Tomorrow's Doctors Posters

WHERE ARE THE WOMEN IN T&O? WHERE ARE THE WOMEN IN T&O?

An Analysis of the Women Orthopaedic Surgeons in Hip Arthroplasty from the National Joint Registry

INTRODUCTION

Despite 50% of UK medical graduates being women, 14.7% of surgical consultants are women (1). In orthopaedics, 20% of specialist trainees and 7 4% of consultants are women (2) Data on the proportion of female consultants within UK orthopaedic subspecialties is limited

RESULTS

METHODS

Publicly available data from the National Joint Registry (3) was used. This included GMC number, procedure type and number, and patient demographics Surgeons performing less than five hip arthroplasties in the last year were considered low-volume surgeons (LVS) The GMC website was used to obtain gender, practising region, and registration date data (4). Surgeons registered within the last year were excluded due to expected low caseloads.

1750 out of 2895 surgeons on the NJR performed hip arthroplasty in the last 12 months, out of these 1750 surgeons, only 50 were women

Over the last year, female surgeons performing primary hip replacements were more likely to be low-volume surgeons (52%) than males (20%) The same phenomenon was seen in hip revision surgery, where female surgeons were more likely to be LVS (67%) than males (45%).

The Channel Islands, Isle of Man, North Wales, and Northern Ireland had none.

50 OUT OF 1750 11

Southeast England had the most female hip surgeons

CONCLUSION

The proportion of female orthopaedic surgeons working in hip arthroplasty is limited Some regions have none Female surgeons perform fewer primary and revision joint replacements than males

High-volume surgeons primary hip replacement average

High-volume surgeons hip replacement revision average

REFERENCES

WOMEN 59

42

MEN

NATIONAL AVERAGE 76

WOMEN NATIONAL AVERAGE MEN 7 13 8

Rebecca Beni,Laura Casey,Arya Anthony Kamyab,Konstantinos Devetzis,Alexa Papanastasiou,Shreya Gupta,Chloe Scott,Caroline Hing Department of Trauma and Orthopaedic, St. George's Hospital, London, United Kingdom

Assessing the Effectiveness of 3D Printing as a potential future teaching method for Surgical Anatomy

Authors- Hayyan Khan, Nafisa Zilani

Affiliations- GKT School of Medical Education Email of Corresponding

Introduction

Three-dimensional (3D) printing has emerged as a promising field with the capability to revolutionize operative experience and surgical training programs (Langridge et al., 2017). However, the limited exposure of medical students and junior doctors to this technology hampers their ability to effectively utilize it in future clinical practice and surgical training.

To address this issue, a study was conducted with the aim of assessing the pre-existing knowledge among medical professionals regarding the significance of 3D printing in surgery. Subsequently, a follow-up pilot study was conducted to evaluate the effectiveness of a surgical 3D printing workshop as an intervention to enhance their understanding of 3D printing as a surgical anatomy teaching tool and its potential applications in surgery.

Aim

To assess the effectiveness of 3D printing as a potential future teaching method for surgical anatomy.

Methods

84 attendees completed pre- and post-event questionnaires using a 5-point Likert scale. The event itself included a host of technology-based surgical workshops including 3D printing. After the conference, the attendees participated in several technology-based surgical workshops. The scores were analyzed using the Shapiro-Wilk test to assess normality, and a one-tailed test was used to assess statistical significance.

Author- hayyan.khan@kcl.ac.uk

Results

Attendees demonstrated an increase in understanding of the significance of 3D printing in anatomy and its potential applications for surgery (p= 0.00000078). However, although there was a mean increase in agreement with the use of 3D printing as a teaching method for surgical anatomy after the event, it was not significant (p=0.11) [p < 0.05 = significant].

Discussion

The results of the study have shown valuable information about the importance of 3D printing in the context of surgical anatomy. The attendees had shown, post-workshop, a greater understanding of the use of 3D printing in anatomy and the workshop had shown a greater potential application for its use in surgery.

This highlights the value of 3D printing in visualisation, in a new matter which will not use cadaveric dissections for example. Greater visualisation of anatomical structures will lead to greater understanding of these anatomical bodies and their interactions; and this will enhance surgical quality and effectiveness, eventually leading to enhanced patient outcomes.

While attendees recognised the advantages of technology-based teaching methods, there was no significant increase in agreement regarding their overall effectiveness. This discrepancy may indicate that reservations may exist about the comprehensive impact of these methods on surgical education. Concerns may include reliability, limitations in simulating complex scenarios, and the need for further research.

Conclusion

To conclude, this event, which involved a surgical 3D printing workshop, was successful in increasing attendees' understanding of the significance of 3D printing in anatomy and its potential applications for surgery. However, there was not a significant increase in agreement regarding the use of 3D printing as a teaching method for surgical anatomy after the event. This suggests that further efforts may be necessary to convince attendees of the effectiveness of 3D printing as a teaching tool in surgical anatomy.

References

Langridge, B., Momin, S., Coumbe, B., Woin, E., Griffin, M., & Butler, P. (2018). Systematic Review of the Use of 3Dimensional Printing in Surgical Teaching and Assessment. Journal of Surgical Education, 75(1), 209-221.

Acknowledgements

We extend our thanks to all the members of FSA Conference Committee as well as volunteers for their help in making this conference successful.

Special thanks to Professor Kawal Rhode for facilitating this workshop

Background and Purpose

Zoledronic Acid Injections as a Promising Treatment Option for Symptomatic Schmorl’s Nodes in a

Paediatric Patient: A Case Report.

Ali Khalid, Ameer Khamise, University of Buckingham

Investigations

Outcomes and Patient Perspectives

Schmorl’s Nodes (SNs) are malformations of the vertebral endplate, characterised by herniation of the intervertebral disc nucleus pulposus into the neighbouring vertebral body SNs strongly correlate with increasing age, particularly in individuals between 40 and 60, with higher prevalence in males (Kyere et al., 2012). Symptomatic SNs present with lower back pain and lumbar disc disease (William et al., 2007). This case report aims to demonstrate the potential of Zoledronate (a bisphosphonate) in managing symptomatic SNs in a 15year-old female patient. Treatment was assessed using the Visual Analogue Scale (VAS), a subjective and standardised tool for acute and chronic pain al., 2018).

Case Description

This case report reviews a 17-year-old female suffered from chronic lower back pain Despite no history of axial force exposure injuries, she was diagnosed with SNs aspects of L3-L4 and L4-L5 regions. The referred to a paediatric orthopaedic clinic investigations (Table 1). SNs were diagnosed scans at the age of 13 in 2018 (Figure concern revolved around the patient's pronounced pain, which significantly impacted her overall life. The back pain presented a challenge as effectively managed through conventional interventions such as NSAIDs and physiotherapy the patient's young age and absence of spinal nerve compression, surgical intervention deemed unsuitable.

Zoledronate Treatment

A multidisciplinary team comprised of a paediatric spine surgeon, a paediatric physician, and radiologists devised an experimental treatment regimen involving administering six intravenous Zoledronate injections over 29 months, which commenced in October 2020. VAS score was measured in the clinic follow-ups a month after each injection to evaluate the back pain (Figure 2,3)

Tests

Genetic testing: Marfan Syndrome Negative

CT spine

Bone scan

Rheumatological blood tests (Including HLA-B27)

Results

Excluded space-occupying lesions

Increased uptake in L3 and L4 vertebrae

Negative

Table 1:Back pain investigations and results.

Initial Evaluation

29-Month Treatment Period

" I experienced excruciating back pain which affected my ability to attend school”.

4th Injection " significant improvement in my ability to perform daily activities"

6th Injection (Final)

" I effortlessly go through my daily routine, hardly experiencing any pain."

Discussion and Conclusion

- There is insufficient literature on managing symptomatic SNs in paediatric patients; however, a course of six injections of Zoledronate demonstrated successful management of chronic back pain

- The case report demonstrates the potential of Zoledronate in managing symptomatic SNs, particularly in paediatric patients, where it reduced the VAS score from 9 to 2, significantly improving the child’s quality of life.

- The case report allows for further research to establish Zoledronate treatment’s long-term safety and efficacy.

After excluding other confounding factors, SNs were found to be the primary cause of back pain. Considering the hyperintense changes on MRI and increased uptake in L3 and L4 vertebrae on bone scan, Zoledronate was used to strengthen the anterior aspects of the intervertebral endplates and to decrease nucleus pulposus protrusion.

References

nodes: Common, highly heritable, and related to lumbar disc disease’, Arthritis & Rheumatism, 57(5), pp. 855–860. doi:10.1002/art.22789.

3. Delgado, D. et al. (2018) "Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults", JAAOS: Global Research and Reviews, 2(3), p. e088. doi: 10.5435/jaaosglobal-d-17-00088.

Figure 1: T1-weighted (left) and T2-weighted (right) MRI scans show SNs on the anterior aspect of endplates of L3-L4 and L4-L5 regions where hyperintense changes were noted.

Figure 2:VAS Score through the

Figure 3: Patient’s Perspective Throughout the Treatment.

Improving clinical staff awareness regarding Methamphetamine use and Psychosis

Nayan Dhokia, Aiman Ibrahim and Abbie Edwards Supervised by Dr Eduardo Iacoponi

BACKGROUND

• Rates of methamphetamine use in Lambeth, Southwark and Lewisham are amongst the highest in the UK 1 , and have led to a sharp increase in acute mental health presentations to hospitals and community health centres2

• Care coordinators at an early intervention community team in Lambeth (LEO) reported difficulties in identifying and managing patients with full/partial methamphetamine - induced psychosis, reporting an average confidence rating of 2.69 out of 5 (n=16).

• Furthermore, in response to a questionnaire, many suggested vague and non - specific answers regarding advice and treatment options for these patients.

WHY IS AWARENESS LOW?

PRIMARY OBJECTIVE

We aim to improve LEO clinical staff confidence around the relationship between methamphetamine use and first episode psychosis by 50% over 9 months (October 2022 – June 2023)

METHODS

Surveys of clinical coordinators at LEO were conducted using a pre - intervention questionnaire to gauge staff awareness of methamphetamine - induced psychosis and self- confidence ratings. Responses were used to guide delivery of interventions.

PDSA cycle 1:

Deliver a presentation and information leaflet (figure 2) on characteristics of LEO patients with methamphetamine - induced psychosis and evidence - based management options. Information was sourced by studying the LEO patient caseload and clinical notes of methamphetamine users.

PDSA cycle 2:

Display posters (figure 3) in the care coordinator team office to remind staff of management options when considering patients using methamphetamine.

RESULTS AND DISCUSSION

References:

• The average confidence rating before PDSA 1 measured 2.688 (blue bar), which rose to 3.115 amongst all care coordinators surveyed (16% gain – yellow bar). Average confidence rose to 3.417 (27% gain – orange bar) amongst care coordinators who interacted with the PDSA 1 interventions.

• Though these gains were short of the 50% gain required to achieve our target average of 4.035 (green bar), they demonstrated improvements in average staff confidence.

• The difference in percentage gain between the group who interacted with PDSA 1 and those who did not was 28%. Care coordinators who interacted with PDSA 1 were also able to display more robust suggestions towards questionnaire questions regarding desired and undesired symptoms of methamphetamine use, advice, and treatments for users.

• Following PDSA 2, care coordinators who had engaged with both interventions scored an average confidence rating of 4.5 (purple bar) which exceeded our target confidence score.

• However, the number of care coordinators who had fully engaged with PDSA 1 and 2 was low (n=2) meaning PDSA 2 was not as accessible as we had hoped. We believe increasing the number and size of posters in the team office can help bring this number up.

SCOPE FOR THE FUTURE

• Incidence of methamphetamine use amongst populations of gay men in London has risen dramatically, alongside the practice of chemsex and polydrug use – it is therefore paramount for staff at London - based Early Intervention Psychosis clinics and hospitals to feel confident in their approach to managing their patients.

• Though our PDSA 1 and 2 interventions contained information tailored specifically to LEO clinical staff, much of the evidence - based management options presented can be transferrable to other NHS Early Intervention clinics.

• We are arranging for our questionnaires and interventions to be introduced to King’s College Hospital’s mental health liaison service, to support staff who encounter patients using methamphetamine that present to hospital.

SUSTAINABILITY

with

To ensure our interventions were made to be long lasting and contribute positively to society and the environment, we used triple bottom line framework to assess sustainability of our proposed changes.

Figure 1: fishbone diagram used to perform root cause analysis of why awareness and confidence around methamphetamine use and psychosis is poor

Figure 2: front page of the information leaflet designed alongside our presentation for care coordinators

Figure 3: information poster which was displayed around the LEO care coordinator team office

Melody for Maladies: A Literature Review of Music Therapy in the Management of Paediatric Pain

Vidisha Handoo, Isabella Gavazzi

Introduction

• Hospital settings contribute to ↑ pain and anxiety in paediatric patients

• Music Therapy: a non-invasive, cheaper and side-effect free alternative to alleviate pain

Methodology

• PubMed search: (“paediatric” OR “pediatric” ) AND “pain” AND “music”

• Only Clinical Trials + RCTs

• 20 relevant results

Results

Classical and relaxing music most frequently used

Headphones + Live musicians used most. Live and engaging performances particularly effective

Wong-Baker FACES scale + Physiological measures e.g. heart rate + BP most used

Conclusion

• Research in field = scattered,

• Structure + stricter parameters to optimise

• Research gap in young age group (0-3 years)

• Possibility to use technologies e.g. fMRI + VR

REASONS BEHIND FALLING FERTILITY

INTRODUCTION

LEVELS IN MEN

WORLDWIDE

Several studies have reported a decline in sperm count over the past few decades. A comprehensive analysis published in the journal Human Reproduction Update in 2017 found a significant decline in sperm concentration and total sperm count among men from Western countries between 1973 and 2011.

Concerns over implications of the decline in fertility levels and sperm count in men

OBJECTIVES

To identify patterns of falling fertility in men

Explain the reasons behind the pattern

To identify if decreasing fertility has any global impact

Offer some solution or plan to combat the issue

REASONS AT A GLANCE

STATISTICS

Global figures suggest sperm concentration has halved in 40 years

Average decline in mean sperm concentration of 1.6% per year, and an overall decline of 59.3%

Decline became steeper from 2000 onwards and now sits at 62.3% globally Declines in sperm concentration were seen not only in the region previously studied, but in Central and South America, Africa and Asia.

Global fertility rate from 2010 to 2020

POSSIBLE SOLUTIONS

Encouraging men to adopt a healthy lifestyle can positively impact fertility

Raising awareness about the potential hazards of environmental pollutants and toxins can help men minimise exposure

Regular check-ups with healthcare professionals can help identify any underlying medical conditions that may affect fertility

Raising awareness about male fertility issues, providing access to reliable information, and offering support groups or counseling services can be beneficial

GLOBAL IMPLICATIONS

Graph depicting decreasing fertility pattern around the world from 2010-2020

Shifting diet patterns leading to diabetes and obesity

Increase incidence of sexually transmitted diseases

Genetic defects such as undescended testicles

More advances age of reproduction affecting sperm count, quality and sperm motility

Environmental factors such as increased air pollution and exposure to radiation

Chronic stress can affect male fertility by disrupting hormone production, reducing sperm quality, and impairing sexual function

Occupational hazards: jobs that involve prolonged sitting, driving, or using laptops on the lap can raise scrotal temperatures and affect sperm health

Falling fertility rates have significant implications for population dynamics, social structures, labor markets, and the economy. These include an aging population, declining workforce, strains on pension and healthcare systems, and potential shifts in the age structure of societies.

CONCLUSIONS

Falling patterns of fertility in men is well established

Psychological impact aside, this pattern is concerning from a global perspective

Short, medium and long term planning is needed stabilise the fertility levels

Solutions exist which involve education, public health and promoting lifestyle changes in men

More support should be available for men families to reduce psychological impact

Investigating clinical variables associated with scar formation in acute myocarditis

Background

Acute myocarditis (AM) involves a complex inflammatory response1 . In certain patients, excessive inflammation leads to fibrosis and scar formation2 , however the full pathophysiology driving scar formation in AM remains unknown1 . Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging is used to identify myocardial scar3 and is associated with worse prognosis in AM4 . However, current prognostic markers of AM either identify patients who are already known to be at increased risk of mortality5 , require invasive techniques such as biopsy5 or CMR imaging4 which is not always available.

Aims

1) Identify inflammatory phenotypes associated with formation, presence, and persistence of myocardial fibrosis in AM

2) Identify potential novel biomarkers associated with scar formation and prognosis

Methods

• Retrospective cohort study including all patients presenting to King’s College Hospital NHS Trust with a CMR-confirmed diagnosis of AM.

