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Introduction: In 2014, the General Medical Council introduced the concept of resilience training to the medical school curriculum. Aims: This cross-sectional study assesses resilience, coping mechanisms and professional quality of life in medical students. Methods: Medical students at Queen’s University Belfast (HUB) were invited to participate in an anonymous online survey during 8 weeks (2019), comprising three validated psychological scales: Connor-Davidson Resilience Scale (CD-RISC), Professional quality of life scale (ProQOL V) and BRIEF COPE. Results: 324 HUB students (years 1-5) participated (response rate: 25%). Mean CD-RISC score was 68.5 (SD 11.5) (low for resilience). Mean burnout (BO) was 26.9 (6.0) (worse than population mean: 20), mean compassion satisfaction (CS) was 37.8 (5.8) (similar to population mean: 37) and mean secondary traumatic stress (STS) was 22.3 (5.9) (worse than population mean: 11). Pre-clinical students had higher compassion satisfaction than clinical students (p=0.01). More than a quarter (27.4%) of medical students had high burnout and 21 (8%) had high BO, high STS and low CS. Common coping mechanisms were planning and active coping. Discussion: The high levels of burnout in HUB medical students suggest that they may benefit from interventions to develop resilience and improve professional quality of life.., Problem: The on call weekend team is primarily in place to deal with emergencies, however a large amount of their time is spent performing routine jobs left over from weekdays. Strategy for change: To reduce the number of routine tasks left for weekend staff to complete by 25% by March 2020 Measurement of improvement: Initial discussions with foundation doctors revealed that the most common routine tasks were IV cannula, bloods to be taken and checked, insulin prescriptions. Baseline audit of number of tasks left for weekend staff to complete (4 weeks), then weekly audit, using ward jobs list as reference. We adapted and introduced the known F.R.I.D.A.Y.S. checklist. We used the PSDA model and implemented 3 cycles in order to achieve improvement. Effects of change: Baseline data revealed an average of 25 routine jobs left to be carried out. By end of PDSA cycle 3, there was an average of 10 jobs left. Discussion with juniors and nursing staff revealed that they were happier with less bleeps, nurses were able to complete tasks more timely and overall satisfaction had improved. Discussion: Overall F.R.I.D.A.Y. checklist was a successful tool for reducing weekend routine tasks. When implemented correctly, it reduced the number of routine jobs (40% reduction in our ward), improved communication between team and staff and improved patient safety., Introduction: Studies based on molecular testing of oral/nasal swabs underestimate SARS-CoV-2 infection due to issues with test sensitivity and timing of testing. Aims: To report the presence of SARS-CoV-2 antibodies, consistent with previous infection, and to report the symptomatology of infection in children. Methods: This multicentre cohort study, conducted between 16th April - 3rd July 2020 at 5 UK sites, recruited children aged 2 to 15 years of age. Participants provided blood samples for SARS-CoV-2 antibody testing and data were gathered regarding unwell contacts and symptoms. Results: 992 participants were included in the final analysis. The median age was 10·1 years. There were 68 (6.9%) participants with positive SARS-CoV-2 antibody tests indicative of previous SARS-CoV-2 infection. Of these, 34/68 (50%) reported no symptoms. The presence of antibodies and the mean antibody titre was not influenced by age. Following multivariate analysis 4 independent variables were identified as significantly associated with SARS-CoV-2 infection. These were: known infected household contact; fatigue; gastrointestinal symptoms; and changes in sense of smell or taste. Discussion: The symptoms of SARS-CoV-2 infection in children were subtle but of those reported, fatigue, gastrointestinal symptoms and changes in sense of smell or taste were most strongly associated with antibody positivity., Introduction: Prior to the pandemic there were already difficulties in delivering postgraduate medical education (PGME) with attempts to balance service delivery and training requirements. Social distancing guidelines imposed due to COVID added the final blow to traditional postgraduate teaching. Aims: We wanted to reintroduce a PGME programme that was: - safe - accessible to all - sustainable. Method: We opted to deliver teaching remotely. Numerous platforms were trialled with Zoom being preferred. Initially we focused on one weekly session and with initial positive engagement momentum built and we systematically increased the opportunities available. Results: There is now a comprehensive PGME programme within the Southern Trust with all activities available remotely. There have been up to 50 participants availing of multiple sessions per week across all sites and specialties. Feedback has been positive: - 100% liking remote teaching format - 100% viewing remote delivery as safer alternative. Discussion: For the majority of trainers and trainees this was a new concept requiring adaptability and overcoming barriers. However this innovative approach has been positively received. We recognise that this is a work in progress and seek feedback, evolve with alterations and addition of new elements., Introduction: Faced with a pandemic, educational activities stopped with teaching and training a distant memory. However, we recognised that an appetite for learning persisted and that our commitment to lifelong learning must never stop. EDHEAD was born to put education back on the agenda. Aims: - Offer platform for paediatric healthcare professionals to access everyday clinical problems answered in evidence-based format using 5-minute peer reviewed, quality-assured videos.- Offer leadership and educational opportunities as part of lifelong commitment to learning.- Improve team moral by incorporating technology and humour within educational videos, with video element allowing for social distancing. Method: The EDHEAD team created a ‘wish-list’ of clinical questions. All members of the paediatric team were invited to prepare 5 minute videos based on guidance provided. These were submitted electronically and EDHEAD team peer reviewed, quality assured, edited and uploaded to shared platform. Results: We have had great engagement from multiple team members with the catalogue of videos steadily increasing. Feedback is collated to inform future clips. Discussion: We have created a pandemic-proof approach to education! We plan to share learning and evolve by collaborating with other departments., Introduction: The Academic Foundation Programme (AFP) provides foundation doctors with protected time for the development of the skills and aptitudes required in academic medicine. The NI AFP programme was established in 2008 with 9 AFP posts each year. To date, there has been no analysis of this cohort. Aims: We sought to describe the academic and career outcomes of the Northern Ireland AFP cohort. Methods: Anonymised data regarding AF2 post-holders from 2008-2018 was obtained from HUB and NIMDTA. A structured questionnaire was distributed to this cohort of 99 AFP trainees. Results: 41 males (41.4%) and 58 (58.6%) females completed the AFP with the majority (59.6%) being HUB graduates. The response rate was 44.8%. Of the respondents, 76.9% have presented and 46.2% have published their AFP project with 61.5% applying for a higher degree or academic position. 86.6% agreed that completion of the AFP has enhanced application for future training programmes and 76.9% believe that the AFP has influenced their intended or actual career pathway. Discussion: Our survey shows that participation in the NI AFP programme leads to research outputs, enhanced career opportunities and a clear pathway to academia, Background: Continued medical education (CME) for postgraduate Obstetrics and Gynaecology trainees is normal delivered by the consultant body in a face-to-face capacity, on a bi-monthly basis. Due to COVID-19, these teaching sessions were not able to occur. With the current pandemic it is important that we explore other options for delivering CME to postgraduate trainees including virtual delivery. Aims: To assess the viability of the consultant body delivering a virtual CME programme for obstetrics and gynaecology trainees in Northern Ireland Methods: Survey monkey sent to consultants to find out about their experience with virtual teaching and whether they would be comfortable teaching on a virtual session. Results: 41 consultants completed the virtual teaching survey, 67% had never used video-conferencing to teach doctors. 40% were not confident in sharing presentations and 92.5% in managing break-out sessions. 34 consultants would consider delivering CME if this became the standard teaching platform, with 82% having no objections to the sessions being recorded for trainees unable to attend. Conclusions: Consultants are keen to provide this method of teaching but require further training to deliver. Having consultants teach via zoom improves access to a diverse and rich knowledge base for postgraduate trainees., Background: Obstetrics and Gynaecology trainees in Northern Ireland attend bi-monthly postgraduate continued medical education (CME). COVID-19 restrictions meant these teaching sessions could not occur. Collaborating with senior trainees we developed a virtual postgraduate teaching series via ZOOM. Aims: To assess the viability of virtual CME for obstetrics and gynaecology trainees in Northern Ireland. Methods: Survey monkey sent to participants/non-participants exploring experiences and attitudes towards this teaching series. Results: 33 trainees completed the participant survey, with most attending 1-2 ZOOM teaching sessions. Over 50% had never attended teaching via video conferencing before. 66% of trainees were confident in using video conferencing for learning. 27 participants agreed that pre reading for each topic added to their learning. All participants agreed that CME should be mapped to the current RCOG curriculum. 87% of participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME. 15 trainees completed the non-participant survey, with 93% of trainees stating that work commitments meant that they were unable to attend the ZOOM sessions. Interestingly 2 trainees were unable to work ZOOM. 73% of non-participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME, with 80% stating that if sessions were recorded and they were unable to attend, that they would use the recording for learning. Conclusions: Virtual teaching is an appropriate method to provide the necessary volume and quality of postgraduate medical education., Introduction/Aims: This study explored what is known about training for rare, time-critical procedures in Emergency Medicine. Methods: A scoping review of the published literature was performed, 40 papers were found which discussed aspects of training in rare, time-critical procedures, relating to Emergency Medicine. Results: Gaining experience in rare, time-critical procedures is challenging as trainees have limited exposure during their training. Skills gained decay quickly, so maintenance of skills is difficult. Simulation is widely practised; it is seen as an ethical imperative as skills can be gained and maintained without putting patients at risk of harm. Skills need to be practised frequently to combat skill decay; the optimum frequency of practice has not been established. New educational techniques may help maintain competency if incorporated into educational programmes. Discussion: There are many challenges to gaining and maintaining skills in performance of rare, time-critical procedures in Emergency Medicine. Frequent practice is required, and this should take the form of simulation in the absence of frequent clinical practice. Further research is needed into the best type of simulation for specific time-critical procedures and into what impact simulation training has on clinical outcomes., Introduction: As junior doctors we remember the difficulties with starting out as an FY1. Although Trust induction is comprehensive, in our experience, there is minimal induction covering the intricacies of daily workings of the ward and what life is really like as an FY1. Aim: To provide a peer-to-peer induction programme that is Trust specific but also role specific. We wanted to share invaluable tips gained through experience and ease transition into working life. Method: Four sessions were offered to all incoming FY1s. Given the current climate these were facilitated remotely. Current FY1s were recruited to deliver the sessions. To determine content we asked current FY1s to reflect on what they wished they had known when starting as a doctor and incoming FY1s were surveyed about what they wanted included. Results: Of the incoming FY1s that availed of the sessions 100% found them to be enjoyable, useful and increased their confidence for starting their new roles as junior doctors. Discussion: This initiative highlights the necessity and usefulness of a peer-to-peer element of induction. To improve this for further years we are currently in the process of seeking additional feedback., Introduction: The outbreak of a novel coronavirus in 2020 required significant and rapid changes to standard operating procedures within the psychiatric inpatient unit, in order to protect patients as well as staff. Aims: To develop standard operating procedures (SOPs) for managing Covid-19 positive patients, and to refine these and train staff using simulation based education. Methods: Phase 1 of the simulation exercise involved “run-throughs” of the SOPs with the MDT on a closed ward to identify latent safety threats and issues with equipment and supplies etc. SOPs were refined based on the issues identified and these were used in Phase 2 which focused more on training redeployed staff and managing anxiety. Results: Feedback was obtained using a staff survey. 