between 18.5months (95% CI: 14.4-not estimable) for ipilimumab/nivolumab combination and 5.6months (95% CI: 4.5-7.3) for dabrafenib, but there were differences in the characteristics of each regimen cohort. Raised lactate dehydrogenase levels and Eastern Cooperative Oncology Group performance status ≥2 negatively impacted overall survival. Conclusion: The patients had a shorter median overall survival than those in pivotal trials. This was expected, given that this real-world cohort included patients with poorer prognostic indicators, typically excluded from trials.

The association between KRAS mutational status, clinicopathological factors including the preoperative systemic inflammatory response and outcomes in TNM stage I-III colon cancer.

193 Background: TNM Stage is the most significant prognostic indicator in colon cancer however other tumour and host factors (eg the systemic inflammatory response (SIR)) are associated with long-term outcomes. The relationship between the tumour and the host SIR remains poorly understood. KRAS mutations are associated with adverse outcomes in metastatic disease and have been reported to have an inflammatory phenotype however this has not been widely studied in non-metastatic disease. The present study investigates the association between KRAS mutations, clinicopathological factors including the SIR and outcomes in TNM I-III colon cancer. Methods: Two cohorts of patients (single centre–2000-2008 and regional-2011-2014) undergoing curative surgery for TNM I-III colon cancer in the West of Scotland were shown to be well-matched and combined. Mutational status was analysed retrospectively. The SIR was stratified using Systemic Inflammatory Grade (SIG). 3-year overall and cancer specific survival (OS and CSS) were measured from date of surgery until date of death. Results: 267 patients were identified, 45% with KRAS mutations. KRAS mutations were associated with: right sided (p=0.013), well differentiated (p=0.011), BRAF-wt (p&lt;0.001), PIK3CA-wt (p=0.027) and P53-wt (p=0.002) tumours. A trend was seen between KRAS mutations and female sex (p=0.074) and increased SIG (p=0.072). No association was seen with age, deprivation, smoking, ASA Grade, TNM Stage or EMVI. KRAS mutant status was associated with adverse 3-year CSS (74% versus 82%, p=0.006) and OS (69% versus 78%, p=0.070). For CSS, TNM Stage (HR 2.92, p&lt;0.001), KRAS mutant status (HR 1.64, p=0.050) and Systemic Inflammatory Grade (HR 1.34, p=0.004) were independently prognostic. For OS: age (HR 1.39, p=0.022), TNM Stage (HR 1.50, p=0.016) and SIG (HR 1.25, p=0.005) were independently prognostic. A trend was seen between KRAS mutant status and adverse OS (HR 1.47, p=0.079). Conclusions: The present results show an association between KRAS mutational status and SIG. Furthermore, both of these factors were associated with adverse oncological outcomes. Further investigation into the association between KRAS-mutant status and the local/systemic inflammatory response in TNM I-III colon cancer is warranted. While comprehensive genomic profiling is likely to become increasingly common place, staging the host (SIR) should also be routinely undertaken.

Necrotising fasciitis of the head and neck: A case series from the West of Scotland.

The authors declare no conflict of interest. The peer review history for this article is available at https://publons.com/publon/10.1111/coa.14035. The data that support the findings of this study are available on request from the corresponding author, [SD]. The data are not publicly available due to containing information that could compromise the privacy of research participants.

The impact of urbanisation on body condition and size in Bombus hypnorum and Bombus lucorum agg. (Hymenoptera: Apidae) in urban (parkland and brownfield) and rural sites in the west of Scotland

The impact of urbanisation on body condition and size in Bombus hypnorum and Bombus lucorum agg. (Hymenoptera: Apidae) in urban (parkland and brownfield) and rural sites in the west of Scotland

Reflecting on students’ perspectives of a pre-entry psychology course in academic skills (2017–2021)

It is known that first-year retention rates are a cause for concern within higher education. One way in which to tackle this is to consider how institutions can best prepare new students for the transition to university. The current paper details a project from the University of the West of Scotland where first year psychology students enrolled on a pre-entry academic skills induction course in order to support their transition to university. The course consisted of engagement with five interactive magazines to allow students to begin experiencing the digital environments, skills, and resources that they would need throughout their degree (‘ What is psychology?’, ‘How do I study?’, ‘The importance of critical thinking’, ‘What’s involved in psychological research?’ and ‘Life after university’ ). Focus groups were conducted with students shortly after taking part in the course, and again four years later upon graduation, to explore its perceived value both as a new student, and across time at university. A deductive thematic analysis showed a positive reception to the materials, but that some topics were less relevant at the beginning of a degree course. We reflect upon these findings in the context of current HE practice.