• CMR quantification of LGE mass at baseline and change in LV mass over follow-up

• Linear regression analysis with inflammatory cells and cytokines

• Hierarchical clustering to identify cytokine phenotypes

Results

• 56 patients with CMR-confirmed AM included

• Baseline LGE was positively correlated with TNF-alpha (p=0.047) and negatively correlated with IL-10 (p=0.025) (Fig 1)

• Change in LGE over follow-up (delta LGE) was positively correlated with neutrophil lymphocyte ratio (NLR) (p=0.032) and negatively correlated with TNF-alpha (p=0.047) (Fig 2)

• 18 patients with CMR-confirmed AM included for hierarchical clustering

• Hierarchical clustering generated 4 cytokine clusters with individual cytokine profiles and differing

• Inflammatory markers such as NLR and cytokines are predictive of the extent of inflammation and scar formation

• Inflammatory markers may be useful in risk stratification in the future

• Larger patients studies with biopsy-proven AM are required to understand the interaction between aetiology, inflammation, scar formation and prognosis

G, Figliozzi S Sanguineti F Aquaro GD, Di Bella G, Stamatelopoulos K, et al. Prognostic Impact of Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance in Myocarditis: A Systematic Review and Meta-Analysis. Circ Cardiovasc Imaging. 2021 Jan 1;14(1):E011492. 5. Caforio ALP, Calabrese F Angelini A, Tona F, Vinci A, Bottaro S, et al. A prospective study of biopsy-proven myocarditis prognostic relevance of clinical and aetiopathogenetic features at diagnosis. Eur Heart J [Internet]. 2007 Jun 1;28(11):1326–33. Available from: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehm076

Emma Ferone1, Daniel I. Bromage1,2, Stefania Rosmini2, Antonio Cannata1,2 , Prashan Bhatti2, Roman Roy1,2, Mohammad Al-Agil2, Allen Daniel2, Antonio Jordan2, Barbara Cassimon2, Susie Bradwell2, Abdullah Khawaja2 , Matthew Sadler2, Aamir Shamsi2, Josef Huntington1, Alexander Birkinshaw2, Irfan Rind2, Susan Piper2, Daniel Sado2, Mauro Giacca1, Ajay M. Shah1, Theresa McDonagh2 and Paul A. Scott2 1. School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom, 2. King’s College Hospital NHS Foundation Trust, London, United Kingdom

Fig 4. Radar plot of cytokine levels by cluster

Fig 1. Scatter plot of baseline LGE against TNFalpha and IL-10

Fig 2 Scatter plot of delta LGE against NLR and TNF-alpha

The comparison of the removal of frontozygomatic dermoid cysts via the indirect or the direct approach

Authors: Vishali Desai1, Chelsea Todd1, Mobin Syed1, 2, David Parry1

Affiliations: 1King’s College London, 2Guy’s and St Thomas NHS trust

INTRODUCTION RESULTS DISCUSSION

Dermoid cysts are abnormal growths of ectoderm outside the skull. These form due to a congenital defect in cranial suture lines, allowing sebaceous glands, hair follicles, and debris to be trapped outside the skull1. Surgery is the preferred management of dermoid cysts2,3. Two approaches are primarily used – the direct and the indirect4,5. Current literature focuses on cosmetic appearance and post operative complications6,7, however this cadaveric study compares the structures at risk in each procedure.

METHODS

Cyst Insertion: Water beads (cysts) were inserted into unembalmed cadavers. The cysts were placed above the eyebrow, 5cm from the lateral border of the eyebrow, in the periosteal plane. Surface anatomy markings were made (Figure 1).

Approach for removal: The direct approach involved an incision 5mm above the lateral border of the eyebrow, 15mm long, followed by blunt dissection down to the periosteal plane to expose the cyst. The indirect approach involved an incision through the eyelid crease (Figure 2). Dissection continued with longitudinal incisions through the orbicularis oculi (OO) muscle, followed by superior and lateral blunt dissection to expose the cyst the in periosteal plane.

No significant difference was found in the operating time (p=0.358) or the TBFN distance (p=0.343), and both procedures achieved complete cyst removal in all 10 cases. 2 out of 5 cysts were ruptured with the indirect approach, whilst 4 out of 5 ruptured with the direct approach. The ease of plane exposure for the indirect approach showed a significant trend (p=0.006), with a strong positive correlation (R=0.99). The zone of caution (ZoC) was entered in 3 out of the 10 indirect approaches, and 2 of these correlated with the extension of the initial incision.

The lower average time for the direct approach may be due to the shorter dissection plane involved, or the increased skill required for the indirect approach. A shorter operative time is advantageous in improving patient outcomes by reducing the risks of infection, blood clot formation, and post-operative nausea8. Experienced surgeons may not elicit this discrepancy in operative time due to comfort with the techniques, which can be optimised with training.

The TBFN was not seen to be at an increased risk, based upon distance from incisions, compared in both procedures. Measurements cannot infer risk and the results imply an equal risk in both techniques. This was supported by the confidence ratings in avoiding the TBFN.

Plane exposure was achieved with greater ease with the indirect technique, likely due to the increased visual field, though this did not affect the ease of cyst exposure. Exposure to surgical planes is particularly important in minimizing damage to surrounding tissues9. The significant improvement with plane exposure for the indirect technique further emphasises the need for training to gain confidence.

The ZoC, marking the sentinel vein, was at increased risk in the indirect approach, consistent with previous research10. Caution is advised during dissection in this area, particularly when extending incisions, due to this risk.

REFERENCES

Post procedure measurements:

The temporal branch of the facial nerve (TBFN) and frontalis were measured to the midpoint of the lesion and of the incision. OO depth was measured using callipers, from the skin to muscle. Operative time was measured. After the procedures, ease of exposure to cyst and planes, cyst rupture, and harm to adjacent structures were graded. Self-scoring and observer score sheets were completed after each treatment and after the skin flap.

alternative approach for frontozygomatic dermoid cyst excision. Ann Plast Surg 44, 591-4; discussion 594-5.

5 - GUR, E., DRIELSMA, R. & THOMSON, H. G. 2004. Angular dermoid cysts in the endoscopic era: retrospective analysis of aesthetic results using the direct, classic method. Plast Reconstr Surg, 113, 1324-9.

6 - KÖSE, R. & OKUR, M. I. 2009. Comparison of superior eyelid incision and directly over the lesion

Though not statistically significant, cyst rupture was higher with the direct approach; this aligns with other literature4, 11, 12. Cyst rupture can lead to infection, an increased risk of recurrence, inflammation and in rare cases an oculomotor palsy, and so affects patient outcomes3, 12, 14, 15 .

CONCLUSION

No superior procedure was found with our study. The direct approach was faster. The indirect approach improved and so may be comparable with training. Both approaches had equal risk to structures like TBFN, but the indirect approach posed risk to the sentinel vein. The indirect approach showed lower cyst rupture and ease of exposure to planes. Overall, the indirect procedure has no increased risk. Further studies are needed with greater sample size for definitive conclusions.

Figure 1: Showing surface anatomy markings. Pitanguy's line (TBFN) in blue. The ZoC, location of the sentinel vein, in red. The cyst is circled, with a dot at its midpoint.

2: Illustration of the indirect incision (left) and of the options for direct incision (right): supra, infra, and through-brow incision.

3: Graph showing the average operative time for the direct approach vs indirect.

Figure 4: Graph showing the average scores for exposure to surgical planes.

Clinical Problem

This is a case of 24 year old, male came with difficulty of breathing. Patient had a history of Bronchial Asthma, family history of Pott's Diseaseanda9packyearsmokinghistory.

THE GREAT MIMICKER

Salient Features

2yearsPTA,thepatientsufferedfrom intermittentepigastricpainandvomiting butsoughtnoconsult.7monthsPTA, therewashoarsenesswhichwas diagnosedaslaryngopharyngealreflux.6 monthsPTA,FLwasdonewhich suspectedalaryngealmasswithan improvementinhishoarseness.3weeks PTA,thepatientwascomplainingof wheezingandwasworkedupfora probableTB.Onthedayofadmission,the patient'schiefcomplaintwasasudden onsetofdyspnoea.

HistoryofPresentingIllness Pathophysiology

Increasing the number of referrals made by care coordinators in a community mental health team

Nashra Maheen¹, Olivia Parkinson¹, Hollanda Babbington¹, Dr Stelios Orfanos²

• The Croydon Central Locality Team is facing a high caseload with a poor doctor to patient ratio (2 consultants organizing the flow of 450 patients with 14 care coordinators).

• Our initial research showed that care coordinators were unaware of resources directing them to potential third – party organisations and this is important to avoid re-presentation of patients into the system.

• Our primary aim: 50% of discharges from the team to be discharged with a referral or signpost to third sector organisations within 1 month prior to the discharge date and in turn we aimed to reduce the caseload.

BACKGROUND METHODS

• Cause and effect diagram drawn out to identify what factors were leading to the high caseload within the team – this showed current resources highlighted outdated referral pathways

• 6 weeks of baseline data was collected

• PDSA 1: Initial introduction of the flowchart, distributed via email

• PDSA 2: Improved version of flowchart distributed via email with verbal and email reminders

• PDSA 3: Flowchart uploaded to a central Microsoft Teams page with reminders and posters

• Total data was collected over 20 weeks and the project ran from October 2022 –February 2023

RESULTS

• Our goal was met on 7 occasions. For 10 data points, 6 runs were identified which overall indicated that there was no change of statistical significance.

• Reported use of the flowchart increased from 12.5% after PDSA 1 to 62.5% after PDSA 3 and there was no reported increase in workload due to our intervention

DISCUSSION

•Changing the culture within a workplace and maintaining engagement from care coordinators was difficult which our project relied on heavily

•A longer timeframe was needed – guidelines suggest projects should run for 6 months to see results of significance (RCGP, 2015)

•In the future, the flowchart can be edited online and updated to reflect the latest services. Its use can be increased to PDP meetings with integrated links to referral forms. Dissemination of a similar flowchart to other sectors within the NHS would help to tackle a system wide problem and may be of significance to clinical directors.

ACKNOWLEDGEMENTS AND CONTACT

This project was undertaken as part of the Year 4 Quality Improvement Project module at GKT School of Medical Education.

nashra maheen@kcl ac uk

Twitter: @NashraMaheen306

Safety first: Improving Staff Safety Huddles to Reduce Violence on a Medium-Secure Psychiatric Ward

Authors: Priyanka Trivedi1, Joseph Vayalil Lawrence1 ,Walid Anwar1, Kaisha Patel1 , and Dr. Anil Kumar2

Overall incidence of violence

Background

Violence on forensic psychiatric wards is not well-researched. One study found 70% of staff had been assaulted over 12 months (Kelly et al., 2015, Journal of Advanced Nursing), leading to profound psychological effects (Needham et al , 2005, Journal of Advanced Nursing) Thames ward (Bethlem Royal Hospital) is a medium-secure forensic unit with a median of 2 violent incidents per week (including physical aggression, verbal aggression and near misses)

What are safety huddles?

Safety huddles (SH) are different from a handover as they are intended to be fast and informal. The purpose of the huddle is to allow staff to freely express opinions on patients relevant to the topic of the huddle. This facilitates a collaborative approach to managing aggression on a forensic ward. On Thames Ward there is a daily staff safety huddle following the afternoon safety huddle

Pre-intervention staff survey

A survey revealed that the primary issue with the huddles was the lack of attendance, particularly from non-nursing disciplines. Some staff were not even aware the huddles were occurring. Overall, the effectiveness of the huddles in mitigating violence on the ward was perceived to be limited.

Aims

Our aim was to reduce the median weekly incidence of violence on Thames ward by 50% during our 13-week intervention period during which we tried to improve staff safety huddle awareness and attendance.

Methods

PDSA 1: Creating a weekly huddle attendance sheet which allows staff to track numbers of different MDT members that attend the huddle each day

PDSA 2: Whole ward email bulletin reporting results of preintervention questionnaire and remind them of the importance of the huddle

PDSA 3: Set the Wednesday safety huddle timing to 2pm - this was the most suitable time for medical staff (consultant and SpR) to attend

Outcome measures

Our primary outcome was the incidence of violence, including physical, verbal and near misses. This data was collected via Datix and safety cross records Our secondary outcomes were safety huddle attendance and perceived effectiveness in reducing violence This was measured using the daily attendance form as well as pre and post intervention surveys to evaluate staff perception.

Data was collected from 1st August 2022 to 6th February 2023.

A run chart demonstrating the effect of the planned interventions on the overall incidence of aggression in a high-security psychiatric forensic ward. Median incidence of violence per week (IQR) was 2 (1-3) over the 28-week period from the week commencing 28th August 2022. Interventions were implemented in week 16 (PDSA 1), week 20 (PDSA 2) and week 25 (PDSA 3)

Median incidence of violence and aggression during the intervention period (week 16 to 18) was 1 (IQR = 1-2) compared to a pre-intervention median of 2 (IQR = 1-3)

Safety huddle attendance from Nov 2022 to Feb 2023

Implementation

Limitations

PDSA 1 was introduced but staff did not implement change

We carried out a ward visit and spoke to ward manager to ensure it was fully implemented

As a medium-secure unit ward visits were not straightforward and required extra considerations

Thames Ward has a high administrative workload so there was concern that we were adding to this

However this also means they were good at filling our form from PDSA 1 after further encouragement

Barriers

1. Extra paperwork deterred staff

2. Variable timings of the huddles

3. Strong reliance on pre-existing ward guidelines regarding safety huddles

4. Not all incidents reported via Datix as it can be timeconsuming

5. Most data kept as hard copies on the ward – which is difficult to access as it is a medium-secure unit

Discussion and future work

The safety huddle takes place on an informal basis – it has no fixed time As predicted, form uptake was initially poor However, after further encouragement we found that they were filled out consistently from 26/11/22 to 01/01/23, albeit not always accurately

The pre-intervention questionnaire revealed themes such as staff not being aware that there is a daily SH, and not believing that the huddle is effective. The post-intervention questionnaire showed that all respondents were now aware of the huddle, so it is possible our project contributed to improved awareness.

Perceived effectiveness of safety huddles

Staff members also try to attend huddles remotely, even when they are not working, as being aware of aggressive patients contributes significantly to personal safety The huddle also occurs between the morning and afternoon shift handover resulting in difficulty for all staff to attend simultaneously, as this means removing all nursing staff from the ward floor. This is not feasible, particularly on a forensic ward. Methods to update staff who cannot attend with information shared in the huddle should be considered going forward.

Although it is unclear whether our interventions affected the overall rate of violence, it has identified several barriers to this, especially with regards to the SH which can be used as starting points for further interventions to maintain improvement

1. GKT School of Medical Education, King’s College London.

2. South London and Maudsley NHS Foundation Trust

Aiman Ibrahim¹

¹ Kings College London

inflammatory diseases

Introduction

Herbal medicine is thought to be a great untapped resource for novel pharmaceutical preparations.

This study looks at the herb Justicia adhatoda L ( J.adhatoda), popular in Ayurvedic medicine, assessing its anti-microbial and anti-inflammatory impact alongside mechanisms of action in controlled environments.

Methods

A literature review was performed on articles mentioning the anti-microbial, anti-inflammatory or anti-cancer uses of J.adhatoda from 2011-2022 (Figure 1)

Synonyms of the herb such as Vasaka or Malabar nut seen on ‘plantlist.org ’ were used to find relevant research.

References of the articles were also reviewed to maximise the inclusion of key studies and mitigate against misspellings.

Pubmed search term

Results (continued)

Pro-inflammatory cytokine reduction of IL-6 and TGF-β1 alongside TNF-α and COX-2 was seen in animal models and invitro studies respectively [3,4]. J.adhatoda’s effectiveness against various cancer cell lines was also shown through proposed inhibition of JAK2/STAT3 signalling [5].

Key active components of the herb include alkaloids such as vasicine, vasicinone and 2-acetyl benzylamine.

Discussion

Components of J.adhatoda such as vasicine and vasicinone have shown to reduce inflammatory mediators involved in acute, allergic and autoimmune inflammation in in-silico and in-vivo studies. Their involvement in the inhibition of key pathways such COX and 5-LOX (Figure 2) highlight the herb’s pharmaceutical potential in dampening inflammation.

Discussion (continued)

Despite little research on the anti-bacterial and anti-fungal mechanisms of J.adhatoda its wide range of effects against various strains showcase its antimicrobial therapeutic potential. [6,7,8].