85% felt that the SOPs had improved after their involvement in the Sim, 87% felt more confident about managing Covid positive patients, and 81% felt less anxious after attending the Sim. Discussion: Simulations are a useful way to test new care pathways and can identify latent safety threats, engage staff in improvement, and provide a forum for raising concerns and managing anxiety., Introduction: There are over 1.2 million chronically lonely people in the UK. Admission to hospital increases the prevalence of loneliness. Loneliness can significantly increase morbidity and mortality. Aims: The aim of this project was to reduce loneliness by an increasing awareness, befriending scheme, posters and a loneliness protocol. Methods: Use of patient surveys with qualitatitive and quantitive data. Open and closed questions used with implementation of a UCLA loneliness scale. Results: Each intervention decreased the median UCla scale, the befriending scheme had the greatest effect on Ucla reduction. Discussion: Due to social distancing policy, there has been a reduction in number and duration of visitors. Patients described loneliness as loss of purpose, days being very long and not feeling close to others. Many felt a shame associated with loneliness. Patients were reluctant to tell hcps about loneliness due to fear of offending staff. Loneliness was seen by many patients as a natural part of growing old. Patients felt face masks reduced ability to engage with Hcps., Problem: Foundation doctors are contacted regularly out of hours to complete routine prescribing tasks that should be completed in normal working hours. Strategy for Change: The “KIWI Checklist” is a communication tool designed to be used at ward level to ensure completion of 4 routine prescribing tasks within normal working hours. These include: rewriting of Kardexes; Insulin Prescribing; Warfarin prescriptions and IV fluid plans. Measure of Improvement: The primary outcome measure for this project was the percentage of bleeps out of hours received by FY1 doctors that were for routine prescribing tasks. Effects of Change: Data was collected over 10 weeks from October 2019- December 2019. The KIWI Checklist was introduced to 2 wards in BCH after week 5. Ward 7N had a reduction in the percentage of bleeps out of hours that were for routine prescribing tasks from 40% to 0% and Ward 9N had a reduction from 70% to 20%. Discussion: A simple checklist at ward level reduces the burden of prescribing out of hours, improving patient safety. Senior medical and nursing leads within have approved the checklist for rollout across a number of divisions in BHSCT., Problem: The need to reduce the number of general surgical inpatients to create capacity in preparation for the COVID-19 pandemic. Strategy for change: Restructuring of our emergency general surgery (EGS) service, including establishing an enhanced ambulatory service, and non-operative management of selected conditions. Measurement of Improvement: Patients referred by the emergency department were prospectively identified over four weeks from the date of reconfiguration (COVID) and compared to patients retrospectively identified from the equivalent period the previous year (Pre-COVID), followed up for 30 days. Data was extracted from handover documents and electronic care records. Effects of Change: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Rates of admission decreased (78.1% to 41.7%) whilst there were increased rates of ambulation (7.1% to 17.3%) and discharge (6% to 22.6%). Duration of admission decreased (6.9 to 4.8 days), and there were fewer operative and endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39), telephone reviews (0 to 39), and use of early CT to facilitate discharge (5% to 34.7%). There were no differences in 30-day readmission or mortality in any group. Discussion: Restructuring of our EGS service in response to COVID-19 facilitated a 62.7% reduction in inpatient bed days (1519 to 567) whilst maintaining patient safety., Problem: Sleep, both in the recommended duration and quality, is a controversial area. However, it is acknowledged that sleep plays an important role in recovery from illness. Hospital wards are loud, busy and bright – an environment not conducive to sleep. Strategy for change: We sought to tackle two issues negatively impacting patient sleep – noise and light. We offered ear plugs (PDSA cycle 1) and ear plugs with an eye mask ( PDSA cycle 2) aiming to improve the amount of sleep on the respiratory ward in BCH by 25% in a 4 month period. Measurement of improvement: We distributed qualitative and quantitative patient surveys prior to our intervention and after. We compared the data from these surveys. Effects of change: PDSA cycle one (ear plugs) showed evidence of a significant improvement in patient sleep – achieving our aim. PDSA cycle two did not show that the use of both ear plugs and eyes masks had a significant impact than ear plugs alone. Discussion: These were simple changes which could reduce consequences of sleep deprivation such as delirium and hasten patient recovery., Problem: No collection of data on morbidity for discussion occurring in the EMSU Strategy for change: Implementation of morbidity function on the excel handover template already in use, before discharging any patient from the handover a prompt would appear for consideration of morbidity discussion. Teaching to all junior staff about the morbidity function on the excel handover was then provided. At the beginning of the placement a core trainee was designated as the responsible person for collection of morbidity data. Measurement of Improvement: From April to June 0 morbidity cases were discussed prior to change, from July to September 49 cases were discussed. The change was sustained with 45 cases discussed from October to December. Discussion: The problem with morbidity collection was compounded by constant rotation of senior staff. Giving the responsibility of improving the morbidity collection and discussion to a core trainee, who was permanently based in the EMSU, empowered them to organise the rest of the team and make a sustained change, provided permanent point of contact for the team on site. The prompt on the excel handover sheet ensured that patients were not removed from the handover without consideration of morbidity status., Problem: Poor handover process in place for postnatal ward; Handover was handwritten via a ward diary. Often due to lack of space, unclear handwriting or no verbal handover taking place – there were a number of antibiotic doses not given for suspected neonatal sepsis, missed clinical reviews of infants amongst other concerns. Strategy for change: Introduced a new typed & printed handover template and face-face handover to occur between each change of shift. Senior member of staff (Registrar/Consultant) met with post-natal ward SHO mid-morning to address any issues. Measurement of Improvement: Staff questionnaires (initial, re-audit x2 over 6 months) to nursing and medical teams and the recording of any incident report forms completed. Effects of Change: No incidents of missed antibiotics/clinical reviews/concerns were recorded after the introduction of the typed, formal face-face handover. Improved staff morale overall amongst staff – clear, face-face handovers were now expected and became the norm. Staff felt more supported as a result of a formal meeting with registrar/consultant midmorning to trouble-shoot any issues. Discussion: As a result of our QI project, babies were better cared for and were placed at less risk. The project has demonstrated that clear communication at all times has the ability to enhance patient care and staff wellbeing., Problem: Central Venous Access devices (CVADs) are common on medical and surgical wards. Complications including blockage and infection are relatively common. These need addressed appropriately to prevent loss of IV access, days without TPN or line sepsis. There is limited training in hospitals, therefore junior doctors can be unsure in dealing with issues that arise. Strategy for Change: To improve junior doctor aptitude and confidence in managing CVADs, a survey was prepared which consisted of two sections. Firstly one which junior doctors’ rated their confidence on a 1-10 scale and a further section which tested technical knowledge of CVADs and their associated guidelines. An education session was then set up with information provided by the Infusional Services team. Measurement of Improvement: The survey was re-taken after the education session to assess areas which improved and areas which still required attention. Effects of Change: Junior Doctor confidence increased 36% overall for all 3 types of CVAD. There was a 57% improvement in the technical knowledge of CVADs and management of complications. Discussion: Both junior doctor confidence rating and technical knowledge greatly improved after the education session. To ensure retention of knowledge we plan to re-audit. Further measures for implementation include easy access to CVAD protocols on the trust intranet., Problem: During the COVID-19 pandemic, surgical service and practice has been adjusted in order to reduce acute surgical admissions. Acute appendicitis accounts for a significant proportion surgical admissions in the UK. Strategy for Change: Intercollegiate general surgery guidance during the COVID-19 pandemic advised appendicitis should be managed conservatively, or with an open appendicectomy if indicated. Our aim was to determine the efficacy and safety of our ambulation service in the conservative management of acute uncomplicated appendicitis. Measurement of Improvement: Data was collected prospectively from 30th March 2020 – 16th August 2020 on all patients presenting with suspected appendicitis. Stable patients with clinically suspected or CT-proven appendicitis were discharged with oral antibiotics as per trust guidance. Readmissions for ambulated patients were recorded. Effects of Change: 190 patients presented with suspected appendicitis (range 5-71years). 49.4% patients were deemed suitable for ambulation on initial assessment, 22% of which had a CT confirmed diagnosis on discharge. 65% of the ambulated patients underwent a telephone review within a 72 hour window. 