107. Deep Neck Infections – A single centre analysis of 100 cases in West of Scotland (WOS)

This study reviews the clinical presentation, investigation, and management of deep neck infections in our department. We aim to identify predisposing factors for serious complications, with a view to improve prognosticating.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios: associations with mortality in a haemodialysis cohort.

Lymphocyte ratios reflect inflammation and have been associated with adverse outcomes in a range of diseases. We sought to determine any association between neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and mortality in a haemodialysis cohort, including a coronavirus disease 2019 (COVID-19) infection subpopulation. A retrospective analysis was performed of adults commencing hospital haemodialysis in the West of Scotland during 2010-21. NLR and PLR were calculated from routine samples around haemodialysis initiation. Kaplan-Meier and Cox proportional hazards analyses were used to assess mortality associations. In 1720 haemodialysis patients over a median of 21.9 (interquartile range 9.1-42.9) months, there were 840 all-cause deaths. NLR but not PLR was associated with all-cause mortality after multivariable adjustment [adjusted hazard ratio (aHR) for in participants with baseline NLR in quartile 4 (NLR ≥8.23) versus quartile 1 (NLR <3.12) 1.63, 95% confidence interval (CI) 1.32-2.00]. The association was stronger for cardiovascular death (NLR quartile 4 versus 1 aHR 3.06, 95% CI 1.53-6.09) than for non-cardiovascular death (NLR quartile 4 versus 1 aHR 1.85, 95% CI 1.34-2.56). In the COVID-19 subpopulation, both NLR and PLR at haemodialysis initiation were associated with risk of COVID-19-related death after adjustment for age and sex (NLR: aHR 4.69, 95% CI 1.48-14.92 and PLR: aHR 3.40, 95% CI 1.02-11.36; for highest vs lowest quartiles). NLR is strongly associated with mortality in haemodialysis patients while the association between PLR and adverse outcomes is weaker. NLR is an inexpensive, readily available biomarker with potential utility in risk stratification of haemodialysis patients.

‘We are the (simulation) champions – evaluating the role of simulation champions to enrich the diversity of simulation practice placements within higher education institutions undergraduate healthcare programmes’