However, at the moment it is difficult to assess the exact effects of J.adhatoda as each study uses different preparations, dosages and measures effects against different microorganisms. As a result, this review used in-silico studies in an attempt to reduce confounding variables and identify potential mechanisms of action and true efficacy of the herb.

Furthermore, many studies didn’t meet the all the desired quality control measures such as:

• Authentication of the plant

• Having positive and negative controls

• Clear Methodology

81

J.adhatoda and its components have anti-proliferative effects against various cancer cell lines. Its component 2-acetyl benzylamine is shown to be effective against leukaemia cells lines via inhibition of JAK2/STAT3 signalling (Figure 3). Therefore, the herb may also possess modulatory properties on immune mediated inflammation and proliferation [5].

*These articles and their references were used to find key studies which have all been included and referenced in tables throughout the review.

Results

After discarding duplicates, 21 out of 81 articles met the inclusion criteria. Articles mainly consisted of in-vitro and insilico studies of J.adhatoda and its components.

Its preparations had wide anti-microbial action similar to control penicillin formulations [1]. Effects against Influenza and COVID19 were reported with docking studies highlighting antiviral targets [2,3].

Figure 2 illustrates COX and 5-LOX pathways inhibited by components of J.adhatoda

Figure 3 illustrates JAK receptor signalling which J.adhatoda molecules have been exhibited to inhibit. NK: Natural killer, Treg: Regulatory T cells

More uniformity is needed between methodology of different studies to confirm the true potency of anti-inflammatory and antimicrobial effects of different J.adhatoda preparations.

Conclusion

This literature review, highlights J.adhatoda as having various anti-infective and anti-inflammatory properties highlighting its wide therapeutic potential. Research has found COX and JAK inhibition to contribute to the herb’s anti

Studies in this review should be tested for reproducibility at a larger scale to isolate active components that have the greatest potential to be novel anti-inflammatory agents.

References

Please scan the adjacent QR code to visit list of references and

PGI/PGE: Prostaglandins, LTB/C/D: Leukotrienes

Introduction

Gleamer was established in 2017, and its first prototype, Gleamer BoneView (GBV), was developed in 2018, to assist detecting fractures on X-rays. In 2023, it received European Union Medical Device Regulation clearance Recently, GBV became the first Artificial Intelligence (AI) system to receive FDA clearance for fracture detection in children

The orthopaedic department at the Milton Keynes University Hospital adopted the GBV system in February 2023, replacing the 'Red Dot System,' which was based on analyses made by the team of fifty-one radiographers.

Objective

This study investigates the accuracy of the GBV system in detecting lower limb fractures in children, compared to the previous 'Red dot system.'

Methods

Study group: The X-rays were assessed by the AI GBV system. It includes 350 X-rays, taken between the 1st of February and to 31st of March 2023.

Comparative group: The X-rays were assessed by the ‘Red Dot system.’ It includes 297 X-rays, taken between the 1st of November and to 31st of December 2022.

Eight radiographers were the 'reporting radiographers' of the team of fifty-one, who participated in the Red Dot System. These reporting radiographers are trained to write a descriptive report on each X-ray

The reporting radiographers’ written reports were used to assess the accuracy of the diagnoses provided by both the GBV and the Red Dot systems.

Exclusion criteria

• Absent written reports

• Congenital and other joint pathologies such as Perthes and osteochondritis

• Soft tissue pathologies

• ages <4 and >15 years old

Inclusion Criteria

• Study group: includes Xrays assessed for fractures and joint effusion

• Comparative group: Includes X-rays assessed only for fractures.

Conclusion

Results

• The new GBV system showed higher accuracy in identifying fractures on X-rays compared to the red dot system.

• 3.4% of the fractures were missed by the GBV system.

• 4.7% of the fractures were missed by the Red Dot system.

• The GBV system has higher sensitivity for detecting paediatric lower limb fractures than the red dot system.

• The Red Dot results coincided more closely with the reporting radiographer's findings than the results from the AI

• Most of the mismatches between the GBV system and the written reports were due to false positive results in the GBV system

Implications

• Further improvements could be made in the GBV system to increase the specificity of detecting fractures.

• GBV could be recalibrated to recognise secondary ossification centres as a normal feature in paediatric patients.

• GBV could be programmed to avoid recognising artefacts in X-rays such as casts as pathology.

• More research is required in this new and promising field in Orthopaedics and Radiology

Accuracy of an Artificial Intelligence system (GLEAMER BoneView), for the detection of paediatric musculoskeletal fractures in the lower limb compared to the reports produced by radiographers

Akriti Karki, Danielle Furness and Mr Nikos Reissis

Improving the implementation of

Patient-Initiated Followup (PIFU) Appointments in the Type One Diabetes (T1DM) Department at King’s College Hospital (KCH)

Priyanka Iyer1, Aribah Naveed1, Rahul Goel1, James Tang1, Dr. Sophie Harris2 1GKT School of Medicine, King’s College London; 2King’s College Hospital

INTRODUCTION

• Patient-initiated follow-up (PIFU) is when a patient requests a follow-up appointment based on a change in their symptoms and/or circumstances instead of booking in traditional regular follow-ups.

• Suitable PIFU patients include those with stable and uncomplicated T1DM

• PIFU empowers patients, increasing satisfaction while reducing Do Not Attends (DNAs) and managing case loads, therefor benefiting the patient, clinician and the hospital.

• PIFU is part of the 2022/23 Operational Planning Guidance.

AIM

To increase the number of patients placed on the PIFU pathway from 0 to 44 (2.5% of the total 1760 patients) in the type 1 diabetes mellitus (T1DM) department at King’s College Hospital by 14th February 2023.

METHODS: PDSA Cycles

PDSA1 Amended T1DM outcome form to include PIFU options so that patients could be discharged to this pathway.

RESULTS

Run chart showing number of patients discharged to the PIFU pathway per week. The median was 1 and the goal was 2 patients being placed on PIFU per week. A total of 19 patients were discharged to PIFU.

DISCUSSION & CONCLUSION

Although we had a SMART goal, we were unable to meet our goal, perhaps as our interventions were not particularly sustainable. Our interventions can be scaled up easily to other departments though, especially the poster and website changes.

Challenges

Next Steps

PDSA2 Created posters on PIFU, its benefits, patient eligibility criteria and the new outcome form to spread awareness. These were put up around the doctor’s offices and emailed out in the fortnightly newsletter.

PDSA3 Delivered a presentation in the virtual morning meeting to create awareness around PIFU and answer any questions the clinicians had regarding the process.

PDSA4 Made a draft of changes to the KCH Diabetes website so that it could include information of PIFU and relevant contact details for patients to contact if needed. This was incomplete due to IT issues.

References

Updating the website and getting patient feedback

Speaking to other departments that have successfully implemented PIFU

Compiling list of eligible patients and creating refresher presentations

NHS 2022a. 2022/23 priorities and operational planning guidance. Version 3, 13.

NHS 2022b. Implementing patient initiated follow-up. Guidance for local health and care systems., 5.

Comparing

Bea Duric1

Barts Cancer Institute, Queen Mary University of London, London, U.K.1

Introduction

• Large abdominal aortic aneurysms (over 5.4 cm in diameter) should be surgically excised to prevent fatal rupture

• Elective AAA repair is performed either via open or minimally invasive surgery, with endovascular aneurysm repair (EVAR) considered the gold standard in the UK

• Laparoscopic surgery, notably hand-assisted (HALS) and total laparoscopic surgery (TLS) emerged in the 90s as alternatives to EVAR for elective AAA repair

• HALS and TLS have been very slow to develop in the UK and are not offered on the NHS

• Though a lot of evidence exists favoring EVAR over open surgical repair in terms of post-operative complications and inflammation, not many studies have compared EVAR with HALS and TLS

• EVAR is associated with high post-operative reintervention rates due to endoleak and poor long-term graft patency

• TLS and HALS are associated with better long-term graft patency rates than EVAR, with similar mortality and morbidity

• TLS and HALS are more cost-effective than EVAR, and may be better suited for patients with anatomical variations

• NICE guidelines may benefit from including other minimally invasive techniques for elective AAA repair

Objective

To compare the mortality and post-operative reintervention rates of patients undergoing HALS, TLS, and EVAR for elective treatment of AAA. This is to inform NICE guidelines.

Methods

MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Library were searched between January 2023 and March 2023. Cohort studies and RCTs comparing at least 2 of the 3 minimally invasive techniques were eligible. Chi-squared and Kruskal-Wallis tests were used to test for association. Cramer V and epsilon-squared tests will be used for effect size.

Results

8 cohort studies and one RCT were included. A total of 500 HALS, 263 TLS, and 438 EVAR patients were included in the statistical analysis. Studies comparing both primary outcomes (mortality & reintervention rates) were included. Secondary outcomes like surgical duration and intraoperative blood loss were also evaluated.

Discussion

• Mortality

• In-hospital, 30-day, and 1-year mortality did not differ among the 3 groups

• Reintervention rates

• TLS had the highest rate of 30-day reintervention rates (χ2= 14.94; p=0.00056; φ=0.11)

• HALS and EVAR did not differ between themselves in 30-day reintervention rates (χ2= 0.089; p=0.765)

• 1-year reintervention rates did not differ (χ2= 5.16; p=0.0755)

• Duration of surgery

• TLS had the longest surgical duration (χ2= 6.936; p=0.0311; φ=0.409)

• Conversion to open surgery

• TLS had the highest rate of conversion to open surgery intraoperatively whereas EVAR had the lowest (χ2= 44.749; p<0.001; φ=0.221)

• Blood loss, transfusion volume

• TLS had the most intraoperative blood loss and the highest transfusion volume; the results did not reach statistical significance, but the effect sizes were large

• Length of ICU stay, length of hospital stay

• TLS had the longest ICU stay; the result did not reach statistical significance, but the effect size was large. Length of hospital stay did not differ.

• Major complication rates

• Post-operative complication rates did not differ

Clinical Implications

• HALS and EVAR had the most similar clinical outcomes

• 1-year reintervention rates and mortality did not differ across the 3 groups, suggesting that laparoscopic aortic surgery is a safe and efficacious alternative

• TLS may be less suitable for more frail / unwell patients, although it is possible that these limitations are the result of a steep learning curve as opposed to a fault of the technique itself

• Laparoscopic aortic surgery is a more cost-effective solution and should be offered as a first-line treatment alongside EVAR for elective AAA repair

Conclusions

• This systematic review finds that TLS had the least favorable clinical outcomes overall; however, all 3 techniques were comparable in terms of mortality and long-term surgical reintervention rates

• Further research with a larger sample size and a longer follow-up is needed to establish safety and efficacy across all 3 groups

the clinical outcomes of laparoscopic surgery, including hand-assisted and total laparoscopic surgery, versus endovascular aneurysm repair for the elective treatment of abdominal aortic aneurysms: A Systematic Review

Background

A Cross Section of Treatment Escalation Plans in Trauma and Orthopaedic Patients

Results

Trauma and Orthopaedic patients at St Helier Hospital are almost always acute admissions. They have multiple co-morbidities, such as Chronic Kidney Disease, Hypertension and Frailty. Prior to crisis, treatment escalation decisions, regarding ceiling of care are to be made.

This could involve the use of a DNAR form, however this is only a part of it.

Standard

Treatment Escalation is documented on a Personalised Treatment Escalation Plan (PTEP). Trust’s guidelines indicate that all patients should 1) Have a PTEP form placed at the front of the medical notes; 2) which is completed within 72 hours of admission and 3) the decision should be communicated to the patient, their family and the staff involved in the delivery of care.

PTEP allows for clear discussion of ceilings of care, for example escalation to HDU/ITU if required and the use of NIV. This is an invaluable resource during medical emergencies.

Aims

1) To audit the completion of PTEP forms in Trauma and Orthopaedic patients (Cycle 1)

2) To see if the implementation of a proforma will improve the completion of PTEP forms in this cohort (Cycle 2)

3) SMART Aims:

a) S - the number and average ages of patients and their treatment escalation status

b) M - measurable through looking into patient’s clinical notes

c) ART - achievable through taking a short sample of days and doing it in real time

Figures

Methods

Our initial PDSA cycle involved assessing how many orthopaedic admissions had PTEP forms completed to the standard of trust guidance, between 11-19th January 2023. A ‘C.O.W. proforma’ (Figure 1) was then implemented to the inpatient list, reminding foundation doctors which patients had a valid PTEP forms and a PTEP champion was appointed, after which data was resampled from 27th February – 3rd March 2023.

Conclusions

In the initial cycle 59 patients were sampled and 39 patients were sampled in the 2nd cycle. Results showed a statistically significant 41% (P<0.0001) increase in the number of PTEP forms signed and a 16.7% increase in those signed by a consultant in the first 72h of admission. Going forward, this data will be reaudited to see if the intervention has been sustainable, in order to improve patient-centred care.

Next Steps

Going forward, the allocation of a PTEP champion to each team can be implemented, in order to ensure that a junior is making sure that PTEP forms are signed. Furthermore, more Involvement of the MDT to note when PTEPs are not signed can be used to increase accountability.

Other ideas, such as a proforma behind the bedside to mark PTEP status, , Day 1 post-op review and post-op XR has been done.

Chirag Rao1, Nikhil Pattani1, Laid Habes1, Jessica Flanagan1, Genevieve Lawrence1, George Turner1, Jonathan Craik1, Markus Baker1

Introduction

Investigating the incidence of hypertension in patients with high blood pressure readings through student-led clinics

Sheveen Wijesuriya, Samarth Saxena, Vidisha Handoo, Raj Vaghela, Rishik Pilla, Tahia Hussain, Zahra Aynee FareedAslam, Sathana Inpakumar, King’s Undergraduate Medical Education in the Community team, Dr Minato Hata

Aims/Objectives

2 Simultaneous Goals

1. Patients: Improve health outcomes for patients with high BP readings

2. Medical students: Improve communication & confidence during patient interactions

Method

Before our clinics, we used EMIS to compile a list of patients with previous BP readings and invited them to our clinics

▪ During our clinics, we measured BP, calculated BMI and discussed lifestyle factors as pairs

▪ Estimated 1.28 billion people with hypertension [1]

▪ Only 42% of cases are diagnosed

▪ As 2nd year medical students, we investigated hypertension incidence through student-led clinics at our longitudinal GP placement

▪ Early prevention through modifiable lifestyle changes is essential to limiting complications such as cardiovascular disease and stroke [2]

References

(1) - World Health Organisation (WHO) (2023) [Online] Available at: https://www.who.int/news-room/fact-sheets/detail/hypertension

(2) - GOV.UK, Public Health England (2017) [Online]. Available at: https://www.gov.uk/government/publications/health-matters-combating-highblood-pressure/health-matters-combating-high-blood-pressure

- Graphics and images from Canva

To learn more about our project

Outcomes

▪ Patients taking increased ownership of their health

o Tailored to their work schedules

▪ Increased confidence as medical students at an early stage of our careers

o Putting us in good stead for future clinical practice

Discussion

Limitations/Challenges

▪ Small sample size

▪ Navigating discussions about weight

How we overcame the limitations

▪ Shortening slots from 30 mins to 20 mins for more patients to be seen

▪ Reflective diary for personal & professional growth

Future improvements

▪ Questionnaire for medical students

▪ More quantitative questions in patient questionnaire

▪ After our clinics, we collected patient feedback via anonymous questionnaires, wrote reflective pieces and had supervisory debriefs

▪ Completed 2 PDSA cycles

▪ An Excel sheet tracked patient management, including home BP monitoring, appointments, hypertension diagnoses, and medication provision

Results

How much did the consultation inform you about lifestyle changes you can make?

▪ Our clinics resulted in 12% of our patients being diagnosed with hypertension and initiated on pharmacological management

▪ We identified 14 patients requiring further interventions

Building the Surgeons of Tomorrow: Assessing the impact of transitioning from Traditional to Technology-Based Anatomical teaching for Surgical Practice

Authors- Nafisa Zilani, Hayyan Khan

Affiliations- GKT School of Medical Education Email of Corresponding

Author- nafisa.zilani@kcl.ac.uk

Introduction

Anatomy, a fundamental subject in medical education, plays a crucial role in developing surgical skills and knowledge. Traditional teaching methods in anatomy, such as textbooks, lectures, and cadaveric studies, have been the cornerstone of medical education for decades. However, rapid advancements in technology have now introduced novel teaching methods, including ‘Three Dimensional Printing’ and ‘Virtual Reality’, which have the potential to revolutionise anatomical education (Khot, et al., 2013).