13.8% of patients represented within a 30 day period, 7.4% of which proceeded to appendicectomy. Discussion: Patients with uncomplicated appendicitis can be safely managed with antibiotics out of hospital, with low representation rates., Reasons for criterion chosen: Belfast’s Rheumatology Department facilitates infusions of biologics on a daily basis. Usual protocol was that patients had routine bloods taken on arrival. We evaluated guidance on drug monitoring, according to British Society of Rheumatology and Summary of Product Characteristics, finding that frequency of blood monitoring was surplus to requirement. We recorded bloods taken and were struck by the unnecessary frequency of blood monitoring. We constructed a proforma of correct frequency of drug monitoring according to the British Society of Rheumatology and Summary of Product Characteristics. A one page poster of guidance. Data Collection: Frequency of blood monitoring checked in a two week period went from 80% to 10% with use of our guidance poster. Conclusion: Difference in cost of blood tests sent, in a two week period, after implementation of monitoring guidance was £1681.29. It is important to continually assess whether current practise is correct or could be updated. This project has demonstrated how reviewing guidance can lead to significant saving. This project will save at least £43,713.54, in one Rheumatology Unit, per year., Problem: No allocated time for morning handover at Lagan Valley Hospital contributes to anxiety among F1 doctors. It can result in the night-F1 staying beyond their shift to handover to each ward individually; leads to unfamiliarity of sick patients and outstanding tasks; and has the potential to compromise patient safety. Strategy for change: We propose designating time each morning at 9am for handover between F1 doctors. It will follow a standardised format including: Sick patients Outstanding investigations Deaths overnight Any other outstanding issues/concerns This qualitative project aims reducing anxiety among F1 doctors; familiarise the day-F1 with patients on their ward and improve patient safety by minimising errors associated with poor handover. Measurement of improvement: Qualitative pre- and postintervention questionnaires were completed by F1 doctors in relation to job satisfaction, confidence and the perceived impact on patient safety. Effects of change: All respondents felt that the proposed F1 handover improved confidence among F1 doctors and minimised disruptions in patient care. Discussion: Shift patterns and lack of a formal handover between doctors can disrupt continuity of patient care compromising patient safety. Formal handover ensures safe transfer of patients between doctors and reduces anxiety among F1 doctors., Problem: Given the COVID-19 pandemic, reduce face-to-face consultations to only complex burns or those necessitating hospital admission to Northern Ireland’s Regional Burns Unit. Strategy for Change: Establish a virtual burns service, using a combination of telephone calls, emails, photography and Microsoft Teams software. Our initial adoption of the system was audited during April and May 2020. Through Plan-Do-Study-Act (PDSA) methodology an electronic tertiary-referral proforma was subsequently created prior to closure of the audit cycle in July 2020. Measurement of Improvement: 1. Reduction in face-to-face consultations 2. Completeness of burns referral data (including: demographic, clinical and initial management) both pre- (April & May 2020) and postintroduction (July 2020) of e-Referral pathway. Effects of Change: From the start of lockdown a significant reduction in face-to-face consultations was observed. Given the increasing use of virtual telephone consultation only 19.5% of the unit’s total referrals (April, May and July) were either reviewed face-to-face in dressing clinic or admitted. Following implementation of the e-Referral pathway an improvement in both the detail and completeness (95%) of patient referral information was achieved. Discussion: Our experience demonstrates that virtual burns care can be safely and rapidly adapted in response to evolving need. The potential role of virtual care post-COVID, in selected patients, is an exciting one., Problem: Hospitalisation is associated with a deterioration in patient oral health. The pharmacy team can advise on management of common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Survey data revealed the King’s College Hospital (KCH) pharmacy team had low confidence in these areas and were unaware of where to access appropriate guidance. Strategy for change: Two teaching sessions on management of oral conditions were planned and delivered to the pharmacy teams at two KCH sites. Health Education England’s (HEE) Dental Factsheets for the Pharmacy Team were distributed to all team members, with reference copies kept in each department. Measurement of Improvement: An online questionnaire was circulated to measure confidence in managing common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Effects of change: Confidence in managing all the oral conditions covered showed significant improvement. 75% of participants would consider using HEE’s Dental Factsheets for the Pharmacy Team for further guidance. Discussion: This project enabled and empowered the pharmacy team to take a more active role in improving patient oral health. Future work lies in evaluating the patient impact of these measures., Problem: During the Covid pandemic information for pregnant patients was updated regularly and printed leaflets were often out of date. Strategy for change: Dynamic QR codes were introduced to antenatal clinics across Northern Ireland. Dynamic codes allow for the destination of a code to be changed without changing the printed code. This allows patients to scan the codes on their phones, providing up to date patient information on their device. Measurement of Improvement: The exact number of codes scanned was recorded digitally. A regional staff and patient survey was undertaken. Effects of change: Both staff (82%) and patients (81%) were keen to provide and receive information leaflets via QR codes. Intervention 1 = printed laminated codes used in clinics – 10 scans per day over 4 weeks Intervention 2 = targeted education sessions at clinics – 17.7 scans per day over 3 weeks Intervention 3 = codes included in patient notes – 26.6 scans per day over 3 weeks. Discussion: This 3 cycle QI project was devised due to the challenges created by the Covid pandemic. QR code use has increased with each intervention saving resources and providing patients with up to date information., Problem: Coronavirus Lockdown meant all non-emergency essential services were reduced. Face-to-face epilepsy clinics had to be cancelled. Strategy for change: Instead of cancellations, all scheduled epilepsy clinic reviews were conducted by pre-arranged telephone call. Measurement of Improvement: DNA rates during the virtual clinic review period were compared with face-to-face review clinics during the same 6 month period last year. We found a 37% reduction in non-attendances when using telephone reviews. Qualitative feedback from parents favoured the approach in terms of convenience and stress reduction, but highlighted reservations regarding variable signal quality, and wanting reassurance of a doctor physically seeing their child. Effects of change: Ongoing use of telephone reviews for this stable patient population. Discussion: Successful improvement in attendance rates and positive feedback from patients indicates telephone clinics are an effective form of review. A combination of face-to-face and telephone reviews is likely to be implemented. This raises questions; who is eligible for this review format and how to we decide? Are any other clinics amenable to this pattern? What are the benefits for the clinician and the financial benefits for the NHS?, Introduction: What appears on the skin can be a manifestation of systemic disease; an infectious, autoimmune or malignant process. Not all new inpatient rashes are drug-related. Description of case: We report a 53 year old female inpatient, being treated for decompensated alcoholic liver disease, who developed a widespread, polymorphic rash, with crops of sterile vesicles. Rifaximin had been newly commenced. Drug eruption was a differential. However, histological findings from a skin biopsy were in keeping with herpes virus infection, with background erythema multiforme changes. Subsequent viral PCR confirmed varicella zoster. Dermatology review confirmed a diagnosis of disseminated herpes infection. Aciclovir, potent topical steroid, emollients and anti-histamines were recommended. Discussion: Confirmation of an alternative diagnosis to a drug reaction enabled the patient to continue on necessary medication. Dual pathology may be present. Her confusion and fluctuating cognitive state was proven to be due to encephalopathy on EEG, thought to be explained by hepatic encephalopathy. Herpes encephalitis may have contributed. Immunosuppression puts patients at risk of VZV. This patient had a prolonged ICU admission, and background of chronic alcoholism and poor nutrition. Allow initial presumptive diagnoses to be challenged, with emerging clinical details., Introduction: Spinning is a popular high-intensity training (HIT) exercise which is increasingly reported as a cause of rhabdomyolysis. Rarely, rhabdomyolysis can lead to limb-threatening acute compartment syndrome (ACS) requiring urgent fasciotomy. Description: We describe spinning-induced rhabdomyolysis in three young women, two of whom required emergency bilateral fasciotomies for ACS. None had neurovascular compromise at the time, and all three had a good outcome. Discussion: Patients with exercise-induced rhabdomyolysis present with severe pain, swelling, and weakness of affected muscle groups accompanied with a rise in serum creatinine kinase (CK). Inadequate physical conditioning and increased duration and intensity of exercise are all associated with a higher risk of rhabdomyolysis. Although in itself it is a recognised phenomenon, diagnostic consideration should be given to occult metabolic myopathies in a young patient population. Learning points: Early involvement of senior / experienced surgeons leads to early diagnosis and rapid intervention. Compartment syndrome can occur without neurovascular compromise. The public and exercise instructors should be aware of the risks to new spin-class attendees, and how to mitigate these risks., Introduction: COVID-19 infection can result in a severe viral pneumonia clinically indistinguishable from acute respiratory distress syndrome (ARDS). Mortality rates of mechanically ventilated patients are high and it is suggested that heterogeneity of disease pathophysiology means established therapeutic approaches to ARDS are not applicable in its management. Aim: This case series aims to describe the physiological and outcome data of patients with Covid-19 who were admitted to Intensive Care (ICU) and treated with standardised evidence based guidelines for ARDS. Method: Retrospective case review of all patients admitted to Intensive Care within the Belfast trust with Covid-19 between March and June 2020. Results: 45 patients were included, 37 (82.2%) were male with a mean age of 55. 42 patient (93.3%) fulfilled ARDS criteria at time of admission. Clinical management was highly compliant with institution evidence-based ARDS guidelines. Median length of ICU stay was 14 days and ICU mortality was 8.9%. Discussion: COVID-19 fits within the spectrum of ARDS and results in similar respiratory physiology. Adherence to established evidence based therapies for ARDS in ICU patients with COVID-19 pneumonia is associated with a low mortality in this cohort., Introduction: We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity. Description: A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft. Discussion: Neonatal limb ischaemia is a rare disease entity with devastating morbidity-including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity., Introduction: Sotos syndrome a genetic disorder characterised by delayed neurodevelopment, learning disability, excessive childhood growth and craniofacial abnormalities occurs as a result of a mutation in the NSD1 gene. We present a case series of 5 children with Sotos Syndrome who have been treated for cholesteatoma and review the literature. Case Series: Retrospective case note review of patients cholesteatoma (n = 5 (1 Bilateral)) and Sotos Syndrome between 2012 and 2019. Median age at first surgery was 8 years old (3.5 years – 10.9 years). All children presented with otorrhoea. 