Due to the COVID-19 pandemic, there has been a significant impact on undergraduate healthcare practice placement education [1]. In response, the Scottish Government, committed to ensuring Adult and Mental Health Nursing, Midwifery, and Paramedic Science students have adequate provision to student placements, awarded Higher Education Institutions (HEIs) funding to develop simulation placements. Within our HEI a Clinical Skills and Simulation Team (CSST) has been created comprising 3 Lecturers, a Simulation Technician, and a Digital Technologist. The team then built a Simulation Champions group (n=30) through fostering working relationships, to help promote simulation-based education (SBE) pedagogy across the HEI. The purpose of this study is to explore whether creating a simulation champions group has any impact on the delivery of simulated practice placements within undergraduate healthcare programmes. The Simulation Champions are a diverse group comprised of internal academic faculty and external National Health Service (NHS) partners (such as practice education facilitators) who are passionate educators in SBE. Each external partner has a contact within the HEI, aligned to their area of clinical expertise. Through an agreed Terms of Reference, their aim is to enhance, resource, and assist the delivery of high-quality, high-fidelity simulation placements to students by working collaboratively in line with the relevant professional body standards and proficiencies [2]. The CSST oversee the Simulation Champions, providing strategic direction, leadership, following the HEI strategy [3], and support the delivery of Simulation Placements. The group meets every quarter to discuss simulation practices, explore Continuous Professional Development (CPD) opportunities, and share knowledge and learning. The impact of this team will be measured through staff and student reflection using a framework to objectively analyse scenario diversity, achievement of learning outcomes, and alignment to professional body proficiencies. Following ethical approval, a group of Year 1 Adult Nursing students (n=60) will have completed a 40-hour Simulated Practice Placement designed and delivered by Simulation Champions (n=10). This study will then evaluate and conclude whether there is a need to create and develop a diverse, multi-professional Simulation Champions Group before successful Simulated Practice Placements can be achieved. It will also help determine if securing strong working relationships ensures a smooth transfer of knowledge and skills from clinical practice to the simulation setting within a HEI, and if all of this enhances the student experience. 1. Caplan J, Clements R, Chadwick C, Kadirgamar J, Morgan J, Rao A. Medical education in 2020: developing COVID secure undergraduate hospital placements. Medical Science Educator. 2020;30(4):1677–83. 2. NMC 2018a, 2018b, 2018c, 2018d: Nursing and Midwifery Council. The Code. Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council. Realising professionalism: Standards for education and training. Part 3: Standards for pre-registration midwifery programmes. Nursing and Midwifery Council. Realising professionalism: Standards for education and training. Part 3: Standards for pre-registration nursing programmes. 3. University of the West of Scotland. Strategy 2025. 2020. uws-strategy-2025.pdf. [Accessed on 25/01/2022]

Exploding silos: hacks in creating national simulation networks

Silos of work are a reality in virtually every large organisation and invariably create duplicated workloads, inefficiencies, and in some cases a sense of ‘tribalism’ which risks the integrity and effectiveness of teams [1]. As simulation-based education gains traction and momentum as a teaching approach across Scotland and the UK, silos of work have emerged and risk the effectiveness and efficiency of programme delivery. Our aim was to create an effective simulation user network across the 14 Health Boards of Scotland to eliminate silos and create a collaboration of work across the country. Thanks to an investment from NHS Education for Scotland (NES), insight from the NHS Scotland Academy, and the expertise of the Clinical Skills Managed Education Network (CSMEN), a team of regional Senior Educators were recruited to create a functional regional and national collaborative for simulation in Scotland. The story here is how the team have come together and the lessons learned in networking, negotiating, and establishing a new and growing sense of collegiately across the country. Starting in the East of Scotland, a questionnaire was designed and delivered across simulation teams and stakeholders across four Health Boards. The data collected was used to feed discussion at an East Scotland Simulation Collaborative scoping meeting which was attended by representatives of all four Health Boards and included medics, nurses, physiotherapists, and pharmacist teams delivering simulation to both undergraduate and postgraduate teams. An East Scotland Simulation Collaborative has been formally established with its inaugural meeting in Autumn 2023. An online space has been established to promote communication and the sharing of resources, and both a quarterly meeting and annual faculty development day designed for the group. Discussions are now ongoing for the development of an East Scotland Simulation Research group to develop new opportunities to conduct multisite studies for the first time. From a national perspective, North and West Scotland Simulation Collaborative groups are now in their formation stages. Like weeds in a garden, silos of work will grow all by itself. Like roses in a garden, an effective network takes both time and tending, but the investment pays dividends. 1. Beattie A. War and peace among the health tribes. 1995. In: Soothill K, Mackay L, Webb C (Eds). Interprofessional relations in health care. London: Edward Arnold.

53 (PB-053) Poster - Targeted axillary dissection or sentinel node biopsy after neo-adjuvant treatment in clinically node positive patients – the West of Scotland experience

Background: For patients with node positive disease who are exceptional responders for neo-adjuvant treatment (NAT), targeted axillary dissection (TAD) or sentinel node biopsy (SNB) with removal of minimum three nodes may be offered for staging. We compared clinicopathological outcomes of patients treated with TAD/SNB to ANC after NAT for node positive disease and describe clinicopathological outcomes after TAD with magseed localisation (TADm), wire localisation or no preoperative localisation (TAD) or SNB in three units in the West of Scotland.