A study was conducted to investigate the impact of technology-based teaching on surgical practice by evaluating the perceptions of medical students and junior doctors before and after attending a surgical anatomy conference.

The conference hosted a series of technology-based teaching lectures and workshops and acted as an intervention for our study, to see if perceptions had changed.

Results

The results showed a significant increase in agreement that technologybased teaching methods are more beneficial in preparing for future surgical practice than traditional methods (p = 0.0000065). However, there was no significant increase in agreement that technologybased teaching methods are overall effective for future surgical practice (p = 0.09).

Discussion

Conclusion

To assess the impact of technology-based teaching methods on surgical practice by evaluating the perceptions of medical students and junior doctors before and after attending a surgical anatomy conference.

Aim Methods

The King’s College London Anatomy Society organised a national conference on the theme of Future of Surgical Anatomy consisting of talks and workshops, giving exposure to technologybased teaching methods of anatomy. 84 attendees filled out pre- and post-event questionnaires assessing effectiveness of traditional versus technology-based methods of teaching anatomy for future surgical practice surrounding the application process and potential career paths for their given course.

This was assessed using a 5-point Likert scale and scores were assessed for normality via the Shapiro–Wilk test; a one-tailed test was used to assess statistical significance.

The findings of this study provide valuable insights into the impact of technology-based teaching methods on surgical practice, as perceived by medical students and junior doctors. as it demonstrates a significant increase in agreement among the attendees that technology-based teaching methods, including 3D printing and Virtual Reality.

This shows that they may be perceived as more beneficial in preparing for future surgical practice compared to traditional methods which suggests that these innovative tools have the potential to enhance the acquisition and application of anatomical knowledge, thus positively influencing surgical skills and patient outcomes.

However, it is worth noting that although there was a significant increase in agreement regarding the benefits of technology-based teaching methods, there was no significant increase in agreement regarding their overall effectiveness for future surgical practice. This discrepancy may indicate that while attendees recognize the advantages of these methods, they may still have reservations about their comprehensive impact on surgical education.

It is possible that participants may have concerns about the reliability and accuracy of the technology, potential limitations in simulating complex surgical scenarios.

Further evidence and research to support the widespread adoption of these methods is required as a result.

In conclusion, the findings of this study highlight the positive impact of technology-based teaching methods on surgical practice as perceived by medical students and junior doctors.

While attendees recognize the benefits of these methods in preparing for future surgical practice, further research is needed to fully convince the medical community of their overall effectiveness.

Nonetheless, these preliminary results lay the groundwork for future investigations that will contribute to the ongoing development and integration of technology-based teaching methods in surgical education.

References

Khot, Z., Quinlan, K., Norman, G. R., & Wainman, B. (2013). The Relative Effectiveness of Computer-Based and Traditional Resources for Education in Anatomy. Anatomical Sciences Education, 6(4), 211-215.

Acknowledgements

We extend our thanks to all the members of FSA Conference Committee as well as volunteers for their help in making this conference successful.

IMPLEMENTATION OF “PREP FOR PREM: NEONATAL OPTIMISATION FOR BABIES BORN BEFORE 37+0

WEEKS”

BACKGROUND

• Prematurity is the leading cause of neonatal morbidity and mortality(1).

• Evidence-based interventions including antenatal corticosteroids, magnesium sulphate, intrapartum antibiotics and optimal cord management can reduce adverse outcomes(2,3).

• Despite this, baseline compliance for these interventions at Medway Maritime Hospital is poor, achieving 35%, 84%, 48%, and 27%, respectively.

AIMS

1. Develop a stakeholder-approved proformacalled “Prem-for-Prem”.

2. Consequently achieve≥90% compliance in all interventionaldomains by February 2023 using QIP (Quality Improvement Project) methodology.

RESULTS

• Patient data (n=87) was collected over 15 weeks from 11th October 2022 to 23rd January 2023, excluding Week 8 as notes from this period were unavailable.

• PDSA Cycle 1 was successful in making a staff-approved proforma.

• Balance measures highlighted by staff suggestions from each PDSA cycle were used to improve the proformas.

METHODS

METHODS

• The proforma was designed by the Foetal Wellbeing Team based on the NHS East Maternity Regional Team’s “Prem 7” education tool (3).

INFORM NEONATAL UNIT Ensu e the Neo a Un a e awa e and

Figure 5. Summary of responses to the question “Do you find this tool useful?" From the PDSA Cycle 1 staff questionnaire.

• There was rise in compliance of the proforma in the week after both pilot and full-implementation by 19% and 40%, with a maximal rise in weeks 9 and 11 by 67% from baseline.

• Of the five interventions, two reached our target threshold –

• Reached threshold: Antenatal corticosteroids (100%) and magnesium sulphate (100%).

• Improved but sub-threshold: IP Antibiotics (80%).

• No change: Optimal cord management.

ed?

22+0 23+6 24+0 34+6 35+0 35+6 ND V DUA P AN COMMENCE CONS DER MD & a en n de p c < +0 s d g en 7 y a an v h k b h 8 M po a ne - o men e s en s c g e p d e s Ma ou o m a o o d o m

3 Do D e T m d o e Da m e d n w h d y - D e

Figure 1. The final “Prep for Prem” proforma updated after PDSA Cycle 3 to be used by staff to optimise the health of prematurely-born babies.

• A QIP was devised to implement this where all 3 PDSA cycles consisted of:

1. Questionnaires to assess staff opinion on preterm optimisation, if staff considered the proforma useful and any improvements they would make.

2. Critical appraisal of the proforma using balance measures highlighted by staff suggestions.

3. Updating the tool further and redistributing it.

CONCLUSION

• This project demonstrates improvements suggesting continued use of the proforma could better clinical outcomes.

• The pro-forma is a promising low social and financial cost print-out that would benefit other hospitals.

• Long-term improvement will be assessed by an audit in six months' time.

REFERENCES: [1] Richter LL, Ting J, Muraca GM, Synnes A, Lim KI, Lisonkova S. Temporal trends in neonatal mortality and morbidity following spontaneous and clinician-initiated preterm birth in Washington State, USA: a populationbased study. (2019) [2] British Association of Perinatal Medicine. Antenatal Optimisation for Preterm Infants less than 34 weeks: A Quality Improvement Toolkit. (2023) [3] NHS South East Clinical Delivery and Networks. PREM 7. (2020)

Stefanie Berkes1, Shivam Chotai1, Pranav Patel1, Rohit Chennupati1, Sarah O'Connell1, Michelle Keeler2, Jordan Rudd2, Sarah Faith2, and Gavin Guy2

1. Faculty of Life Sciences & Medicine, King’s College London, Strand, London. WC2R 2LS, UK.

2. Medway NHS Foundation Trust, Windmill Road, Gillingham. ME7 5NY, UK

Figure 2. Uptake of the “Prep for Prem” proforma.

Figure 3. Run chart of the compliance to intrapartum antibiotics, antenatal corticosteroids, and magnesium sulphate.

Figure 4. Run chart of the compliance to care planning and optimal cord management.

See one, do one

Rohan Bhate, Rahul Ganguly, Rebecca Beni, Konstantinos Devetzis, Noor Haddad, Mona Jaffar-Karballai St. George's, University of London, London, United Kingdom

introduction

Surgical training at medical school is stipulated by both the General Medical Council (GMC, 2022) and the Royal College of Surgeons (RCSEng, 2022) St George’s Surgical Society hosted its annual surgical event ‘See one, do one’ with an emphasis on surgical workshops in the fields of Orthopaedics, General Surgery, Ear, Nose and Throat and Urology led by surgeons in those specialities

AIMS

1 Investigate if a surgical workshop could enhance students’ interest in the specialities

2 Investigate the student's confidence at handling surgical instruments

INSIGHTS FROM A SURGICAL SOCIETY-LED WORKSHOP DAY results

In total, 58 participants completed both questionnaires and consented to the research. 63.8% of the participants identified as women, whilst 362% identified as men. The most common age group was

methods

Pre-conference questionnaire - Demographic data, interest in surgery and specialties (ENT, T&O, Urology and General Surgery), confidence in handling surgical equipment.

Workshop day: participants had 1.5 hours to practice bowel anastomoses, laparoscopy skills, orthopaedic skills (arthroscopy, DHS, tibial plating) and epistaxis management

Conclusion

Our surgical workshop has increased the participants' interest in surgery and their confidence in assisting in surgical procedures across different specialities

Post-conference questionnaire analysing the same domains. Likert-scale question responses were analysed using simple t-tests with Welch correction. Free-text questions were converted into specific theme for analysis

WHY THE PARTICIPANTS TOOK PART IN THE WORKSHOP DAY?

Showcase research (5)

Learn practical skills (26)

Gain knowledge about surgery as a career (18)

Already set on surgery (14) Increase surgical exposure (10)

Increasing Venous Thromboembolism (VTE) Assessment Frequency On The Orthopaedic Post-Take Surgical Ward Round

A.Ismail, A.Mavadia, S.Abdi, S.M Chiang, Mr Saman Horriat

• The lack of timely VTE assessment increases the risk of deep vein thrombosis and pulmonary embolism (PE), with PE being the leading cause of preventable in-hospital death.

•Attended the Orthopaedic ward round.

• Pre-intervention data found that less than 30% of patients were assessed for VTE prophylaxis during the Orthopaedic post-take surgical ward round.

•Noted the number of patients where VTE prophylaxis was discussed during the ward round.

Pre-intervention data collection

Day 1-7

• This is a nationwide issue, whereby Orthopaedic surgery represents the leading recipient of VTE-related clinical negligence claims.

• Aim: To increase VTE assessment frequency of Orthopaedic patients during the post-take surgical ward round to 100%, in accordance with NICE guidelines.

Our data shows a total of 21 data points; we achieved an expected number of runs (8), therefore suggesting no significant effect.

No shifts, trends or astronomical points were noted, indicating no significant changes following both PDSA1 and PDSA2. Following PDSA2, our goal of 100% VTE assessment frequency was achieved for 3 ward rounds. However, these improvements were not maintained over time, and the lack of intervention embedding is highlighted by these results.

PDSA1

Day 7-14

•Placed a poster on the door of the Orthopaedic meeting room to remind the team to assess VTE status on the post-take ward round.

•Delivered a teaching session on the importance of VTE assessment in surgical patients.

PDSA2

Day 14-21

• Data was collected from 21 post-take ward rounds over a 20-week time period.

• A sample size of 5 patients per day was chosen, due to daily variations in the number of patients seen (usually between 5-10 patients).

• A total of 105 patients were included in the study.

• Data was calculated as a percentage of VTE assessments performed per ward round.

Principal findings: This QIP did not successfully maintain increased VTE assessment frequency over time. The lack of intervention embedding could be attributed to: frequent staffing changes, resistance to change from Consultants, and most importantly, the absence of a uniform template/structure leading to inconsistencies.

The most important lesson learnt from this QIP is the presence of many inadequacies in the Orthopaedic post-take ward round. This highlighted the importance of frameworks to standardise patient care and to improve awareness of the delegation of roles and responsibilities that may become unclear, especially among larger multidisciplinary teams.

Sustainability: VTE can be responsible for high morbidity and mortality rates, increased hospital stay and ongoing complications such as post-thrombotic syndrome. From 2012 to 2022, VTE injuries cost the NHS over £23 million. Increasing VTE assessment frequency will mitigate these negative outcomes.

Future direction: We plan to upload the Surgical Assessment For Emergencies (SAFE) ward round tool onto hospital software for Orthopaedic team access. This would be a tremendously sustainable intervention, with no additional environmental implications, zero cost, and the potential to spread to other departments and contexts.

1. Background

2. Methods

Figure 1: Run chart demonstrating the percentage of patients who received VTE prophylaxis assessment during the posttake ward round.

Figure 2: Trends identified on the Run Chart from Figure 1.

3. Results

4. Discussion

Experiences and Perspectives of Users of Period Tracking Apps: Data Input and Attitudes

• Period tracking apps are increasingly popular - they are the 4th most popular app among adults (1), and 50 million people around the world have already downloaded one (2)

• The apps use a calendar-based algorithm to predict menstrual cycle dates (3), but few use evidence-based methods of period tracking (1)

• The main reason for using these apps is tracking period start dates, with the second most common reason to avoid pregnancy (4,5)

• This project looked at the responses from the Broad et al., 2022 (5) survey on feelings towards period start date predictions.

➔ What apps the participants used

➔ Typical data input by participants

➔ Frequency of/changes in data input by participant

➔ How the participants value/trust the data that the apps provide them

Methods

50 open-ended and multiple-choice questions covering:

Demographics

Menstrual Cycle Characteristics

Menstrual Health Education

Themes

Data Entry

Quantitative

Mean

Standard deviation

Percentage of participants

Data Analysis

Qualitative

Thematic Analysis

Period start date predictions

Symptom tracking and general health

Fertility tracking

Concerns about data and costs

● 83.0% of participants felt their period tracking app helped educate them on their menstrual cycle

● May combat previous lack of education on menstrual health, but currently many lack evidence-based methods

● Enable empowerment over menstruation and general mental and physical wellbeing

● Main drawback is inaccuracy in accurately predicting cycle dates

● Only 2.6% of participants entered data biological markers of ovulation

● 73.3% of participants do not trust or only partly trust the data that is provided to them in their period tracking apps

● Period tracking apps deceive their users, causing potentially serious implications

● Automated data entry would make data input easier and more regular

● No clarity on how personal data is used or shared by the apps

● Exclusionary design centred around cisgender, heteronormative women

● Analysis of full data set

● More large scale analysis of period tracking apps

● More education onmenstrual health

● Clarity on data privacy

● New,inclusive, genderneutral designs

Uma Patel,Anna Broad, Rina Biswakarma, Joyce C Harper UCLInstitute

Health, 86-96 Chenies Mews, London, WC1E 6HU, UK

Moglia, M.L., Nguyen, H.V., Chyjek, K., Chen, K.T. and Castaño, P.M. (2016). Evaluation of Smartphone Menstrual Cycle Tracking Applications Using an Adapted APPLICATIONS Scoring

Figure 1. Data Output VS Data Input

Figure 2. Attitudes to Data Input

A proposal for the use of invasive/non-invasive biomedical sensors in a ‘wireless on-body sensor network’ to aid diagnoses on the fly

Sivan Hamda, University of Buckingham Medical School, England, UK

Abstract

With advances in wireless technology, this report proposes a Bluetooth networking system of wireless on-body biomedical sensors that will provide continuous monitoring of bed bound patients. The sensors included in this proposal utilise two key concepts; they measure a particular physiological parameter(s) that is essential to a whole diagnosis, and they include BLE4.0, NFC or ZigBee connectivity, enabling wireless communication.

Introduction

The application of biomedical sensors has been vital in assisting healthcare professionals. The fundamental principle of any medical sensor is the ability to detect/measure a particular physiological parameter and transmit this information to a monitoring/analysis hub. Biomedical sensors aim to be unobtrusive, operator friendly, secure and reliable. During the literature research such considerations were key in ensuring viability of a cohesive system.

Literature

Conclusion

The proposal for a wireless network of on-body sensors, spanning multiple physiological parameters has potential to aid monitoring and diagnostics. In clinical practise such sensors would discover illness before it manifest itself in a more serious form. I have come to understand that the NHS Innovator Accelerator programme supports innovative ideas, this project could be a suitable candidate for such a programme .

The proposed ‘wireless on-body sensor network’

Respiration

Fall detection system (FDS) (C) Digital tilt sensor, accelerometer sensor, shock sensor.

Skin surface temperature and pressure

IEEE 802.15.4 (ZigBee) 62 days

NFC Induction Battery free sensor Entire body (Non-invasive)

waist (Non-invasive) Body temperature and pressure mapping (D)

Wrist ECG2 (E) ECG, cardiac electrical activity BLE 4.0 30 days Wrist (Non-invasive)

CardioMEMS blood pressure sensor (F)

Eversense continuous glucose monitoring (CGM) (G)

Pulmonary artery blood pressure

NFC Induction Battery free sensor

NFC Induction (between chip and external sensor)

Blood glucose level

90 days

BLE 4.0 (between external sensor and monitoring hub)

Table 1: List of sensors and specification

Near pulmonary artery root (Invasive)

Subcutaneous in upper arm (Minimally invasive)

StrongyloidesstercoralisintheUnitedKingdom:a systematicreviewandmeta-analysisofpublishedcases

C. Ozdemir1, A.M. Alam1 , N. Reza2, 1GKT School of Medical Education, King's College London, London, UK 2Institute of Infection, Veterinary, and Ecological Science, University of Liverpool, Liverpool, UK

Background Results

Strongyloides stercoralis s a soil-transmitted intestinal helminth which can cause lifelong infections in humans Symptoms of infection can vary, whilst many may be asymptomatic.