4 children (5 ears) had abnormal hearing thresholds (>30dB HL) pre and post operatively. Median follow up is 32 months with 50% risk of recurrence and 25% risk of residual disease at 24 months. PubMed search of the MEDLINE database returned no articles reporting cholesteatoma in children with Sotos Syndrome. Discussion: Cholesteatoma has not previously been reported in Sotos Syndrome. Otolaryngologists should be vigilant for cholesteatoma in children with Sotos Syndrome., Introduction: Bartholin’s glands provide lubrication to the vagina and are a common site for infection. Lifetime incidence is 2-7%. 1,3,4,6 Bartholin’s abscesses cause pain, dyspareunia, incontinence and obstructive voiding symptoms. 1,5 Scarcely reported in literature are simultaneous presentations of Bartholin’s and peri-urethral abscesses. Peri-urethral abscesses typically follow trauma caused by childbirth or surgical interventions. 2,7 Case Study: A 23 year old was admitted in the spinal unit with acute urinary retention, saddle paraesthesia, back pain and a reduction in lower limb power and unusually high inflammatory markers. MRI spine ruled out cauda equina. On vaginal examination a right sided Bartholin’s abscess was detected. Following a Gynaecology review CT abdomen and pelvis demonstrated a peri-urethral abscess deviating the urethra to the left side. Treatment: The abscess was incised and drained at the bedside. She was discharged with an indwelling catheter and oral antibiotics to return in one week for trial removal of catheter which was successful. Outcome and Follow Up: She was clinically well, discharged and no follow up arranged. Discussion: A common gynaecological pathology presented in an atypical way. Although good clinical history and examination findings are key, imaging modalities can be a vital adjunct for patient care., Introduction: Collisions tumours are a rare but well documented phenomenon. They comprise of two histologically distinct tumour types occurring in the same site. The mechanism of which this comes about can be; 1) Two tumours arising with the same organ in close vicinity, 2) One tumour metastasizes into another tumour (tumour to tumour metastasis), 3) Two different tumours metastasize to a different organ, commonly a lymph node. Collision metastasis of two different primary tumours within the same lymph node is extremely rare. Description of Case: The authors report a case of a 74 year old woman found to have collision metastasizes of lobular breast carcinoma and adenocarcinoma of the caecum metastasizing to the same mesenteric lymph node. Discussion: The case is, to the best of the author’s knowledge, the first to describe the metastatic spread of two tumours to a single lymph node involving breast carcinoma and adenocarcinoma of the colon., Introduction: The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern. Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries. Description: We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings. Discussion: Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full skin thickness burns warranting operative intervention., Introduction: Endometrial ablation is an established treatment option for the management of women with Heavy Menstrual Bleeding. Following this procedure, women may still conceive and therefore effective contraceptive methods are recommended. We report 3 cases of unplanned pregnancies following endometrial ablation. Our series demonstrate the spectrum of possible complications and outcomes. Cases: Case 1 is a 43-year-old woman who had an unplanned pregnancy following hydrothermal balloon ablation. Her pregnancy was complicated by Fetal Growth Restriction and Morbidly Adherent Placenta at delivery. Case 2 is a 40-year-old presenting with a missed miscarriage after previous Bilateral Tubal Ligation at C-Section and subsequent Novasure endometrial ablation. She underwent management by Total Abdominal Hysterectomy. Case 3 is a 41-year-old woman who had an unplanned pregnancy after Novasure endometrial ablation but went on to have relatively uncomplicated pregnancy and delivery. Discussion: Pregnancy after endometrial ablation has the potential to increase patient morbidity significantly. According to Bauer et al. there is a 20-fold increased risk of morbidly adherent placenta. The overall risk of termination, ectopic pregnancy or miscarriage was quoted to be about 85% in another study. Consequently, it is important that appropriate contraceptive methods are discussed with patients post-ablation. The risk of failure of contraceptive methods should also be included in the discussion and an appropriate plan made if this occurs., Introduction: This case demonstrates the complexity of diagnosing and treating a tooth associated with a mandibular fracture and fixation. Description of Case: This 19-year-old male patient attended with a history of severe spontaneous pain lower RHS. On examination the LR7 was acutely TTP, heavily restored and associated swelling painful on palpation. Pre-operative radiographs revealed periapical radiolucency associated with apical third LR7 and a radiopaque mini-plate with an associated tracking sinus. The patient was diagnosed with chronic apical periodontitis with an associated draining sinus. Treatment options; - Endodontic treatment at GDP - Specialist endodontic referral - Extraction Treatment was carried out under LA and a recall for review set at 6 months. Discussion: The challenge was the difficulty of diagnosis. It demonstrates how mini-plates can interfere with accurate diagnosing. It is likely that damage was a result of the trauma or surgery (2 years previously). It highlights the potential that all modern endodontics could routinely use 3D imagery, CBCT. Conclusion: It is important to recognise teeth with an associated history of trauma or elective surgery involving mini-plate/screw placement. Thorough radiographic and assessment with monitoring is required to ensure an accurate diagnosis., Introduction: Radial artery pseudoaneurysm is a rare complication of a common procedure such as trans-radial arterial catheterisation. There are multiple risk factors increasing the likelihood of developing pseudoaneurysms, including traumatic insertion of the radial catheter or concomitant infection. Few cases are reported, and no established cause is described in literature. We describe a case of a young patient who developed an iatrogenic pseudoaneurysm post arterial line cannulation. Description of Case: A 36 years old male was admitted with subarachnoid haemorrhage (SAH) due to a ruptured intra-cranial aneurysm. He underwent invasive monitoring with radial arterial line catheter during coil embolization treatment. He underwent the procedure uneventfully but was complicated later by the development of a pseudoaneurysm. Discussion: In our case, the patient had borderline levels of inflammatory markers on blood examinations and no overt signs of local infection. There was a history of multiple attempts at arterial cannulation, and he was also commenced on antiplatelet therapy post coil embolization of the aneurysm. Concurrent use of anticoagulation agents is associated with an increased risk of formation of pseudoaneurysms. Arterial line monitoring is an invaluable aid in assessing the critically ill patient, however pseudoaneurysms is a potential complication with high morbidity even in younger age groups. Atraumatic insertion and careful removal are strongly recommended for its prevention., Introduction: Squamous cell carcinoma arising in a dermoid usually affects elderly persons and usually found in 1% of mature teratomas. It usually has a poor prognosis and quite rare in the middle aged women. Dr Tom Murphy Description of Case: The case report presented is a 49year old lady referred from the GP with a large right ovarian mass with radiology suspecting to be an ovarian teratoma. Underwent a laparoscopic BSO with histology coming back as Stage 2b, CT afterwards showed no metastatic disease, she underwent Laparotomy, TAH, recto sigmoid colectomy, end colostomy, appendectomy, anterior caecal resection, SB resection, omental biopsy, re implantation of urethra, urethral resection, stent Right ureter. Histology post op coming back as Stage 3b. She deteriorated quite rapidly despite measures to improve outcomes, knowing that prognosis is usually poor when disease has spread beyond the ovary. Conclusion: A high index of suspicion should be indicated for women in that age group with a pelvic mass. The length of time from diagnosis to death was 7months and begs the question if any of the surgical interventions were of benefit., Introduction: The aim of this case report aims to discuss the surgical management of deep facial lacerations, specifically for dental trainees transitioning to a position in Maxillofacial Surgery. It covers the important anatomical structures that need assessed and repaired. Description: Assessment of a patient with a full thickness facial laceration with a chainsaw, extending into the oral cavity. On examination the patient had some loss of function to the buccal branch of their facial nerve. Intra-orally the parotid duct was located and checked for patency, ensuring that it was not severed and it did not require stenting. The wound was closed in layers, aiming to reattach severed muscle bellies to maximise post-operative function. Postoperative wound care management was carried out as well as post-operative instruction. Discussion: Dentists entering Dental Core Training typically may find the transition to a maxillofacial surgery post daunting as it is extremely out of their comfort zone. This article aims to highlight some stages which are key to address when assessing facial soft tissue trauma as well as ways in which to manage these., Introduction: Colorectal villous adenomas are common. A rare but important complication of rectal villous adenoma is the electrolyte and water “depletion syndrome” which can be elusive as a diagnosis. If recognised and managed expediently, severe metabolic and renal sequelae can be prevented through appropriate replacement therapy and timely surgery. Case Description: We present a case of an elderly female who gave a 2-year history of progressive chronic watery diarrhoea, necessitating multiple attendances to her GP and several hospital admissions where she had been treated successfully with fluid and electrolyte replacement and a diagnosis of autonomic neuropathy was made. It was only after a thorough examination of the patient including a rectal examination that a large mass was detected and biopsies revealed a giant villous adenoma. She ultimately came to surgical resection with complete resolution of her symptoms Discussion: Villous adenomata have a propensity for secreting large volumes of mucus rich in potassium and sodium and the losses can be so great as to result in cardiovascular, neurological and renal sequelae. Where rare, this case highlights the values in carrying out a thorough clinical assessment., Introduction: Upper ministernotomy(UMS) for Aortic valve surgery is a well-established approach.It has been proven to be a competitive alternative to full sternotomy with improved aesthetic appearance and non-inferior safety. Aims: We present our single centre experience showing short and medium term surgical outcomes of UMS approach for aortic surgery. Methods: Retrospective analysis of patients who undergone UMS Aortic valve procedures over the last five years. Analysis of patients’ demographics, intra-op findings and evaluation of early/medium term outcomes. Data presented as median (interquartile range) or percentages. Results: 231 patients had UMS Aortic valve surgery at our Hospital over 5 years (Sep2014-Sep2019). Mean age: 67 (37-86) years, BMI >30 in 120 (52%). Majority were done in J shape hemi-sternotomy (87%) and through Right fourth ICS (94.4%). Central cannulation was the most favoured approach (99.2%). The aortic valve was replaced in 230 patients, mechanical valve: 37 (16%) and bio-prosthetic valve:193 (84%). Combined aortic surgery was performed in 7 patients(3%),cross clamp time: 60 (33-170) min, CPB time: 108 (51-190) min. 30-day Mortality: 1 (0.4%), conversion to full sternotomy: 11 (4.7%), reoperation for bleeding: 8 (3.4%), ICU stay: 1 (1-20) day, hospital stay: 8 (3-32) days, new onset AF: 8 (3.4%), CVA/TIA in 0.86%, 30-day readmission: 7 (3%). Early follow up echo mean gradient: 9. 