When an infected host is immunocompromised, S stercoralis has the potentia to cause a ‘hyperinfection’ – a life-threaten ng disseminated disease with mortality up to 71% Given treatment with anti-parasitic agents has a high eradicat on rate, successfully screening at-risk groups can reduce the threat of hyper-infection, part cular y in those who may be immunocompromised.

We conducted a systematic review and metaanalysis of S. stercoralis infections reported in the United Kingdom to describe the demographics and clinica features in those with this parasitic infection.

Aims

•The actua prevalence of strongy oides nfect on is estimated worldw de to be 8 1%

•However n the UK, the number of strongyloides infections is unknown and main y seen in migrants and those after travel ing to areas endemic to the disease

•There are currently no studies that have systematically reviewed reports of strongyloides infection w th n the United K ngdom

•Our study aims to help clinical practice by recognising high r sk populations and the symptomo ogy of strongy o des

Methods

•We searched PubMed (MEDLINE) and Scopus for English language peer-reviewed primary research art c es pub ished until 25th January 2023

•Search terms used a combination of the words ‘Strongyloides’ and ‘United Kingdom’

•We included studies which reported cases of S. stercora is diagnosed in the UK, regardless of se ect ve populations.

•Screening of titles and abstracts and subsequent y full-texts manuscripts were undertaken in parallel by two reviewers and conflicts were resolved through consensus Data were then extracted by the two authors

Seventeen studies with 1361 pat ents were ana ysed. The WPP [95% CI] of asymptomatic cases was 31 0% [27 5% - 34 6%, I2=92 3%] The most reported symptoms were abdom na pain (WPP 30.8% [27.4% - 34.3%], I2=91.6%), rash (WPP 28.4% [25.3% - 31.7%), I2=98.8%) and diarrhoea (WPP 9 4% [6.0% - 13.1%], I2=80.7%]). Returning trave lers were more likely to be asymptomatic with a WPP of 44.63% (38.6% - 50 8%), wh lst m grant groups common y presented with abdomina pain (WPP 42 4% [35 1% - 47 9%]) and diarrhoea (WPP 65 3% [25 2 - 96 8%]) Rashes were a frequent comp aint in those diagnosed in the armed forces (WPP 75.3% [70 2%80.1%]). The most common diagnostic modality in reported cases was serology (51.8%), followed by stool microscopy (30.8%). The average eos nophi count was 1.75x109/L (standard dev ation ±1.24x109/L). Of the 478 pat ents followed up, 255 were treated successfully (30 8%) There were only 4 reports of hyper- nfection

Conclusion

1/4 patients within our meta-ana ysis who have a posit ve strongyloides infection are asymptomatic. Therefore, we need to find a good way to th nk of who we shou d screen

The most common symptoms are diarrhoea or a rash. This is non-specif c, and therefore cl nicians should keep strongloides stercora is infect on in mind for at risk populations

There is a difference between the symptoms of migrant and return ng travel ers, so there is no one size fits a l approach for the clinical diagnosis of the parasitic infection

There is not enough information on specific cohorts, such as people iv ng w th HIV infected with strongy oidiasis and those outside of L verpool and London

Developing a Treatment Pathway For Immunotherapy-Associated Endocrinopathies (IAEs)

a. GKT

Introduction

Introducti

A common side-effect of immunotherapy-based cancer treatment is damage to endocrine organs, called immunotherapy-associated endocrinopathy (IAE [1]).

London, London, UK b. Maidstone and Tunbridge Wells NHS Trust, UK

Results

Conclusion and Discussion

The clinicians' survey has shown that most clinicians (95.8%) believe referral pathways will be beneficial (See Figure 2). We found that the majority would prefer these patients to be managed in a multidisciplinary team setup instead of solely by the oncology team (See Figure 1).

Aim: To reduce the number of referrals from the oncology department to the endocrinology clinic due to IAE, whilst maintaining the same quality of patient care.

Methods

We used the Allscripts Sunrise and Patient Administration Systems to read through clinic letters and determine the frequency of hospital referrals (55 patients).

Distributed two questionnaires investigating the referral process.

• The first asked healthcare clinicians about their experiences treating patients with IAE (24 clinicians).

• The second involved phoning the patients to ask about their experiences being referred from the oncology department to the endocrinopathy clinic (17 patients).

We then produced a set of evidence-based clinical treatment pathways drawing from the European Society for Medical Oncology [2] guidelines for managing the most common IAEs.Results

The top 4 most suggested improvements were:

1. Information on how to refer patients

2. Guidance on relevant investigations and their interpretation

3. Guidance on relevant hormone replacement

4. Guidance on how to ask for help/ follow up of these patients

The only positive finding regarding standard of care from our questionnaire was that only two of the patients had the risks of the endocrine side-effects explained to them clearly, and the only topic covered with the other two patients were the sick-day rules.

Therefore, while the oncology team has access to our new pathways, a further review is needed to ensure that this initiative will benefit both the endocrinology team, and oncology teams (See Figure 3). Effective collaboration between these medical specialties will lead to comprehensive and coordinated care for these patients.

References and Acknowledgments

[1] Hattersley R, Nana M, Lansdown AJ. Endocrine complications of immunotherapies: a review. Clin Med (Lond). 2021 Mar;21(2):e212e222. doi: 10.7861/clinmed.2020-0827. PMID: 33762389; PMCID: PMC8002767.

[2] J. Haanen MO, L. Spain et al, on behalf of the ESMO Guidelines Committee. Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. 2022. Acknowledgements

The authors would like to thank Dr Siva Sivappriyan for his supervision and support.

Figure 1. A Pie Chart Illustrating Who Clinicians Believe Should be Involved in the Treatment of IAEs

Figure 2. A Pie Chart Highlighting the Need for a Clinical Referral Pathway

Figure 3. An Exemplar of One Clinical Referral Pathway for Hypothyroidism (Subtype of IAE).

Zaynah Ahmeda , Caitlin Allwina , Natalia Moreira Bargea , James Maddena , and Dr Siva Sivappriyanb

School of Medical Education, King's College

Do you think a streamlined pathway will benefit these patients?

Who do you think should manage these patients?

Documentation of Tourniquet Pressures in keeping with BOAST guidelines

Background and Aims

Documentation of Tourniquet times and pressures is an important aspect in lower limb orthopaedic surgery.

Aim: To investigate compliance of a Major Trauma Centre (MTC) with BOAST guidance on maximum tourniquet pressures in lower limb surgery.

BOA Standards for Trauma & Orthopaedics: Audit Standard: The Safe Use of Intraoperative Tourniquets ● Patients >16 years should have a tourniquet pressure of systolic blood pressure plus 70-130 mmHg for the lower limb and 50 -100 mm Hg for the upper limb.

Methods

At a major trauma centre, we retrospectively collected data on orthopaedic patients who underwent lower limb procedures involving tourniquets use between January to March 2022.

Data included patient-specific risk factors including smoking, peripheral vascular disease and diabetes, tourniquet pressure and time, and initial systolic blood pressure. Prospective data will then be collected on the subsequent patients.

Results

Discussion & Quality Improvement

This audit has demonstrated a consistent mean compliance of 49.3% tourniquet pressures documented as being above the 130mmHg above systolic blood pressure.

Moreover, the audit has concluded that the location of documentation is variable, both spread within operative notes and intra-operative notes.

This investigation has also collected data on tourniquet use in patients with peripheral vascular disease, smoking, T2DM and other cardiovascular co-morbidities; crucial considerations in tourniquet time and pressures in patients at greater risks of cardiovascular complications.

Interventions/PDSA cycles currently implemented:

1. Visual prompts placed in theatres areas with BOAST guidelines (Fig 4:)

2. Incorporation of BOAST guidelines into operative note templates

3. Guidelines and directions for documentation given to SpRs

Conclusions

1. Average 49.3% non-compliance with BOAST guidelines

2. Tourniquet use in patients with peripheral vascular disease, smoking, T2DM used.

3. Location of documentation variable- intra-operative document vs operative note.

BOAST guidelines compliance is currently not optimised at this MTC. There is potential for quality improvement to increase compliance.

Limitations: Lack of clear current recommendation in BOAST guidelines of what time the systolic BP should be measured.

Figure 1: Graph to show co-morbidity variance in patients undergoing tourniquet associated procedures

Figure 2: Bar graph demonstrating pre-intervention location of documentation by month

Figure 3: Bar graph demonstrating pre-intervention compliance with BOAST guidelines

Targeting Nrf2 with 3 H-1,2-dithiole-3-thione to moderate OXPHOS-driven oxidative stress attenuates IL-17A-induced psoriasis

,

,

a China Medical University Hospital, Taichung, Taiwan, b China Medical University, Taichung, Taiwan, c Indiana University School of Medicine, Fort Wayne, IN, USA, d Manchester University College of Pharmacy, Natural and Health Sciences, Fort Wayne, IN, USA, e Aston Medical School, Birmingham B4 7ET, UK, f Asia University, Taichung, Taiwan, * Co-corresponding authors: poyuan@mail.cmu.edu.tw (P.-Y. Wu), hungrongyen@mail.cmu.edu.tw (H.-R. Yen)

Abstract Methods

Psoriasis, a chronic autoimmune disease characterized by the hyperproliferation of keratinocytes in the epidermis and parakeratosis, significantly impacts quality of life. Interleukin (IL)− 17A dominates the pathogenesis of psoriasis and facilitates reactive oxygen species (ROS) accumulation, which exacerbates local psoriatic lesions. Biologic treatment provides remarkable clinical efficacy, but its high cost and unignorable side effects limit its applications. 3 H-1,2-Dithiole-3-thione (D3T) possesses compelling antioxidative capacities against several diseases through the nuclear factor erythroid 2-related factor 2 (Nrf2) cascade Hence, we aimed to evaluate the effect and mechanism of D3T in psoriasis

We found that D3T attenuates skin thickening and scaling by inhibiting IL-17A-secreting γδT cells in IMQ-induced psoriatic mice. Interleukin-17A markedly enhanced IL-6 and IL-8 expression, lipid peroxidation, the contents of nitric oxide and hydrogen peroxide, oxidative phosphorylation and the MAPK/NF-κB pathways in keratinocytes IL-17A also inhibited the Nrf2-NQO1-HO-1 axis and the activities of superoxide dismutase and glutathione peroxidase D3T significantly reversed these parameters in IL-17A-treated keratinocytes ML‐385, a Nrf2 neutralizer, failed to improve D3T-induced antiinflammatory and antioxidative effects in IL-17A-treated keratinocytes.

We conclude that targeting Nrf2 with D3T to diminish oxidative and inflammatory damage in keratinocytes may attenuate psoriasis.

The effect and mechanism of D3T in psoriasis were studied on imiquimod (IMQ)-induced psoriasis-like mouse model, skewed mouse Th17 cells and human keratinocyte HaCaT cells through evaluation of psoriasis severity, histological examination, flow cytometry, cytokine assay, immunoblotting, analysis of oxidative stress and measurement of the oxygen consumption rate

Results

Conclusions

The present study demonstrates that D3T not only inhibits IL-17A by downregulating STAT3 in IL-17Asecreting cells but also decreases OXPHOS-driven oxidative stress and MAPK/NF-κB-dominated inflammation in keratinocytes through activation of the Nrf2/HO-1 axis. Therefore, targeting Nrf2 to diminish oxidative and inflammatory damage in keratinocytes may attenuate IL-17A-dominated psoriasis. In conclusion, our study provides the first evidence for the potential of D3T in the treatment of psoriasis

Highlights

• D3T alleviates IMQ-induced psoriasis-like skin inflammation in mice

• D3T inhibits IL-17A by downregulating STAT3 in IL-17A-secreting cells.

• D3T decreases OXPHOS-driven oxidative stress and MAPK/NF-κB-dominated inflammation in keratinocytes through activation of the Nrf2/HO-1 axis

Chuan-Teng Liua,b, Jui-Hung Jimmy Yenc, Dennis A Brownd, Ying-Chyi Songa,b, Mei-Yun Chua,b, Yu-Hsiang Hunga, Yi-Huan Tange

Po-Yuan Wua,b,*

Hung-Rong Yena,b,f,*

Fig. 1. D3T alleviates dermal psoriasis in mice.

Increasing adherence to BOMSS guidelines for post-bariatric surgery micronutrient optimisation: A closed-loop Quality Improvement Project

N.Limaye1*

Background and Aims

Bariatric surgical procedures have significant impact on postoperative nutrition and dietetics play a crucial role in optimising management. Re-configuration of GI anatomy in bariatric procedures can increase the malabsorption of micronutrients. (MN)

Identifying low MN levels both pre- and post-operatively can help plan and optimise patients’ overall surgical care.

Aims:

1. Retrospectively analyse patients undergoing specific bariatric procedures between 01/09/22- 30/01/23 with low preoperative MN values

2. Comparison with national (BOMSS (MN) guidelines 2014 and 2020)

3. Implementation of 3 Plan-Do-Study-Act (PDSA) cycles with individual interventions tailored to identify and manage postoperative MN deficiencies

4. Re-audit following each PDSA cycle to track and quantify change

5. Plan to embed changes to create sustainable quality improvement

Discussion & Quality improvement

3 PDSA interventions were applied following the initial audit analysis.

PDSA 1: Bariatric FY1 Word list on shared P drive (Fig.1)

PDSA 2: Visual posters placed in theatre areas (Fig.1) PDSA 3: Active handover/meeting with aims and goals of QIP given to next rotation of General Surgery FY1s

Table 1 demonstrating post-intervention reaudit by type of surgery :

Conclusions and Sustainability

This project has generated a successful statistically significant quality improvement and we hope this will be beneficial to patient outcomes in nutrition management and ERAS post bariatric surgery.

Sustainability was also a crucial consideration in this QIP, we have avoided excess cost through testing by identifying at-risk patients. We have also embedded our interventions for longterm, sustainable quality improvement.

References: Guidelines:

1 Imperial Weight Centre, St Mary’s Hospital, London

Fig. 1 PDSA interventions

Figure 3: Box and whisker graph demonstrating statistically significant Quality improvement

Figure 2: Bar chart illustrating improvement in BOMSS MN Adherence by month

literature review

R. MIZORI1 , R. SIOW1 , M. T. AHMAD1

1. Background

The debate on using n3-PUFAs for cardiovascular disease has spanned more than 50 years1 . Studies among the Greenland Inuit revealed a correlation between high n3-PUFA intake and reduced CVD rates. A 1976 experiment compared Eskimo and Danish diets, highlighting significantly higher n3-PUFA levels in the former (0.84 vs 0.24)2 . This literature review explores the anti-inflammatory properties of n3-PUFAs and their potential to improve vascular endothelial function, contributing to the field of cardiovascular research.

2. The Impacts of N3 -PUFAs

2a. Inflammation, Endothelial Dysfunction and Eicosanoids

• Arachidonic acid is a primary component in the production of eicosanoids. N3 - PUFAs can reduce inflammation by substituting arachidonic acid as a substrate for eicosanoid production, inhibiting its conversion into inflammatory compounds.

• Additionally, the structural differences between EPA and arachidonic acid - derived eicosanoids contribute to the lower biological activity of EPA- derived eicosanoids. (Figures 1 & Figure 2) 3 .

2b. Effects on Gene Expression

N3-PUFAs exert their anti-inflammatory effects by influencing the activity of transcription factors involved in the expression of inflammatory genes. Examples of transcription factors affected by n3-PUFAs include peroxisome proliferatoractivated receptor (PPAR) and sterol regulatory element binding protein-1 (SREBP-1)4 . The ability of n3-PUFAs to impact various inflammatory genes highlights their overall role in reducing inflammation.

2c. Effects on Leucocyte Chemotaxis

Studies investigating the impact of n3PUFAs on leucocyte chemotaxis have shown promising results(5,6) . By reducing leucocyte chemotaxis, the movement of leucocytes toward the site of inflammation is diminished, leading to a decreased inflammatory response. Moreover, n3PUFAs influence the expression of adhesion molecules, further contributing to their anti-inflammatory effects.

3. Conclusion

Numerous epidemiology studies and clinical trials have shown that n3-PUFAs can prevent human atherosclerotic disease development(7) . By reducing inflammation through the various ways discussed in the essay, n3-PUFAs can reduce the incidence of the whole pathway and, hence, decrease the incidence of cardiovascular disease, as observed in the Greenland Eskimo population over half a century ago.

References

4. Jump, D.B., 2008. N-3 polyunsaturated fatty acid regulation of hepatic gene transcription. Curr Opin Lipidol 19, 242–247. https://doi.org/10.1097/MOL.0b013e3282ffaf6a

5. Lee, T.H., Hoover, R.L., Williams, J.D., Sperling, R.I., Ravalese J., Spur, B.W., Robinson, D.R., Corey, E.J., Lewis, R.A., Austen, K.F., 1985. Effect of dietary enrichment with eicosapentaenoic and docosahexaenoic acids on in vitro neutrophil and monocyte leukotriene generation and neutrophil function. N. Engl. J. Med. 312, 1217–1224. https://doi.org/10.1056/NEJM198505093121903

6. Schmidt, E.B., Pedersen, J.O., Ekelund S., Grunnet N., Jersild C., Dyerberg J., 1989. Cod liver oil inhibits neutrophil and monocyte chemotaxis in healthy males. Atherosclerosis 77, 53–57. https://doi.org/10.1016/0021-9150(89)90009-9

7. Zehr K.R., Walker, M.K., 2018. Omega-3 polyunsaturated fatty acids improve endothelial function in humans at risk for atherosclerosis: A review. Prostaglandins Other Lipid Mediat 134, 131–140. https://doi.org/10.1016/j.prostaglandins.2017.07.005

8. Gutiérrez, S., Svahn S. L., & Johansson, M. E. (2019). Effects of Omega-3 Fatty Acids on Immune Cells. International Journal of Molecular Sciences 20(20), 5028. https://doi.org/10.3390/ijms20205028

What impacts do N3-polyunsaturated fatty acids have on vascular endothelial function in order to be able to reduce cardiovascular disease? A

Figure 2: A study using tuna oil consumption found a clear correlation between increased intake and changes in the fatty acid composition of human neutrophils, resulting in reduced production of arachidonic acid-derived eicosanoids

Figure 1: The main building block for eicosanoid production is often arachidonic acid. Examples of eicosanoids include leukotrienes, thromboxane, prostaglandins and more. These eicosanoids are generated by the metabolism of arachidonic acid.

Referral to fracture clinic for acromioclavicular joint dislocation – an audit of appropriacy and efficiency

William Ansley, Arya Kamyab, Duncan Tennent, St George’s, University of London

1. Aims

The aims of this study were:

1. To determine where expert opinions on acromioclavicular joint injury is necessary

2. To assess for areas where quality of service can be improved

2. Introduction

Acromioclavicular joint (ACJ) dislocations account for 9% of all shoulder injuries1 They are more common in men and often occur during contact sports, with the commonest mechanism being direct force applied to the superolateral shoulder whilst the humerus is adducted2

The British Orthopaedic Association Standards of Trauma state patients with an acute traumatic joint injury should have specialist review in a fracture clinic within 72 hours of the injury3 As ACJ dislocations are common, this can put significant strain on consultant time in the fracture clinic, making it essential to determine when it is appropriate for patients to be seen by orthopaedic nurse specialists only In the trust at present, all ACJ dislocations are reviewed by clinical specialist nurses (CNS) in a virtual fracture clinic (VFC), then either further assessed by an upper limb specialist, followed up at 12 weeks or discharged from the service

The Rockwood Classification is used to classify ACJ dislocations with a view to prognosis and guiding treatment. It is summarised in figure 12 . As a general rule, types I-III are treated as “low-grade”, with conservative management, whilst types IV and above are “high-grade” and are considered for surgical management. In order to grade such injuries effectively, both AP and axial (axillary) radiographs are required to assess for supero-inferior and antero-posterior translation of the clavicle4

3. Methods

This study was a retrospective review of referrals to the VFC for ACJ dislocations between May 2021 and May 2022 Patient MRNs were obtained from the ‘Upper Limb Consultants’ WhatsApp group and these were used to search for patient records on the patient databases (iCLIP) and EPR

78 patients were identified with 7 being excluded as they did not have an ACJ dislocation, despite being referred for one For the remaining 71 patients, the following data were obtained: demographics (age, sex, side of injury), Rockwood grade, management approach, outcome of VFC review, and whether the documented Rockwood grade was altered at any point Changes in grade were deemed to have altered management if they were from low-grade (I-III) to highgrade (IV-V) or vice-versa PACS was used to determine whether an initial axial Xray was performed, and if it was, patient notes were subsequently examined to see whether it was of sufficient quality to grade the injury

4. Results

71 patients were included in the study, with a mean age of 36.9 years (SD ±15.7). years. 77.5% (n=55) of patients were male, with the remaining 22.5% (n=16) being female. Right-sided dislocations (62.0%, n=44) were more common than left-sided ones (38.0%, n=27).

Table 1: Rockwood grades of patients included in the study

5. Discussion and Recommendations

NICE guidelines on ACJ injuries state that Rockwood grades III and above should be seen by an orthopaedic specialist for further evaluation5 Following initial CNS review in the VFC, 47 9% of patients were referred for further assessment by an upper limb specialist Given that only 39 4% of patients had injuries graded III and above, there may be some scope for streamlining the patients referred on to the consultants in clinic.

Using the NICE guidelines as a stricter template for this is one potential measurepatients with injuries graded I and II should not be referred on to the consultants for further assessment The only 2 patients who had their grade changed in a way that would likely alter their management after specialist review were changed from a high-grade to a low-grade injury (grade IV to grade II) This suggests that the CNS team can adequately detect grade I and II dislocations to make the suggested measure of only referring grades III and above to the consultants safe

The standout issue detected by this audit concerns the efficiency of the service when dealing with ACJ dislocations Axial X-rays are a key investigation required for grading the injury effectively, however, 21.1% of patients did not have have an initial axial X-ray performed whilst in A&E, and of the 78 9% who did have one, 26 8% of those needed to have it repeated as the films were not of sufficient quality to grade the injury Overall, 42 2% of patients had an absent or insufficient axial Xray at the first instance This delays their management and the flow of patients through the fracture clinic, and provides an inconvenience for patients as they must return to the hospital to have the X-rays repeated before it can be determined whether they will need subsequent specialist review or not.

Of the 71 patients seen in VFC, 7 0% (n=5) were discharged following initial CNS review, 45.1% (n=32) were followed up at 12 weeks, and 47.9% (n=34) were referred for further assessment by an upper limb specialist. (Figure 2)

Figure

total, 9 patients (12 7%) were treated operatively, whilst the remaining 62 patients (87.3%) were treated non-operatively

.1% (15 patients) did NOT receive an initial axial X-ray Of the 56 patients 78.9%) who did receive an initial axial X-ray, 15 patients (26.8%) had to return to hospital to have it repeated as it was of insufficient quality to grade the injury

Figure 3: Charts showing the proportion of patients who received an initial axial Xray, and the proportion of those X rays that were of sufficient quality for grading

A potential measure that can be taken here is education for the A&E radiology department and A&E staff on the issue of axial X-rays in ACJ injuries. An ‘ACJ imaging protocol’ could be implemented where all patients with potential ACJ injuries get AP and axial views as standard, and this is checked by the A&E staff caring for them before they are referred on to the VFC

6. Limitations

Some patients who were referred to the VFC for ACJ dislocations may have been missed when initially identifying the study population because not all referrals are spoken about in the ‘Upper Limb Consultants’ WhatsApp group

The data were gathered using a combination of patient record systems (iCLIP and EPR) At times, there were discrepancies between the content of the documentation between the two Additionally, the patient notes are a combination of contributions from different caregivers, which can be another source of inconsistencies

The data doesn’t always account for individual clinical situations, and clinical uncertainty surrounding the grading and subsequent discussions and management approaches for ACJ injuries.

7. Conclusions

Overall, the majority of referrals for ACJ dislocations are appropriate, however, the process can be streamlined and pressure relieved by only referring on grades III and above to the specialists The major issue with the service surrounds the acquisition and quality of axial X-rays in the first instance, which must be addressed to improve efficiency

References

Interestingly, 32 4% (23 patients) had their Rockwood grade changed after review in VFC, however, only 2 of those (2.8% of the total cohort) resulted in a change in management, with both being a change from grade IV to grade II 17 patients who had their grade changed were initially ungraded due to inadequate imaging or requirement for clinical assessment.

Figure 1: Rockwood Classification of ACJ dislocations 2,4 Mild sprain of acromioclavicular ligament with no displacement visible on radiographs

Posterior translation of clavicle through the trapezius muscle Gross superior dislocation with coracoclavicular distance increased 100300%

Diversity of Speakers in Health and Social Care

Mona Jaffar-Karballai1, Meenakshi Jhala1, Katie Knight2, Nada Al-Hadithy3, Lucia Magee4, Greta McLachlan5 and Rose S. Penfold6,

1. Department of Medicine, St George’s University of London, London, UK 2. North Middlesex University Hospital, London, UK 3. Oxford University Hospitals, Oxford, UK 4. Population Health Research Institute, St George's University of London, London, UK 5. Cleveland Clinic, London, UK 6. Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Introduction

Women comprise the majority of the UK’s health and social care workforce yet remain underrepresented in healthcare conferences and events (1). Women Speakers in Healthcare (WSH) aims to address this by building the UK’s largest database of women speakers in health and social care to increase gender diversity across all healthcare conferences and events (2). This study analysed the diversity of WSH's current speaker database and identified underrepresented groups, to guide WSH and others seeking to improve diversity within their organisations

Methods

Data was analysed between 1st April 2020 - 23rd June 2021 The WSH’s speaker signup form invites participants to state their profession, stage of career, speciality, geographical location and their diversity characteristics. Data was categorised by ethnicity, profession and geographical location data.

Results

Of the 576 speaker sign-ups during this period; the most prevalent ethnicity in the database was White (42.0%), profession was Doctor (38.0%) and location was Greater London (33.2%). The least prevalent ethnicity was Mixed (1 5%) and location was Northern Ireland (0 7%) Of the professions represented in the database, students were the least common. A number of professions were not found in the database at all. Diversity characteristics included statements about sexuality, parental status and living with disability.

Conclusion

This study identifies that the speaker database is diverse in many aspects, but improvements can be made to increase wider diversity in aspects aside from gender to achieve parity of opportunity for all. This could be achieved by increasing BAME representation on the advisory board, actively recruiting underrepresented groups to the database and recruiting more junior representatives who are at an early stage of their career.

Table 1: Ethnicity: frequency and percentages

Table 3: Geographical location: frequency and percentages

Words

Table 2: Profession: frequency and percentages

* Includes campaigner, charity officer, clinical trial execuHon, digital technologist, equality-diversity-inclusion lead, journal editor in chief, lawyers, negoHaHon and conflict management consultant, social worker.

* Includes Australia, Canada, France, India, Ireland, Malawi, Mexico, Netherlands, New Zealand, Nigeria, Singapore, South Africa, Sweden, USA.

Exploring the Impact of Digital Health on Rare Disease Healthcare in the United Kingdom – a Review

Mona Jaffar-Karballai1 and Heather May Morgan2

1. St George’; university of London. 2. University of Aberdeen

Background

Despite 1 in 17 people in the UK being affected by a rare disease, they remain deprived of adequate healthcare (1).

The UK Government released ‘The UK Rare Disease Framework’ in January 2021 to help change that (2). The four key priorities that were identified in the framework include:

� Priority 1: Helping patients receive a faster diagnosis

� Priority 2: Increasing rare disease awareness among healthcare professionals

� Priority 3: Improving care coordination

� Priority 4: Improving access to specialist care and treatments.

The integration of digital health could help the nations achieve these milestones.

Methods

Using mixed methods analysis and search terms such as, “digital health” and “rare disease”, this review analysed a range of online data including, published scientific literature, government documents, stakeholder interviews, and media. Under each framework priority, this paper critically appraised exemplar digital health applications in rare disease care.

Conclusions

Digital tools remain in their infancy stages with a small number of recorded rare diseases. Ethical concerns in relation to privacy, data ownership and informed consent were identified as major challenges in digital health. Digital exclusion of rare disease patient and carers, due to lack of digital literacy and financial inequity, also play a role in the slow adoption of digital health on a societal level. Whilst these challenges are significant, they could be overcome through stakeholder collaboration, education, and empowerment of the patient voice.

References

1. What is a rare disease? - Rare Disease UK [Internet]. Available from: https://www.raredisease.org.uk/what-is-a-rare-disease

2. The UK Rare Disease Framework [Internet]. Available from: https://www.gov.uk/government/publications/uk-rare-diseases-framework

3. Our Solution for Rare Diseases | Mendelian.co [Internet]. Available from: https://www.mendelian.co/solution

4. Global Commission: To End the Diagnostic Odyssey for Children with a Rare Disease [Internet]. Available from: https://www.globalrarediseasecommission.com

5. Rare disease discussion app [Internet]. Available from: https://en.medshr.net/groups/rare-disease

6. Rare Aware: putting the spotlight on rare disease [Internet]. https://www.samebutdifferentcic.org.uk/rare-project

7. Rare Revolution [Internet]. Available from: https://rarerevolutionmagazine.com

8. Buddy Healthcare [Internet]. Available from: https://www.buddyhealthcare.com/en/

9. European Reference Network on Rare Multisystemic Vascular Diseases [Internet]. Available from: https://vascern.eu

Results

� Priority 1: Helping patients receive a faster diagnosis

Mendelien – MendelScan (4)

Global Commission (5)

� Priority 2: Increasing rare disease awareness among healthcare professionals

• MedShr : Clinical discussions mobile app (6)

• Digital Storytelling: Rare Revolution magazine (7)

� Priority 3: Improving care coordination

A survey conducted by Rare Disease UK reported that only 13% of respondents with a rare disease had a designated care coordinator by comparison to 87% of people with cancer (8)

� Priority 4: Improving access to specialist care and treatments.

• eHealth Working Group: European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN App) (9)

Multifactorial Machine Learning to Recognize Symptom Patterns & Enable Collaboration Tools for “Intelligent Triage” and Clinical Geneticist Virtual Panel Consultation

Figure 1: Timeline of the events leading up to the publication of ‘UK Framework for Rare Diseases’ and anticipated future events following its publication (3).

Background

Treatment for infective endocarditis (IE) is usually medical, with surgery reserved for those failing medical management or developing complications (1).

Currently, 25-50% of patients undergo surgery for IE with a 70-80% immediate survival rate. However, there is controversy over the timing of surgery following cerebrovascular events, which occur in 15-30% of IE patients (2).

Aims

1. Investigate whether surgical management is superior to medical management in patients with IE

2. Determine the optimal timing for surgery following the development of neurological symptoms

Methods

Data was collected retrospectively between 2012 and 2018 from 436 patients diagnosed with IE and treated at our tertiary teaching hospital The authors analysed the type of treatment, the timing of surgery, and the outcomes of these including mortality, IE recurrence, and length of hospital stay.

Results

A total of 421 patients were included in the analysis. 69.1% of patients underwent surgical intervention. The survival rate of patients having surgery for IE was 77.2%, compared to 50.7% in patients that did not undergo surgical intervention. 6.8% of patients presented with neurological symptoms; 73.3% of these patients had surgery within 14 days with a 90.9% survival

Conclusion

This study finds surgery to be safe with a seemingly higher survival rate compared to medical management alone, although this may be confounded by patients in the medical group being less likely to have surgery. Surgery in patients presenting with neurological symptoms is safe within 2 weeks from presentation with excellent outcomes

START: 436 patients

Diagnosed with infective endocarditis at UHS between 2012 and 2018

TOTAL: 421 Patients

After exclusion due to insufficient data or being under 18 years old at admission

A Single Centre Experience of the Management of Infective Endocarditis

Mona Jaffar-Karballai1 , Mariam Abdelghaffar2, Abdul Badran3 , Henry Rowe3, Tat Sing Yam3, Sunil K Ohri3 and Amer Harky4

1. St George’s University of London, London, UK.

2. School of Medicine, Royal College of Surgeons in Ireland, Bahrain.

3. University Hospital Southampton UK.

4. Liverpool Heart and Chest Hospital, Liverpool, UK

References:

1. Prendergast BD, Tornos P. Surgery for Infective Endocarditis. Circulation 2010;121:1141–52. https://doi.org/10.1161/CIRCULATIONAHA.108.773598.

2. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta J-P, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis. Eur Heart J 2015;36:3075–128. https://doi.org/10.1093/eurheartj/ehv319

TOTAL: 130 patients

Medical management

TOTAL: 291 patients

Surgical management

Figure 2: A Kaplan Meier Survival Analysis graph, showing the survival rates of medically managed patients (blue) and the surgically managed patients (red) up to 1 year after discharge (p<0.001).