7 (3-34) mmhg. Follow up: 2.8±2 years. Discussion: Aortic valve, aortic root and ascending aorta surgery is amenable by mini sternotomy incision with good outcomes taking into consideration careful patient selection. It is essential to respect the learning curve and accepting low threshold for conversion to conventional full sternotomy when required, Introduction: The incidence of cutaneous malignant melanoma (cMM) is increasing; Vitamin D deficiency at presentation is associated with increased tumour thickness and poorer outcomes. Aims: To examine the epidemiological and histopathological characteristics of cMM in Northern Ireland (NI), and to correlate with socioeconomic status (SES) and Vitamin D levels. Methods: A retrospective review was performed from August 2015 - March 2020. Patients were identified from electronic theatre records and a prospectively-collected database; further information was gained from paper and electronic clinical records. SES was determined by the NI Multiple Deprivation Measure 2017. Results: 440 patients presented with cMM; there are some differences in tumour site between the devolved nations. Vitamin D levels were assessed in 27%, of whom 44% had deficient levels. Higher SES correlated with increased incidence of cMM (Correlation coefficient (CC) 0.922). This did not correlate with thicker tumours (CC -0.020). There was only a very weak negative correlation between Vitamin D deficiency and tumour thickness (CC -0.14). Discussion: Despite being included in the NICE guidelines since 2015, almost three-quarters of patients had not had Vitamin D levels assessed. Interestingly, higher SES was related to higher incidence of cMM but with presentation at earlier stage of disease., Introduction: Many developed countries have reported a recent rise in non-tuberculous mycobacterial (NTM) infections but the trend in Northern Ireland (NI) is unknown. This study aimed to characterise the epidemiological profile of mycobacterial species isolated from NI patients between 2007-2019. Methods: All positive mycobacterial culture results reported by the NI Mycobacterial Reference Laboratory between 2007-2019 were analysed by species and specimen site. Annual population data was obtained from the NI Statistics and Research Agency. Results: 2193 mycobacterial isolates were captured in the study period. Mycobacterium tuberculosis (M.tb) isolates remained stable at ~3 per 100,000 population whereas NTM isolates increased from 3.2 to 8.1 per 100,000 between 20072019. Eighteen different species of NTM were identified, five of which accounted for ~75% of isolates. Mycobacterium avium complex (MAC) species accounted for the greatest rise in NTM (1.8 to 4.6 per 100,000), of which over 90% were isolated from pulmonary specimens. Discussion: NTM isolates now outnumber M.tb in NI, with a substantial rise in pulmonary MAC specimens. Clinicians in all specialties will increasingly encounter these poorly understood and drug-resistant organisms. More research into NTM disease is required to tackle this emerging problem., Introduction: The global pandemic has resulted in mass cancellation of elective operations; impacting cancer procedures, waiting times and training opportunities. In the Southern Trust, Craigavon Area Hospital is the designated “COVID site” and Daisy Hill the “Non-COVID site”. Aim: To assess if systems introduced resulted in low postoperative COVID cases in a COVID site compared to a non-COVID site. Method: A prospective audit of elective surgeries performed on COVID site from May-July and non-COVID site AprilJune 2020. Data collected using standardized audit proforma with 30 day follow up. Measures introduced included PPE, a separate ‘clean ward’, routine staff and patient testing, 7 day patient self-isolation prior to surgery and a no visiting policy. Results: 44 elective operations performed in COVID site and 21 in non-COVID site. 2.3 %( 1/44) developed clinical COVID 6 days post-op on COVID site - did not require ICU and alive at 30 days. Zero COVID cases in non-COVID site and zero staff cases across both sites. Discussion: Precautionary methods introduced may have contributed to low numbers of COVID and were enough to enable elective operations to continue on a COVID site. In light of recent rising community COVID cases, a re-audit will be conducted., Introduction: UK guidelines recommend sentinel lymph node biopsy (SLNB) for patients with malignant melanoma >1mm Breslow thickness; those found to have micrometastatic disease are considered for adjuvant therapy. Aims: Service evaluation of the new NI SLNB service, which began in December 2018. Methods: Consecutive patients were identified from a prospectively-collected database. Results: 166 patients were referred to the service. A total of 115 nodal basins were investigated with SLNB. Seventy-three patients were male, 95 were female; mean age at presentation was 58 (range 20 - 87). Commonest primary tumour site in men was trunk/back (47%), and lower limb in women (41%). Eighteen nodal basins were positive for micrometastases, 91 nodal basins were negative, and SLN localisation failed in 6 nodal basins. Average waiting time from referral to outpatient appointment is 2.6 weeks, less than 3-week target; however, the mean time from diagnosis to surgery is breaching the 12-week target. Almost 10% of patients were not suitable for SLNB surgery, either due to co-morbidities or previous surgery. Discussion: Surgical outcomes will be compared to international data, and considerations in starting a new service will be discussed, along with methods to reduce proportion of unsuitable referrals., Introduction: Evidence from emerging studies suggests that oral bacteria and poor oral health may contribute to COPD exacerbations. Interventions to improve oral health such as periodontal therapy may improve lung function, decrease the frequency of COPD exacerbations, hospitalisations and improve quality of life. Aims: The aim of this systematic review was to analyse the association between poor oral health and frequency of COPD exacerbations. Methods: The databases, Pubmed; Embase; Web of Science; CINAHL and Medline were searched up to May 2020, with no language restriction. Eight articles met the inclusion criteria and were included in qualitive synthesis, five articles were included in quantitative analysis. Results: The data from randomised controlled clinical trials showed a significant reduction in frequency of exacerbations following periodontal treatment (RR 0.28; 95% CI 0.090.83, p=0.02). Based on random-effects meta-analysis amongst case control studies, plaque index (OR=1.63, 95% CI 1.15 to 2.31, p=0.01), probing pocket depth (OR=2.03, 95% CI 1.46 to 2.82, p, Introduction: The inflammasome is a protein complex that initiates immune responses to danger signals by releasing cytokines interleukin-1β (IL-1β) and IL-18. Inflammasomes are thought to be involved in multiple sclerosis. Studies have shown that inflammasome activity can promote CNS repair. Aims: To determine if inflammasomes can be stimulated in CNS cells, and whether inflammasome activity promotes oligodendrocyte progenitor cell (OPC) proliferation and/or differentiation. Methods: Mixed glial cultures were generated from wildtype and Il1r1-/- mouse brains. Cells were stimulated with IL-1β to test glial response to inflammasome activity, or with inflammasome triggers to test endogenous inflammasome response in glial cells. Cells were then stained for oligodendrocyte and inflammasome markers. Results: Glial cells mounted an inflammasome response upon danger signal sensing. The formation of putative ASC specks denoted inflammasome activation. IL-1β increased oligodendrocyte lineage cell numbers, promoted OPC differentiation and increased myelin production in vitro, mediated via IL-1 receptor 1., Introduction: Orofacial granulomatosis (OFG) is a chronic granulomatous oral inflammatory disease and can precede gut Crohn’s Disease (CD). Not all OFG patients have, or ever develop, CD. Therefore, whether OFG and oral CD are one and the same disease is a matter of debate. Aim: To use proximity extension assay (PEA) to interrogate phenotypic differences between health and oral inflammatory conditions. Methods: PEA analysis was performed using ProSeek Inflammation and Immune Response panel. Olink Proteomics (Uppsala, Sweden). Saliva samples from 32 patients with OFG were processed and analysed. Controls included saliva samples from 30 healthy volunteers and 28 patients with Oral Lichen Planus (OLP). Results: No significant difference between the proteome of health vs OFG / OLP vs OFG. Significant differences in the levels of 8 proteins between OLP vs OFG (TWEAK, PRDX1, CDSN, LY75, MCP.1, FGF.23, CLEC4G, CX3CL1). Within the OFG group there were two distinct subtypes that correlate with idiopathic OFG and gut CD. Discussion: Analysis of the oral proteome may offer a means of differentiating between different oral inflammatory diseases. More importantly it may help predict those cases of OFG that will progress to gut CD., Introduction: De Quervain tenosynovitis is a disorder of the tendons of first dorsal compartment of wrist that causes pain and functional disability managed by platelet-rich plasma (PRP). Objective: To determine efficacy of intralesional injection of platelet rich plasma in patients of De Quervain’s tenosynovitis Material & Methods: This is a descriptive Case series conducted over 6 months, 100 patients were included. Platelet rich plasma was obtained after centrifugation, received intralesional injection plus oral non-steroidal anti-inflammatory drug. Results: 57 males and 43 females with mean age of 41.26±11.26 years, 53(53%) were diabetic. Efficacy of treatment was seen among 85(85%) patients, whereas Intralesional platelet rich plasma had. No significant association was noticed between gender of patients and efficacy of Intralesional injection of platelet rich plasma (p-value=0.756). Efficacy of Intralesional injection of platelet rich plasma was not dependent on the diabetic status of the patients (p-value=0.556).Efficacy of Intralesional injection of platelet rich plasma was not dependent on duration of start of symptoms of patients. i.e. (p-value=0.978). Conclusion: We conclude that Intralesional injection of platelet rich plasma can be effectively used for de Quervain’s tenosynovitis., Introduction: COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. Aim: We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Methods: Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (, Introduction: Studies estimate that 21% of patients with XLA (X Linked Agamaglobulinemia) have had at least one episode of infectious conjunctivitis. In contrast, conjunctivitis is not a commonly described problem in patients with CVID (Common Variable Immunodeficiency). Aims: We aimed to determine whether the association of XLA and eye infections is unique amongst primary antibody deficiencies. Methods: A retrospective observational study was carried out. Age-matched CVID patients with absent IgA levels were selected as the control group. Results: 29 patients with XLA and 30 patients with CVID were analysed. 12 patients with XLA (41%) had suffered from recurrent conjunctivitis. No patients with CVID had documented episodes of recurrent conjunctivitis. The mean IgG trough levels were 10.78g/L for the cohort with XLA and 10.41g/L for patients with CVID. Discussion: We demonstrate here the common and perhaps unique susceptibility to conjunctivitis in patients with XLA. What is the underlying cause for the increased susceptibility? Since both groups in our study lacked serum IgA, it seems unlikely that absence of IgA antibodies is the culprit. The group with XLA and conjunctivitis averaged higher IgG trough levels, therefore, inadequate trough levels are also unlikely to be responsible., Introduction: Many patients admitted with confirmed COVID-19 were found to have electrolyte disturbances. Aims: In this new era of COVID-19, we aimed to assess how this multisystem disease affects electrolytes & creatinine. In clinical practice, we noted patients were hypokalaemic with dysnatraemias. We explored potential aetiologies for this & assessed correlation with their clinical journey (e.g. prolonged hospitalisation, CPAP, critical care & death). We explored if age correlated. Methods: Records of all COVID-19 positive patients over a 3 month period were analysed. Each patients electronic care record was interrogated. Serum sodium, potassium, urea, creatinine, bicarbonate, chloride were recorded, as well as a peak sodium. Patients were subcategorised into those requiring CPAP, needing critical care admission & those who died. Results/Discussion: 332 inpatients tested positive for COVID-19 between 11/3/2020-17/5/2020. Average age was 69 (55% male). 