Figure 1: Kaplan Meier Survival Analysis graph, showing the survival rates of the medically managed patients (blue) and surgically managed patients (red) in days after discharge (P<0.001).

Beyond Race and Valve Type: Unpacking An Advanced Rheumatic Heart Disease Review of a Diverse UK Population

M. T. Ahmad1, J. Y. Ng2, M. Ahmad3

Background

Rheumatic Heart Disease (RHD), a chronic cardiovascular disorder resulting from Group A streptococcal infection1, was believed to be on a steady decline in the UK, thanks to enhanced living conditions, healthcare accessibility, and antibiotic therapy advancements2. However, there is speculation about a resurgence of RHD in the UK, potentially linked to increased immigration from RHD-prevalent countries, along with a rise in RHD incidence across Europe3 . A pronounced disease burden disparity has been observed, with non-Caucasian populations, specifically those from South Asia and Sub-Saharan Africa, showing a higher prevalence4. This changing disease landscape necessitates an examination of RHD in the UK, including an exploration of the contributing demographic and sociocultural factors.

Methods

• This was a retrospective study aimed at reviewing valve replacement or repair surgery in patients with rheumatic heart disease at a single centre.

• Data from 9,483 cardiac surgeries performed between September 2017 and October 2022 at a UK tertiary centre were de-identified and recorded in a surgical database.

• Patients who underwent isolated valvular surgery were identified, and those diagnosed with RHD were included.

Results

• Data from 1880 RHD and 151 non-RHD patients was analysed (figure 1).

• We can see how the proportion of RHD cases varied over the years (figure 2).

• RHD patients were more likely to be younger (55.2 ± 13.3 vs 63.2 ± 13.8 years), female, and have a higher incidence of atrial fibrillation (AF) history and NYHA class III/IV symptoms (figure 3), yet despite their younger mean age there was no significant difference in outcomes.

• RHD patients had more double valve procedures and received more mechanical valves.

• On sub-group analysis of RHD patients, Caucasian patients presented at an older mean age (61.8 ± 12.4 years) compared to other ethnicities (48.9 ± 10.1 years).

Figure 3: A graph showing the comparison between RHD and non-RHD patients for a range of different pre-operative patient characteristics and postoperative outcomes.

Discussion

• The variation in the proportion of RHD cases over time suggests the need for continued monitoring and prevention efforts for Rheumatic Heart Disease.

• The comparable outcomes between RHD and non-RHD patients indicate that valve replacement/repair surgery can be performed effectively in patients with RHD, providing reassurance to clinicians and patients.

• The higher rate of mechanical valve implantation among non-Caucasian populations warrants further investigation to understand the underlying reasons and potential impact of warfarin use in this population.

• This study confirms the earlier presentation of RHD among UK non-Caucasian populations.

• Similarly to other international studies, RHD valve surgery is more common in younger female patients5 and non-indigenous6; mechanical valves are also preferred.

• The high prevalence of RHD among non-Caucasian populations has implications for future management including valve surgery choice, early screening programmes and patient education.

References

https://pubmed.ncbi.nlm.nih.gov/36820872/ (Accessed 29 May 2023).

3) Ojha, U. et al. (2022) Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019. European heart journal. Quality of care & clinical outcomes. [Online] [online]. Available from: https://pubmed.ncbi.nlm.nih.gov/36477873/ (Accessed 15 May 2023).

4) Lamichhane Pratik et al. (2022) Prevalence of rheumatic heart disease in South Asia: A systematic review and meta-analysis. International journal of cardiology. [Online] 358110–119. [online]. Available from: https://pubmed.ncbi.nlm.nih.gov/35504739/ (Accessed 29 May 2023).

BMC Cardiovascular

[Online] 14 (1), 1–12. [online]. Available from: https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/1471-2261-14-134 (Accessed 15 May 2023).

2000-2018. Emerging infectious diseases. [Online] 27 (1), 36–46. [online]. Available from: https://pubmed.ncbi.nlm.nih.gov/33350929/ (Accessed 15 May 2023).

Figure 1: A breakdown of the cardiac surgery data.

Figure 1: The trend from September 2017- October 2022.

Eyes on the Future: Next Generation Pupillary Examination

BACKGROUND OBJECTIVES

Plastic pen torches are the most common assessment tool in the ICU for pupillary assessment, however there is limited knowledge regarding user experience and perception1 . Not only does the future of pupillary examination have to be clinically effective, but they also must focus on the aspects of sustainability and environmental impact2 .

To explore nurse’s perspectives on pupillary assessment in the ICU.

METHODS

An electronic questionnaire was sent to the ICU nurses at John Radcliffe Hospital, Oxford, United Kingdom.

DISCUSSION & RESULTS

There was a 27.7% (23/83) response rate, with the nurses conducting a mean of 55 assessments per week. 96% (22/23) of them were performed with pen torches, however there was a large variation in techniques like the ambient lighting they were performed in. 61% (14/23) performed the assessment by assessing each pupil individually whilst 39% (9/23) performed them concurrently. 87% (20/23) sought better first choice tools, expressing the need for an equipment that was both reliable and able to outperform the standard pen-torch in other ways like providing numerical values. (Figure 1)

CONCLUSION

Non-recyclable pen-torches raise significant sustainability concerns. Moreover, there is a need for a standardisation of pupillary assessment, and this can be facilitated by t he use of digital pupillometers. Not only are they more accurate and reliable, but they pave the way for sustainability as they will more easily enable a shared understanding on how to achieve quality critical care; consequently, improving pupillary assessment and thus improving patient care an outcome.

REFRENCES

Mathumie Sivakanthan1 , Mr James Neffendorf1 & Dr Simon Raby1 King’s College London, King’s College Hospital & John Radcliffe Hospital, Oxford

Figure 1. Results showing the response rate, the use of Pen-torches in the ICU, individual assessments of pupil reactivity in comparison to concurrent and the need for better pupil assessment

VTE prophylaxis following elective benign gynaecological surgery at GSTT: an audit measuring compliance with clinical guidelines

Emma Lee1, Dr Beth Selwyn2, Professor Janice Rymer2

1GKT School of Medical Education, King’s College London, 2Guy’s and St Thomas’ NHS Foundation Trust

Background

• Surgical patients have a higher risk of venous thromboembolism (VTE) due to prolonged periods of immobility during recovery1

• Current GSTT (Guy’s and St Thomas’ Trust) VTE prophylaxis guidelines advise clinicians to consider prescribing a 7-day course of pharmacological thromboprophylaxis (dalteparin) following gynaecological surgery based on the patient’s VTE risk analysis2 .

• However, post-surgical VTE prescriptions are ultimately determined by the clinical judgement of the operating clinician

Objective

To assess the compliance of VTE prophylaxis prescriptions with current clinical guidelines, following elective benign gynaecological surgery at the GSTT Obstetrics and Gynaecology department.

Methodology

Data Collection

• Retrospective data collected on patients who were on elective benign gynaecological surgery theatre lists between 01/09 and 01/10/2022 (n=100).

• The following information was collected through the NHS Trust’s Electronic Patient Records (EPR) and MedChart:

Results

• Of all patients on the elective benign gynaecological surgery theatre lists (n=100), 95 underwent surgery.

• 27 were categorised as ‘complex cases’ and 68 as ‘day cases’

Discussion

• Day surgical cases have a higher rate of compliance to VTE prophylaxis clinical guidelines than more complex cases requiring inpatient admission.

Figure 1: Information collected from each patient case.

Data Analysis

• Surgical cases were risk stratified according to the current Trust clinical guidelines.

• Divided into ‘day’ and ‘complex’ cases depending on inpatient admission and length of procedure.

• 88.4% of overall cases adhered to VTE prophylaxis clinical guidelines.

• A greater proportion of day cases adhered to guidelines (97%) compared to complex cases that required inpatient admission (67%)

• There were some discrepancies between consultant decision recorded on operation notes and VTE prophylaxis provided on discharge summaries for more complex cases.

• Further compliance with current clinical guidelines is therefore required for more complex cases

Authors’ Recommendations

• Creation and implementation of VTE prophylaxis guideline refreshers.

• Regular dissemination of the importance of clear documentation in Electronic Patient Records to operating clinicians in the department.

Clinical Documentation

• 63.2% of overall cases had documentation of VTE prophylaxis prescription.

• Both day and complex cases had large (39.7% and 29.6% respectively) proportions of undocumented prophylaxis prescriptions.

Future Direction

• Further analysis of more complex cases, and analysis over a wider time period

• Re-audit annually after the implementation of the above recommendations

1 Nicholson, M , Chan, N , Bhagirath, V and Ginsberg, J. (2020). Prevention of Venous Thromboembolism in 2020 and Beyond Journal of Clinical Medicine, [online] 9(8), p 2467 doi:https://doi.org/10.3390/jcm9082467.

2. Guy's and St Thomas’ London NHS Foundation Trust (2020) GTi Clinical Guideline: Venous Thromboprophylaxis in Adult Surgical In-patients and day surgery (Excluding Orthopaedics). Accessed

Figure 2: Pie charts comparing guideline adherence in day and complex cases.

Figure 3: Pie charts comparing VTE documentation in day and complex cases.

Cortical Development in Fetuses with Isolated Ventriculomegaly

BACKGROUND

Fetal ventriculomegaly describes an enlargement of >10 mm of the cerebral ventricle at any gestational age. It is the most common CNS abnormality detected on prenatal US and can develop as result of obstructive, destructive, or dysgenic dysfunctions. However, in 50% of all cases, no other abnormality can be found in association with ventriculomegaly - when its cause is unknown, the term used is “isolated ventriculomegaly”.

Isolated ventriculomegaly is associated with increased risk of neurodevelopmental delay. These neurodevelopmental outcomes are highly variable, making them difficult to predict, leading to uncertainty in prenatal consultations.

Kyriakopoulou et al. (2014) and Lockwood et al. (2016) have shown that isolated ventriculomegaly is associated with significant cortical volume enlargement and alteration in white matter pathways, which persist well after birth. It is unknown whether these abnormalities affect cortical folding. Gyrification occurs in defined timeframes, and any deviation has been correlated with later neurocognitive deficits.

AIM

By using the same cohort of these previous studies, the aim of this project is to assess whether isolated ventriculomegaly is associated with delayed or abnormal cortical maturation

MATERIALS & METHODS

MRI scans were obtained from 31 fetuses with isolated ventriculomegaly (VM) and 11 healthy subjects (CN), with a gestational age ranging from 21 weeks to 37.

Following 3D reconstruction and brain extraction, automatic segmentation of the brain cortex was performed using a fully automated structural pipeline, inspired by the Developing Human Connectome Project by Makropoulos in 2014. To ensure the quality of the segmentations, manual editing using the software ITK-SNAP was implemented to correct the cortical labels.

To describe and quantify the development of cortical folding, a series of geometrical parameters were extracted – i.e. cortical thickness, surface area, sulcal depth, and brain curvature. Finally, using MS excel, the global mean cortical thickness and total cortical surface area was calculated, as well as the maximum and minimum curvature and sulcal depth. The data was then imported imported onto IBM SPSS to create a GLM and ran an ANCOVA.

RESULTS

The final cohort consisted of only 26 VM subjects and 7 control subjects, as 9 subjects were excluded to due failures in 3D reconstruction.

Analysis of individual cerebral regions showed that VM subjects presented with increased cortical thickness in the right gyri parahippocampalis and ambiens (p = .002). Furthermore, VM subjects also showed an increased surface area in the right cingulate gyrus posterior (p = .002), and a decreased surface area in in the right lateral occipitotemporal gyrus anterior (p = .03) up until the 27th week of gestation.

REFERENCES

DISCUSSION

The results showed that isolated ventriculomegaly was associated with increased cortical thickness in the anterior aspect of the right gyri parahippocampalis and ambiens, and with increased cortical surface are in the posterior part of the right cingulate gyrus and decreased surface area in the anterior aspect of the right lateral occipitotemporal gyrus. These structures have been associated with several cognitive functions, including visuospatial processing and episodic memory. Abnormalities in these structure can affect learning, memory, reward, task engagement, and attention.

The current literature showed that alterations in cortical thickness and surface area have been correlated with neurodevelopmental delays. These findings further confirm and could possibly explain why isolated ventriculomegaly was associated with cortical volume overgrowth, as the same cohort was used, since cortical volume is defined as the product of these two parameters. No differences of statistical significance were found when assessing the sulcal depth and the brain curvature.

CONCLUSION

This project demonstrated that isolated ventriculomegaly in fetuses was associated with alterations in cortical folding in a few regions, especially in terms of cortical thickness and surface area. This is of relative clinical significance, as these two geometrical markers might present the potential of being used to quantify cortical development and for the prediction of future neurodevelopmental delays. The sample size used for this project represents the major limitation.

Sadia A. Joulhash1 , Vanessa Kyriakopoulou2 , Emma C. Robinson3

However, no differences of statistical significance (p > .05) were found when measuring any of the parameters on a global cerebral level.

Should Point of Care Ultrasound (POCUS) be included in the medical school curriculum?

Eleanor Fish

What is POCUS?

Point-of-care ultrasound (POCUS) is a bedside imaging modality that enables physicians to observe and interpret real-time imaging on patients without the need to refer them for radiology services

Its applications span across various specialties, including emergency medicine, intensive care medicine, respiratory medicine, cardiology, musculoskeletal (MSK) medicine, and orthopaedics, among others.

Teaching POCUS

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends the systematic use of ultrasound as an easily accessible and instructive educational tool in the curriculum of modern medical schools

• One study showed medical students using a POCUS device could identify more cardiac pathologies on an HDU than consultant cardiologists using physical examinations

• Several UK medical schools have already implemented POCUS training into their curriculum – it is feasible to do

• POCUS may increase medical students’ confidence at physical examinations and anatomy understanding

Why is POCUS useful?

• Quicker than traditional radiological services

• Improves safety during medical procedures

• Aids diagnostic accuracy

• Reduces time to diagnosis

• Short learning curve for physicians

• Few data on any harm

• Can be used in situations with little space (e.g. prehospital cardiac arrest)

“That it [the stethoscope] will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner; and because its whole hue and character is foreign, and opposed to all our habits and associations” - Sir John Forbes, 1821

Should POCUS be considered the same way today?

Conclusion

Although POCUS does not replace traditional radiological services, it can be used in situations where there is less time or availability, and at the patient’s bedside, by any trained doctor

• Can be taught online, in cadaver labs, and on hospital wards – appropriate for all years of medical students Can be taught alongside anatomy modules, or under “body system” modules

• POCUS is an important tool when they graduate to junior doctors

POCUS should be included in the medical school curriculum where possible, as it is an important skill for junior doctors to be able to implement. It has already been introduced to several medical schools, showing its feasibility, and it is able to be included in multiple areas of the curriculum

It is important for medical school training to remain up to date with current clinical practice and to prepare its medical students to use tools they will be using in their future careers.

References:

‘The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum’, BMC Medical Education, 17(1). doi:10.1186/s12909-017-0928-x.

Cantisani V. et al. (2016) ‘EFSUMB statement on medical student education in ultrasound [long version]’, Ultrasound International Open, 02(01). doi:10.1055/s0035-1569413.

Konge L., Albrecht-Beste E. and Bachmann Nielsen, M. (2015) ‘Ultrasound in Pre-Graduate Medical Education’, Ultraschall in der Medizin - European Journal of Ultrasound, 36(03), pp. 213–215. doi:10.1055/s-0034-1399553.

Wakefield, R.J. et al. (2018) ‘The development of a pragmatic, clinically driven ultrasound curriculum in a UK medical school’, Medical Teacher, 40(6), pp. 600–606.

doi:10.1080/0142159x.2018.1439579.

Smallwood, N. and Dachsel M. (2018) ‘Point-of-care ultrasound (pocus): Unnecessary Gadgetry or evidence-based medicine?’, Clinical Medicine, 18(3), pp. 219–224. doi:10.7861/clinmedicine.18-3-219.

Rice, J.A. et al. (2021) ‘The pocus consult: How point of care ultrasound helps Guide Medical Decision making’, International Journal of General Medicine, Volume

14, pp. 9789–9806. doi:10.2147/ijgm.s339476.

Birrane J. et al. (2017) ‘A scoping review of ultrasound teaching in Undergraduate Medical Education’, Medical Science Educator, 28(1) pp. 45–56.

doi:10.1007/s40670-017-0491-4.