37% had a sodium >/= 145mmol/L. 20% had a potassium, Introduction: Rapid deployment valves are of increasing popularity amongst surgeons. Aims: To compare conventional bioprosthetic with rapid-deployment valves used in aortic valve replacement. Method: A comparison of pre, intra and post-operative outcomes of 120 patients received a rapid-deployment AVR (RDAVR) between Sep2014-Sep2019, with a propensity matched group of patients who had conventional bioprosthetic AVR (Conv AVR). Results: RDAVR (n=120) was compared with Conv AVR (n=120).Both groups were matched in terms of baseline characteristics. However, RDAVR group included more elderly (>80 years) and females (40 vs 11 p, Introduction and Aim: The aim of this study was to investigate the impact of nasal deviation on the perception of the maxillary dental centreline position as judged by orthodontists, general dental practitioners (GDPs) and lay people. The null hypothesis states that there is no difference in perception of maxillary dental centreline position and smile aesthetics with varying degrees of nasal deviation and dental centreline. Methods: This was a cross sectional study which aimed to assess the impact of variations in the position of both the dental centreline and nose on facial aesthetics. An image of a smiling female was digitally manipulated with varying degrees of nasal deviation and dental centreline position. Multiple regression analysis was undertaken to assess the effect of these changes on the perceptions of attractiveness for each rater group. Results: Nasal deviation to the left by 1.5mm was perceived as more attractive if the dental centreline was also deviated to the left by 1.5mm by GDPs (95% CI, 0.4-13.5), orthodontists (95% CI, 7.6-20.0) and lay people (95% CI, 1.7-15.8). Discussion: Overall, there was a preference for the symmetrical dental centreline and nose position. GDPs and orthodontists were more sensitive to changes associated with the dental asymmetry, whereas lay people were more sensitive to nasal changes., Introduction: In our centre, patients undergoing elective transurethral resection of prostate (TURP) and transurethral resection of bladder tumours (TURBT) require a preoperative group and hold (G+H). Local policies requiring pre-operative G&H were developed as TURP/ TURBT historically had a significant risk of bleeding. However, as intra-operative procedures have improved, the risk of bleeding has reduced [2]. Aims: Investigate the rate of blood transfusion in TURP and TURBT patients. Methods: We conducted a prospective analysis of all patients undergoing TURBT/TURP in a two-month period (19/09/2019-19/11/2019). 44 patients were identified using theatre lab lists and cross-referenced with the electronic labs system to confirm if blood products were issued. Patients requiring transfusion (n=2) were further investigated using patient notes to establish contributing factors and timing of transfusion. Results: 4.5% of those undergoing TURBT/TURP required a transfusion. 0% were intraoperative or emergency transfusions. All transfusions occurred over 48 hours postoperatively. Discussion: Our study found that pre-operative G&Hs do not improve patient outcomes. At a cost of £23.77/sample, there is potential to make significant savings without compromising patient care. Our results are in keeping with larger studies performed in other centres [3]. Pre-operative G&H could be performed selectively on those deemed higher risk at pre-operative assessment. Routine preoperative tests for elective surgery: summary of updated NICE guidance - BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3292 (Published 14 July 2016) Cite this as: BMW 2016;354:i3292 https://www.bmj.com/content/354/bmj.i3292 Rassweiler, J, Teber, D, Kuntz, R. Complications of transurethral resection of the prostate (TURP) – incidence, management and prevention. Eur Urol 2006; 50: 969-980. Smith, H., Falconer, R., Szczachor, J., & Ahmad, S. (2018). Routine preoperative group and save for TURP and TURBT – need and cost effectiveness. Journal of Clinical Urology, 11(1), 33-37., Introduction / Aims: Primary aim of gaining quantitative data on levels of sedentary behaviour among GPs and GPSTs, to identify to what extent GP is a sedentary occupation. Secondary aim of gathering qualitative data regarding barriers and facilitators to reducing sedentary behaviour among GPs and GPSTs. Methods: Sequential, mixed-methods model. Stage 1: Online questionnaire based on the International Sedentary Assessment Tool distributed to GPs and GPSTs throughout Northern Ireland. Stage 2: Accelerometer study. Purposive, varied sample of 20 participants, based on questionnaire responses, comprising individuals with a range of demographic characteristics and sedentary behaviour. Accelerometers will be worn continuously on the middle of the thigh for a period of seven-days. Stage 3: Semi-structured interviews. Purposive, varied sample of 6 participants of the accelerometer study will be asked questions related to sedentary behaviour in the GP setting. Results and Discussion: Quantitative data will be analysed to determine current levels of sedentary behaviour in the GP setting. Qualitative data will be analysed thematically to determine barriers and facilitators to reducing sedentary behaviour in the GP setting. Study has been modified due to Covid-19 pandemic., Introduction: Black and minority ethnic communities are at higher risk of mental health problems. Aims: We explore differences in mental health and the influence of social capital among ethnic minority groups in Great Britain. Methods: Cross-sectional linear and logistic regression analysis of data from Wave 6 (2014-2016) of the Understanding Society databases. Results: In unadjusted models testing the likelihood of reporting psychological distress (i) comparing against a white (British) reference population Indian, Pakistani, Bangladeshi and mixed ethnic minority groups recorded excess levels of distress; and (ii) increasing levels of social capital recorded a strong protective effect (OR=0.94: 95% CI 0.935, 0.946). In a subsequent series of gender-specific incremental logistic models-after adjustment for sociodemographic and socioeconomic factors Pakistani (males and females) and Indian females recorded higher likelihoods of psychological distress, and the further inclusion of social capital in these models did not materially alter these results. Discussion: More research on the definition, measurement and distribution of social capital as applies to ethnic minority groups in Great Britain, and how it influences mental wellbeing is needed.

Aim: Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet results in complications. Early reherniation has been reported in alternative xenografts such as Surgisis®. We wondered whether the matrix or decellularization (decel) process led to failure. We compared diaphragmatic reconstructions using SIS and decel porcine diaphragm (DPD), processed with a comparable decel protocol, to Gore-Tex in a fast-growing rabbit model. Methods: Twenty-three 6-weeks-old rabbits underwent intubation, left subcostal laparotomy and 3*3cm hemi- diaphragmatic excision. Defect closure was with a 3,5*3,5cm patch of (a) Gore-Tex® (n=10), (b) Surgisis® (n=6) or (c) DPD (n=7). Rates of herniation or eventration, uniaxial biomechanical testing, and histology were studied at 90days. Results: Eighteen (78%) rabbits survived to 90days. There was mesh failure in all decellularised matrices (p, Introduction: Children commonly present to Emergency Departments (ED) with a non-blanching rash (NBR) in the context of a feverish illness. The approach to assessment of these children is controversial. Aims: Validate clinical practices guidelines (CPGs) for the management of fever and NBR Methods: Prospective multicentre validation study evaluating the performance of available CPGs for feverish children with NBR. The full protocol has been published and is available at https://rdcu.be/bFEtb. Results: 1423 children were recruited from 37 UK sites between the 11th November 2017 to 30th June 2019. This included 77 children with serious bacterial infections (5.4%) and 17 children (1.2%) with confirmed invasive meningococcal disease (MD). Four CPGs (NICE, NBL, London & Nottingham) were prospectively validated. All four demonstrated 100% Sensitivity for identifying children with MD. NICE guidance demonstrated the lowest specificity 10% recommending that 75.3% of children receive parenteral antibiotics and admission to hospital. The NBL, London and Nottingham CPGs all demonstrated a greater specificity ranging from 28% to 41%. Discussion: NICE guidance for the management of NBR performed poorly in this national validation exercise. The alternative CPGs were 100% sensitive and offered greater specificity. Adopting an alternate CPG would reduce painful interventions, parenteral antibiotic use and hospital admissions. Trial registration - NCT03378258. Retrospectively registered on December 19, 2017.., Introduction: Vascular Ehler-Danlos (vEDS or type IV EDS) is the most dangerous subtype of Ehler-Danlos and is rarer than most EDS subtypes, thought to affect 1-200,000. It is autosomal dominant affecting COL3A1 or COL1A1 genes. Symptoms include those of EDS alongside being easily bruised, visible blood vessels on chest, late miscarriage, unusual facial features and aneurysms/dissections, bowel perforation and uterine perforation. Case: A woman presented with acute onset back pain radiating down her right leg after bending over to pick up a heavy object. History and findings were in keeping with sciatica, she was prescribed analgesia. Discharge was delayed due to a trauma call. On reassessment the patient had deteriorated and was noted to be hypotensive and tachycardia and subsequently transferred to resus. She underwent a CT angiogram revealing a ruptured external-iliac artery. She underwent emergency repair. Discussion: The patient has made a full recovery but had she not remained in the department during the trauma call she may have been sent home. This case serves to highlight the dangers of Ehlers-Danlos syndrome and remind clinicians to be aware of such patients and treat them with caution. This is an example of how younger patients compensate physiologically before acutely deteriorating, Problem: The Renal Association guidelines for management of kidney transplant patients (KTP) recommend yearly review of immunosuppression (IS). Patient survival improves by addressing IS related mortality risk factors (MRF) and carefully reducing IS. In our unit, baseline data showed IS reviews were carried out every 32 months. Strategy for change: With multidisciplinary team (MDT) input driver diagrams were generated to set out aims and objectives. Plan-Do-Study-Act cycles facilitated change which was analysed continuously using statistical process charts. A transplant clinic template letter and MDT review assessments were created which were refined through subsequent cycles. Measurement of Improvement: Percentage KTP with documented IS plan and modification of MRF at each clinicFollowing adoption-adherence to template Effects of change: Over 3 month period percentage KTP with IS review rose from 9% to 85% enacting 29% more changes to IS compared to pre-intervention weekly. Modifiable risk factors addressed rose from 8% to 56%. Adherence once template adopted reached 93%. Project generated other change ideas e.g. information & dermatology leaflets. Discussion: This project demonstrates that by utilising the MDT and introducing a