Wong, C.K. et al. (2020) ‘Point-of-care ultrasound augments physical examination learning by Undergraduate Medical Students’, Postgraduate Medical Journal, 97(1143), pp. 10–15. doi:10.1136/postgradmedj-2020-137773.

C., T.E. (1978) ‘Will the stethoscope ever come into general use in clinical medicine?A strongly negative view expressed in 1821’, Pediatrics 62(1), pp. 113–113. doi:10.1542/peds.62.1.113.

Tshibwabwa E.T. and Groves, H.M. (2005) ‘Integration of ultrasound in the education programme in Anatomy’, Medical Education, 39(11), pp. 1148–1148.

doi:10.1111/j.1365-2929.2005.02288.x.

Health Canada approves Butterfly IQ, the world’s first whole-body portable ultrasound, to Combat covid-19 (2020) YouAreUNLTD Available at: https://www.youareunltd.com/2020/04/13/health-canada-approves-butterfly-iq-the-worlds-first-whole-body-portable-ultrasound-to-combat-covid-19/ (Accessed: 07 June 2023).

POCUS being used on a patient (above)

Butterfly IQ probe

The Future of Medicine in Space: Advancements and Challenges

Anita Golash

University of Buckingham

Background

The future of medicine in space holds tremendous potential as humanity expands its presence beyond Earth's boundaries. This review provides an in-depth analysis of current understanding, advancements, and challenges in the field of space medicine. Key areas of focus include space-specific health risks, telemedicine and remote healthcare, 3D printing of medical supplies, space-based research and drug development, and emergency medical situations. By synthesizing existing literature, this review aims to shed light on the importance of addressing the unique healthcare needs of astronauts and the potential impact of space medicine on both space missions and terrestrial healthcare.

Methods

Databases: PubMed, Cochrane, Google Scholar

Keywords: space medicine, future medicine, telemedicine, remote medicine, 3D printing, space drugs, space research, microgravity, radiation, gravity, surgery in space

Number of articles: A total of 21 articles were identified

Analysis: After reading the full-text articles and findings from each article, the data related to the advancements seen in space medicine and the challenges faced was extracted and used.

Inclusion criteria: Data related to progression of space medicine, challenges going forward

Exclusion criteria: Duplicates, not in English, data not relating to medical advancements or the progression of space medicine

Advancements

1. Telemedicine and Remote Healthcare: With the advent of advanced communication technologies, telemedicine will play a crucial role in providing healthcare services to astronauts during long-duration missions. Remote monitoring devices, wearable sensors, and robotic surgical systems will enable real-time health assessments, diagnosis, and treatment guidance from medical experts on Earth.

2. 3D Printing of Medical Supplies: In the limited and isolated environment of space, 3D printing technology will revolutionize the production of medical supplies, including customized surgical tools, prosthetics, and even human tissues. This capability will reduce the dependency on resupply missions and enable on-demand manufacturing of critical healthcare resources.

3. Space-based Research and Drug Development: Microgravity conditions in space offer unique research opportunities for understanding human physiology and disease mechanisms. Pharmaceutical companies and researchers can exploit this environment to develop novel drugs, study genetic changes, and accelerate medical breakthroughs for both space travelers and Earth-based patients.

Challenges

1. Space-specific Health Risks: Prolonged exposure to microgravity, radiation, isolation, and altered sleep-wake cycles poses significant health challenges for astronauts. Understanding and mitigating these risks through advanced medical interventions and countermeasures will be essential for long-duration space missions.

2. Limited Resources and Infrastructure: Space missions have inherent limitations in terms of storage space, weight restrictions, and available resources. Designing compact and lightweight medical equipment, developing sustainable medical waste management systems, and optimizing healthcare infrastructure within confined spacecraft environments will be critical.

3. Emergency Medical Situations: Dealing with medical emergencies or surgical procedures in space environments requires specialized training and equipment. Developing advanced life support systems, establishing surgical capabilities, and enhancing emergency response protocols will be imperative to ensure crew safety and wellbeing.

Conclusion

The future of medicine in space holds immense promise for enhancing healthcare for astronauts and influencing terrestrial medicine. Advances in telemedicine, 3D printing, space-based research, and emergency medical capabilities are crucial for addressing the unique challenges of healthcare delivery in space. However, further research, technological advancements, and collaborations between space agencies, medical institutions, and industry partners are essential to fully realize the potential of medicine in the extraterrestrial realm and its impact on future space missions and healthcare on Earth.

References

Blue, R.S., Smith, S.M., Zwart, S.R. et al. Space radiation and astronaut health: implications for future longduration space missions. Future Sci OA 4, FSO295 (2018). doi: 10.4155/fsoa-2018-0077

Finkelstein, J.P., Duda, K.R., Arias, D.A. et al. 3D printing for space medicine. NPJ Microgravity 4, 23 (2018). doi: 10.1038/s41526-018-0065-9

Hassler, D.M., Zeitlin, C., Wimmer-Schweingruber, R.F. et al. Mars' surface radiation environment measured with the Mars Science Laboratory's Curiosity rover. Science 343, 1244797 (2014). doi: 10.1126/science.1244797

Kanas, N. A. (2015). Space psychology and psychiatry. In Psychology and psychiatry in space (pp. 1-18). Springer International Publishing.

Massa, G.D., Pierson, D.L. & Morrow, R.C. Plants for space exploration: Current activities at Kennedy Space Center. Acta Hortic. 1139, 189-194 (2016). doi: 10.17660/ActaHortic.2016.1139.28

Tang, P., Miller, M.J., Artis, A.L. et al. Surgery in Space: The Future of Surgical Innovation and Intervention. J Laparoendosc Adv Surg Tech A 28, 167–171 (2018). doi: 10.1089/lap.2017.0308

Todd, P. & Whitmire, A. Spaceflight and the Impact of Microgravity on the Human Body. In: Barratt MR, Pool SL, editors. Principles of Clinical Medicine for Space Flight. New York: Springer; 2020. p. 19-42. doi: 10.1007/978-3-030-34113-2_2

Attitudes and current practice in screening, brief intervention, and referral for alcohol among staff working in urgent and emergency settings: a survey

Background: In England, the National Health Service encourages staff to use everyday interactions with patients to discuss healthy lifestyle changes as part of 'Making Every Contact Count' (MECC), which is seen to be a valuable approach to improving population health. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health approach to identifying alcohol users, providing brief advice, and referring them on to rehabilitation and recovery services as appropriate. Studies have shown brief interventions delivered in emergency departments (EDs) to be effective and potentially cost-effective EDs are being identified as an increasingly important setting for capitalising on ‘teachable moments’ that can be used to reduce health-comprising behaviours (e.g., hazardous alcohol consumption, injury prevention, risky driving, cigarette smoking, poor diet, lack of exercise, and sleep deficit) and reduce demand on the healthcare system. An evidence synthesis located very few studies investigating the barriers to implementing health promotion interventions among emergency care workers – most of the research was conducted in the US, Canada, or Australia, only ten surveys were identified (only one of which included data from the UK, Scotland only) and facilitators to health promotion were very poorly captured. The review called for more research to establish whether incorporating health promotion into the roles of staff in UEC settings is acceptable.

Aim: The aim of the study was to ascertain the views and experiences of those working in urgent and emergency care (UEC) settings towards screening, brief intervention, and referral to treatment (SBIRT) for alcohol to inform future practice.

Objectives: To explore:

i) views towards health promotion,

ii) views towards SBIRT,

iii) experience of SBIRT in practice,

iv) facilitators and barriers to delivering SBIRT in UEC settings and

v) training needs to support future SBIRT practice.

Methods: An open cross-sectional survey, using an online self-administered questionnaire with a mixture of both closed and open-ended responses was disseminated. Participants were ≥18 years of age, from any occupational group, working in urgent and emergency care (UEC) settings in any country or region.

Results: 362 respondents (aged 21-65 years, 87.8% shift workers) from 7 occupational groups including physicians (48.6%), nurses (22.4%) and advanced clinical practitioners (18.5%). Most believed that health promotion is part of their role, and that SBIRT for alcohol prevention is needed and appropriate in UEC settings. SBIRT was seen to be acceptable to patients. 66% currently provide brief alcohol advice, but fewer screen for alcohol problems or make alcohol-related referrals. The most common barriers were lack of knowledge and training on SBIRT, lack of access to high-quality resources, lack of timely referral pathways, and concerns about patient resistance to advice.

Prevention is acceptable to the vast majority with recognised patient benefit

• Most view health promotion to be part of their role.

• Most are willing to deliver SBIRT, and believe that screening, brief advice, and referrals (SBIRT) for alcohol is needed and appropriate in UEC settings

• Those with alcohol SBIRT experience believe it is acceptable to patients

• Two-thirds agreed that UEC settings are suitable for promoting other health areas (e g , drugs, smoking, injury prevention, physical activity, diet/weight, violence, health screening, vaccination)

• A minority experience role conflict or uncertainty over who is responsible for prevention

Current practice of alcohol prevention in UEC settings is limited

• Less than two-thirds have ever engaged in alcohol prevention, and almost half have never used an alcohol screening tool

• Brief alcohol advice is more often practiced than alcohol screening or referrals

UEC is a challenging environment to deliver alcohol prevention

• Severe workforce shortages and the impact of the long-lasting COVID-19 pandemic

• The 3 most common barriers to SBIRT implementation are lack of time, lack of training, and lack of appropriate referral pathways

• Other key challenges include stigma, lack of private physical space and lack of staff- and patient-facing resources

• Very few staff have had training relating to brief interventions for (any) lifestyle behaviours

Enablers of alcohol prevention as identified by the UEC workforce

• Increased staff capacity in UEC (e g , better staff-patient ratios, time for triage screening)

• Dedicated staff for health promotion / alcohol prevention in ED (e g , health promotion advocate, social worker resident, alcohol liaison team : including out of hours)

• Guidelines and policies on alcohol (and other) screening, brief advice, and referrals

• Access to private spaces for SBIRT conversations.

• Visible support for prevention activity from senior leadership.

• Increased funding for alcohol detox / abstinence / treatment programmes

• Standardisation of roles to clarify who has responsibility for prevention

• Workforce education and training (e.g., topics: importance / efficacy of SBIRT, reducing stigma, increasing knowledge and confidence in SBIRT; delivered via: online training tools; delivered when: pre- and post-registered healthcare education, UEC staff inductions).

• Availability of high-quality patient-facing resources (e g , posters, leaflets)

• Quick and easy to access referral pathways providing timely and holistic patient support (i e , standardisation of referral processes, and increased service options / availability)

• Mandating and/or rewarding SBIRT activity in UEC .

• Feedback (to staff / organisations) on screening and referral activity and outcomes

Discussion: UEC workers are willing to engage in SBIRT for alcohol prevention but there are challenges to implementation in UEC environments and concerns about workload impacts on already-burdened staff, particularly in the context of global workforce shortages. UEC workers advocate for clear guidelines and policies, increased staff capacity and/or dedicated health promotion teams onsite, SBIRT education/training/resources, appropriate physical spaces for SBIRT conversations and improved alcohol referral pathways to better funded services.

Conclusions: This is the first study to describe the views, experiences, barriers, and enablers of SBIRT for alcohol prevention, and health promotion more broadly, as reported by UEC workers across a range of occupational roles and settings. Implementation of SBIRT could contribute to improving population health and reducing service demand, but it requires significant and sustained commitment of time and resources for prevention across healthcare organisations.

1School of Health Sciences, University of Nottingham, Nottingham, UK,

2NIHR Nottingham Biomedical Research Centre, Nottingham, UK, 3School of Medicine, University of Nottingham, Nottingham, UK, 4Emergency Department, Nottingham University Hospitals NHS Trust, Nottingham, UK,

5East Midlands Academic Health Sciences Network, UK.

Poster prepared and presented by Vinuja Premakumar

Holly Blake1,2, Mehmet Yildirim1 , Vinuja Premakumar3, Lucy Morris4, Phil Miller5, Frank Coffey4.

Assessing the Impact of a Student-Led Mock Objective Structured Clinical Examinations

Authors Alexander Gonzalez-Lamberth, Myles Rice, Jonathan Haddad, Risako Sakatsume, Aahil Damani

King’s College London Medical School

Introduction

References

1 - Gormley G. Summative OSCEs in undergraduate medical education. Ulster Med J. 2011;80(3):127–32.

2 - Burgess A, McGregor D, Mellis C. Medical students as peer tutors: a systematic review. BMC Med Educ. 2014 Jun 9;14:115. doi: 10.1186/1472-6920-14-115. PMID: 24912500; PMCID: PMC4237985.

This study aims to assess the impact and viability of a student-led mock Objective Structured Clinical Examination (OSCE) design, as well as explore medical students' perceptions of peer-led OSCEs. OSCEs are known to induce stress among medical students due to their challenging format and limited practice opportunities1 . While peer-led teaching has been proven to be a valuable and cost effective tool in education, its specific value for OSCEs remains understudied2 .

Methods:

Two 6-station Objective Structured Clinical Examinations (OSCEs) were created by final-year medical students who had successfully completed a similar OSCE at the same level as the participants. To administer the OSCEs, students were enlisted to serve as examiners, actors, and facilitators, managing a total of 12 OSCE stations across a span of two days. The study involved 25 medical students who took part in the OSCEs and provided feedback through completion of feedback forms. The collected Likert data was analysed, and themes were identified by conducting thematic analysis on the open text feedback.

Results:

All 25 participants completed the post-OSCE feedback form. 100% of participants said that they would want to participate in further student-led OSCE style simulation sessions. The main themes from the feedback were that the OSCEs were well-organised, helpful, and good at highlighting areas for improvement.

Conclusion

This study demonstrates the positive impact and viability of incorporating student-led practice OSCEs into medical education. Participants found the student led OSCEs to be well-organised, helpful, and good at highlighting areas for improvement. These findings highlight the acceptability and benefits of student led OSCEs, providing controlled practice environments and reducing stress and anxiety for medical students.

Limitations

The recruitment process followed a first-come-first-served approach, resulting in a convenience sample that carries the potential for sampling bias. It is possible that students who volunteered for the mock OSCE may have been more inclined to perceive it as a valuable learning experience, regardless of the actual design of the mock OSCE. Additionally, the absence of a control group restricts the study's ability to make conclusive statements about the importance of the peer-led aspect in the mock OSCE.

AUTHORS

“Holistic”approachto medicalschoolteaching

INTRODUCTION

Teaching methods vary in medical schools with some following well researched, well adapted methods while some focusing on more practical, hands on approach. The aim of this poster is to provide bases for a Holistic approach to be integrated into medical school curriculum and its potential benefits on student learning

METHODOLOGY

We evaluated different teaching methods and compared student satisfaction rates used in medical schools across the UK. In order to summarise the findings we performed a literature review. The summary of teaching methods is presented below. At the moment of writing there were 36 Medical Schools in the UK As can be seen on the plot, all schools use Integrated approach whilst most incorporating other teaching styles into their curriculum alongside it.

OBJECTIVE

This research clearly defines the parameters that make up the Holistic approach which includes traditional teaching methods, practical skills development through clinical placements, facilitation of learning with the aid of clinical educators and provision of an environment for enhanced peer-to-peer learning.

PBL+negated CBL+negated negated EBL+PBL+ntegated EBL+negated CBL+PBL+ntegated

CONCLUSION

Most medical schools in the UK have adopted an integrated approach for medical school curriculum. More thought needs to be given to the integration of biomedical principles with clinical knowledge as there could exist a disconnect between the two. Amongst all the curriculums, highest student satisfaction ratings belong to universities with Integrated and PBL approach thus depicting the importance of patient based learning and how other medical schools can benefit from them

ANALYSIS

Various teaching methods used in medical schools in the UK were analysed and matched with student satisfaction rates:

a traditional pre-clinical and clinical course an integrated/systems based course problem-based learning (PBL ) case-based learning (CBL) enquiry-based learning (EBL) multi or inter-professional learning course.

Medical schools which use PBL for delivering their curriculum have higher student satisfaction rates as compared to traditional ones. The highest satisfaction rate among students of 84% was observed in University of Lancaster Medical School The institution uses PBL teaching alongside an integrative approach An integrated based course has been proven to be the most effective and is recommended by the British Medical Association. On the other side, the lowest satisfaction rate of 67% was noted in University of Nottingham Medical School which uses CBL, PBL and Integrated methods. Although teaching style plays a significant role in student satisfaction rate, other confounding factors may influence the outcome.

Anna Pogodina, Muhammad Waleed Iqbal

AFFILIATIONS

University of Buckingham Medical School Crewe Campus