standardised approach increased frequency of IS review, adaptions to IS and addressing MRF. This could potentially be replicated by other transplant teams., Background: The traditional method for arthroscopic training relies on appropriate clinical cases, costs particularly with operative time and has implications for patient safety. The Virtamed ArthroS was released in December 2017 and is the world’s first high-fidelity simulator for ankle arthroscopy. The primary aim of this study was to determine the utility of this arthroscopic simulator for training. Methods: Volunteers were recruited from medical students through to consultants. They performed five arthroscopic procedures under control conditions. A 10-minute demonstration on the setup and operation of the simulator was given prior to testing. Performance was evaluated by obtaining predefined metrics for each procedure within the simulator with photo and video acquisition. A questionnaire was administered to evaluate previous arthroscopic and video gaming experience, levels of stress, usefulness and authenticity. Results: Each arm consisted of a minimum of 5 participants from medical students, foundation level, core trainees, orthopaedic registrars and consultants. All groups demonstrated an improvement in time, economy and safety with 20 minutes exposure, reporting high levels of satisfaction and usefulness. Conclusion(s): The Virtamed ArthroS ankle module provides an authentic simulated experience for all levels of training with demonstrable improvements in performance, anatomy knowledge and reductions in adverse events. In the current climate of reduced working times and increased indicative arthroscopy numbers for completion of training the real-world benefits for orthopaedic trainees is promising., Introduction: Colorectal cancer (CRC) is the 4th most common cancer in the UK and approximately 50% of colorectal cancers demonstrate mutations in TP53. Cdc7 kinase is a protein with essential functions in DNA replication initiation and cell-cycle checkpoint responses. It is up- regulated in malignant cells, especially in the presence of a functional TP53 mutation. Aims: To utilise cdc7i to exploit TP53 mutation in CRC, either alone or in combination with current standard of care (SoC) therapies. Methods and Results: Using in-vitro analyses of a novel cdc7i (LY3177833), CRC cell lines with functional mutations in TP53 have an increased sensitivity to cdc7i. Additionally these cells arrest within S and G2/M phases of the cell cycle. SoC chemotherapy in CRC elicits an S- and G2/M- phase accumulation in cells which lack functional p53, with an increased dependency on DNA replication checkpoints, in which cdc7 is involved. Combinations of LY3177833 and SoC chemotherapy significantly reduced long-term survival in cells lacking functional p53. Discussion: Cdc7i either alone or in combination with SoC in CRC, may represent a potential future treatment option, particularly in TP53 mutant CRC. A phase 1 clinical trial of a novel cdc7i as monotherapy is ongoing., Introduction: INR is one of the most common laboratory tests among hospital inpatients. Coaguchek point of care (POC) system has been introduced as a fast and minimally invasive alternative to standard laboratory INR testing in some hospitals. Aims: To assess the correlation between Coaguchek POC and STAGO lab INR readings. Methods: Prospective study involving all patients on warfarin on a single ward. POC and lab readings were taken at the same time and compared. The product-moment correlation coefficients (PMCC) were calculated for various INR ranges. Results: 73 paired samples were received. 62(86%) POC INR readings were higher than lab readings. When lab INR> 2.0, 17 of 35 (49%) POC INR were higher by more than 1.0. Linear correlation between POC and lab INR was strongest between lab INR 1.0-2.0 (PMCC 0.94) but weakens at higher values. When POC INR is between 2.0-3.0, 13 of 24 (54%) lab INR were also between 2.0-3.0. Discussion: Coaguchek system has been recommended by NICE for outpatient self-monitoring. Our data cast significant doubt in its use in hospital inpatients as lab substitute. Inpatient procedures or medications such as enoxaparin may account for the significant difference., Introduction: Submucous clefts are a variant of cleft palate, usually signified by the presence of a bifid uvula. Patients with a submucous cleft tend to present later than patients with complete cleft defects resulting in late primary repair and potentially irreversible speech and language problems. Aim: To review submucous cleft repairs as the rates were increasing in our unit. Methods: The Northern Ireland cleft lip and palate database was used to identify patients born with a submucous cleft over a 7 year period, 1988-1995, and a further 7 year period 15 years later, 2003-2010, for comparison. The Electronic medical records system and the joint cleft palate clinic database were used to collect the data required. Results: A significant rise in submucous cleft numbers over a 15 year period, from 6 to 25 cases. Average age at primary repair reduced from 6 to 5.2years. The unrepaired rate increased from 17->24%. Significant reduction noted in: total length of hospital inpatient stay from 6.3 to 2.7days and total outpatient appointments from 11.7 to 5.3. Conclusions: This review highlights significant changes in the detection and management of patients with a submucous cleft over a 15 year period. Adequate provision must be made to resource the rising demands of cleft surgery., Introduction: The Cleft Nurse Specialist (CNS) plays a key role in counselling and supporting parents from the diagnosis onwards. Aim: The CNS started in 2012 and we aimed to perform a qualitative study to determine the benefits this brought to the cleft community from the parents’ perspective. Methods: The cleft database was used to locate babies born in 2010/2011 and 2013/2014. Parents were contacted by phone and completed a questionnaire on the care and support they received following the diagnosis. Results: Parents of 38 babies completed the survey. In 2010/2011 only 21% had an antenatal diagnosis compared to 47% in 2013/2014. In 2010/2011 68% were counselled by a surgeon, 42% were seen >1week after birth, with some over a month. In 2013/2014 84% were counselled by the CNS, 53% were seen within 48 hours and 100% within 7 days. Parents in 2013/2014 felt more supported by the cleft team throughout pregnancy and the early days, with home visits being particularly advantageous. Conclusion: The introduction of the CNS to the cleft multidisciplinary team has significantly improved the pathway for parents and is a key link with the wider cleft team., Introduction: The diagnosis of cleft lip and/or palate (CLP) can be a difficult time for expectant parents. Antenatal diagnosis ensures the cleft team can spend time with the parents counselling them regarding potential difficulties their baby may have in the early weeks of life as well as providing a support network. Aim: NHS guidelines target: 75% of babies born with a cleft lip should be diagnosed on antenatal ultrasound. Methods: The regional cleft lip and palate database was reviewed over a 5 year period (2014-2018). Numbers of babies born with CLP and rates of antenatal ultrasound diagnosis were reviewed. Results: Over the 5 year period 168 babies were born in the regional unit with CLP. Those with involvement of the lip (cleft lip only or cleft lip and palate) made up 55% of the cohort (92/168). Overall the rate of antenatal detection over the 5 years was 79% (73/92). The annual rates were; 2014: 75%, 2015: 74%, 2016: 89%, 2017: 77%, 2018: 86% Discussion: Over the past 5 years the antenatal diagnosis rate has remained above the NHS guideline target. We are striving towards 100% in the future to ensure parents are counselled antenatally and have time to adjust to the diagnosis before birth., Introduction: Overactive bladder (OAB) is a prevalent, distressing condition. Approximately 40% women will not respond to routinely offered non-invasive interventions (1). Evidence is accruing for the effectiveness of Transcutaneous- Posterior-Tibial-Nerve-Stimulation (TPTNS) (2). This qualitative study is part of a mixed-methods, randomised, feasibility trial of TPTNS in the home versus hospital setting. Quantitative results will be reported separately (NCT03727711). Aims: To explore experiences of women having TPTNS in home and hospital and discover perceived barriers/ facilitators to self-management. Methods: Identification of a subgroup from the larger trial, with a purposive sample of 8 women from each group. Thematic analysis using the method proposed by Braun and Clarke (Nvivo 12 software used) (3). Results: A total of 16 women were interviewed (8 home, 8 hospital). Mean age: 60 years (range 42-78 years). Data saturation was achieved. TPTNS was described as providing ‘confidence’ in addition to physical benefits. Home treatment was viewed favourably as ‘convenient’, especially if the participant was bound by work commitments. Cost of purchasing the machine was seen as a barrier to future use. Discussion: This analysis highlights the willingness of women to use TPTNS as part of a self-management strategy; treatment at home was favoured among those who were working., Introduction: OASIS is a relatively common complication following childbirth with an increasing overall rate which is possibly due to improved reporting and better recognition. Aims: To determine the risk factors for obstetric anal sphincter injuries (OASIS) and to investigate the mode of delivery and recurrence rate in future pregnancies. Methods: A retrospective cohort study of singleton deliveries in the South Eastern trust between April 2012 and March 2017 (n=59236) Results: The overall OASIS rate was 3.7% (593/59236). There was a significantly increased risk of OASIS with an instrumental delivery (p4kg (p25 (p, Introduction: The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is well recognised. Although typically asymptomatic at presentation, VAI can result in neurological deficit, stroke and death. Depending on injury grade and site, management can range from observation, to medical, endovascular and surgical intervention. Aims: To determine the incidence and clinical features of VAI amongst patients found to have cervical spine fractures presenting to the Royal Victoria Hospital, and to establish current practice regarding VAI management. Methods: A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period was conducted. Results: Sixty-eight patients were found to have acute cervical spine fracture. Of these, five (7.4%) were diagnosed with VAI, all of which resulted from fractures of the upper cervical vertebrae following high-energy trauma. One patient sustained an incomplete spinal cord injury. All five patients underwent repeat CT-angiography, none of which demonstrated injury progression. Three patients were commenced on aspirin therapy, one of whom also underwent posterior cervical stabilisation. Discussion: CT-angiography is recommended following identification of fractures involving the foramen transversarium or Type C/ subluxation-type injuries and should also be considered amongst those sustaining upper cervical fractures., Introduction: Management of Dysplastic naevi (DN) is controversial with opinion divided regarding their significance. A recent systematic review and US multi-centre study evaluated subsequent cutaneous melanoma (CM) risk in patients with DN but a paucity of outcome data remains amongst UK and Irish patients. Aims: To evaluate long-term outcomes of histologically confirmed DN in a Northern Ireland Healthcare Trust and incidence of subsequent CM. Methods: Retrospective study of histologically confirmed DN recorded in Trust Pathology Database between 01.01.2008 - 31.12.2013. Cases analysed for demographics, referral source, site, procedure, margins, severity and development of CM. Results: 248 reports were evaluated in 237 patients (104 male, 133 female). Median (range) age 44 (16,82) and mean follow-up period 7.5 years. 93% of DN were removed by excisional biopsy (93%). The back was commonest anatomical site (39%). The majority of cases had clear histological margins (93%). No patients developed CM at the site of a previously excised DN. 2.53% (6/237) patients developed subsequent CM at separate site. Discussion: This is the first long-term study of outcomes for patients with DN in Northern Ireland. Findings support previous studies suggesting subsequent CM risk is low in patients with histologically confirmed DN without prior history of CM., Introduction: Risk-prediction scoring systems are widely used by surgeons to calculate operative morbidity and mortality. They help to stratify level of post-operative care, enable patients to make a fully informed consent and facilitate surgical audit and comparison of units’ performance. Multiple systems have been used for prediction of patient outcome following abdominal aortic aneurysm repair; not much has been done in patients undergoing MLLA. Aim: Our aim was to evaluate VPOSSUM for accuracy of prediction of early mortality and morbidity following MLLA. Methods: Retrospective case review of MLLA carried out in a regional vascular service between Jan-2014 and Jul-2017. Demographic, pre-operative, operative and post-operative data were collected from patient notes and hospital database. VPOSSUM scores were calculated for every procedure and compared with observed morbidity and mortality using SPSS. Results: 181 patients (male=133, female=48, average age 67.6y) underwent MLLA during this study period. Of these, 20 had re-interventions. Revision to a higher level was required in 7 patients on ipsilateral limb within a mean 14.3 days (range=5-33). 13 patients required MLLA on contralateral limb within a mean 216 days (range=5-648). 7 patients had bilateral MLLA at the same session; these procedures were recorded as a single event. Therefore, total number of events was 201. Receiver-Operator Curve (ROC) showed an area-under-curve (AUC) of 0.833 (95% CI 0.740-0.926) for 30-day mortality, suggesting that VPOSSUM was a good score for predicting patient outcome; but was poor for predicting post-operative morbidity (AUC 0.640 (95% CI 0.556-0.724)). Discussion: VPOSSUM performed well with respect to predicting 30-day mortality in patients following MLLA and could be used to stratify patients’ risk from surgery, thus helping us plan level of post-operative care for this group of patients., Introduction/Aim: Oesophagectomy is a complex procedure and associated with high morbidity and mortality. In an effort to reduce the postoperative morbidity associated with open esophagectomy, laparoscopic-assisted oesophagectomy (LAO) has been introduced and developed in recent years. The aim of this study was to present our experience with LAO and assess surgical and oncological outcome and survival. Methods: 100 patients were identified from a prospectively- filled database from July 2010-2017 at a tertiary referral centre. All underwent MIO performed by a single consultant surgeon. Laparoscopic abdominal and trans-hiatal phase plus mini-thoracotomy was performed. Outcome data was retrieved from hospital, laboratory, GP, NHS Spine and coroner’s records. National average (NA) statistics were obtained from National Oesophago-gastrectomy Cancer Audit (NOGCA) 2016 and 2018. Results: Median age of patients 68y (range=41-80). 85% male, 15% female. Pulmonary complications were most common (pneumonia 34%, pleural effusion 19% and pneumothorax 8%). 5% patients had an anastomotic leak. 30- and 90-day mortality was 1 and 2% respectively, compared to NA of 2.4 and 3.9%. Median length of stay 11.5d compared to NA of 9d. Median number of lymph nodes excised was 17 (range=3-32); 58% patients had adequate number of lymph nodes examined (>15). 3-year survival for Stages 1, 2 and 3 was 86.1, 85.7 and 35.3% respectively, compared with NA of 84, 71, and 34%. Discussion: LAO appears to offer marginal benefit to open surgery and is not inferior in the outcomes measured here. This is consistent with current RCTs and adds to the growing body of evidence supporting minimally-invasive surgery., Introduction: Severe fingernail glue burns arising from the exothermic polymerization reaction of cyanoacrylate with the cellulose in cotton fibres have been documented. However, warnings on nail glue bottles, packaging and websites remain poor. We also consider what the optimal first aid should be for such an injury and suggest the publication of this for nail glue consumers, practitioners and pharmacists. Description of Case: A healthy 18-year-old female spilled nail glue whilst applying her acrylic nail tips. The glue eroded through her jeans to leave a substantial deep partial thickness burn on her left medial thigh. No first aid was given. The burn was managed conservatively with silver-impregnated dressings and regular follow-up. Discussion: Review of literature highlighted that pre-teen and teenage girls are most at risk with the majority of incidents occurring in this age group. They are also at high risk of surgical intervention with 80% requiring excision and splitthickness skin grafting compared to 0% of the young children described. The authors recommend publication of first aid advice including: removal of the source - immediate removal of clothing unless already adherent to skin (soak first) and reducing the temperature of the skin as rapidly as possible to minimize thermal injury by soaking in cool water., We report an unusual case of a nineteen-year-old man with Wolff-Parkinson-White syndrome who successfully underwent accessory pathway catheter ablation but subsequently suffered ST segment myocardial infarction (STEMI) through a previously unrecognised mechanism. Post-ablation, the patient complained of new and severe central chest pain. Electrocardiography suggested inferior STEMI and coronary angiography revealed a distal occlusion of the posterior left ventricular branch of the right coronary artery. Flow was established using a ‘standard’ angioplasty wire and a 2.5mm compliant balloon. Given the vessel’s tendency to recoil, despite using a drug coated balloon, stent insertion was necessary to maintain luminal patency. Intravascular ultrasound revealed an oedematous extrinsic compression at the site of the lesion. Subsequent high sensitivity Troponin T assay and echocardiogram were consistent with posterior myocardial infarction. Immediate ECG changes following catheter ablation have been acknowledged and linked to the proximity of ablation site and coronary arteries. This is the first case of post-ablation STEMI caused by oedematous extrinsic coronary obstruction we have noted in our facility, and we have not found any other report in the literature. We recommend that patients describing new post-procedural chest pain should undergo urgent clinical and ECG assessment to consider ischaemia., Introduction: Aortic dissection is a devastating cause of mortality in patients with connective tissue disorders. Personalised external aortic root support (PEARS) is a pioneering approach that utilises a personalised 3D mesh to prevent aortic root dissection without the need for anticoagulation. Description: We describe a retrospective case series of all PEARS procedures performed to date at the Cardiac Surgical Unit, Belfast. Twelve patients have undergone the PEARS procedure of which 2 had concomitant mitral valve repair (9 males; 3 females; median age: 37 years). All cases had evidence of aortic root dilatation. The procedure was technically successful in all cases. Complications: 6 developed tachyarrhythmias, 3 demonstrated ST changes not in keeping with infarction, 1 developed a right coronary artery pseudoaneurysm requiring reoperation and 1 developed circumflex artery occlusion requiring bypass grafting. There were no deaths. The median total hospital admission was 8.5 days (range: 6 – 118 days). Discussion: Although our experience thus far is limited, we demonstrate that a single centre can safely establish a PEARS programme. Our experience highlights the significant learning curve associated with beating heart dissection. Nevertheless, the PEARS procedure offers young patients the advantage of avoiding lifelong warfarin therapy whilst likely preventing further expansion of aortic root aneurysms., Introduction: Timely diagnosis of osteomyelitis is essential for its successful treatment but it is often difficult to recognise despite extensive radiological workup. Case: We outline a case of recurrent sepsis over a seven year period in a patient injured by a car bomb blast and the use of an innovative imaging technique to localise two culprit foci of osteomyelitis. This was a prolonged and difficult diagnosis due to extensive shrapnel injury and associated inflammation as well as significant anatomical disruption from the blast. Discussion: Sites of inflammation associated with shrapnel injury acted as decoys to the true foci of active infection on Fluorodeoxyglucose (FDG) Positron emission tomography/ Computed Tomography) (PET/CT) and a new technique was required to differentiate these. This involved administering a course of antibiotics between two separate FDG-PET/ CT scans and is known as Subtraction PET. Two sites of osteomyelitis were identified among 20-30 other sites of benign granulomatous inflammation and calcification. These two sites of infection were characterised by a significant drop in tracer uptake on FDG-PET/CT after a course of antibiotics while tracer uptake at the remaining sites remained relatively unchanged. This ultimately guided surgical excision of the sequestra and at follow up of two years, the patient has experienced no further septic episodes., Introduction: Over the new year period we recognised a high number of admissions with complications following cosmetic surgery abroad. We aimed to determine the driving forces behind this and financial impact on the NHS. Cases: 6 patients were admitted to the regional unit after independently organising surgery abroad. Countries visited included; Turkey, Belgium, Poland, Estonia and India. Reasons included; cost and access to procedures not recommended by UK surgeon. Type of surgery included; Breast (5), abdominoplasty (2), liposuction (2), labiaplasty (1) and 50% had multiple procedures. Complications included; necrotic wounds (33%), infected breast implant (33%), VTE investigated (33%), wound infection (17%). Overall, 67% required surgery on the NHS. The estimated total cost was £23,976.82 with an average of £4000/patient. Discussion: This surge in cosmetic complications occurred over the New Year. Complications were seen after a range of surgical procedures. All patients required an inpatient stay and 2/3 required surgery with a significant cost burden to the NHS. Patients are unaware of the risks involved, highlighted by the lack of pre-operative counselling and follow up. In addition, this series has highlighted the risks associated with travelling in the peri-operative period., Introduction: Dysarthria is one of the commonest neurological speech disorders resulting from brain injury. It adversely affects psychosocial functioning and rehabilitation due to the inability to communicate effectively. In the majority of patients, it is irreversible. It may be possible to improve the intelligibility and articulation of speech with a pharyngoplasty procedure. This procedure is more commonly performed in patients with velopharyngeal insufficiency (VPI) and a cleft palate. Methods: Data was collected from the regional plastic surgery unit over a ten-year period. Medical records and speech and language notes were reviewed. Outcomes; speech improvement, complications and need for surgical revision. Results: Six patients had a pharyngoplasty. Either a Hynes or the Jackson variant of a flap pharyngoplasty were performed. The majority were male (5/6). Mean time between injury to surgery; 5-years. Overall, 83% of patients had a clear improvement in speech intelligibility and articulation. One patient experienced self-limiting sleep apnoea and one patient developed obstructive symptoms and required a revision. Discussion: We have shown that surgical intervention is an effective method of improving speech intelligibility and articulation in patients with both traumatic brain injury and following CVA. Although speech and language therapy is the pillar of management, certain patients have the potential to benefit further from surgical intervention. The aim of this paper is to highlight this option and heighten the awareness that a pharyngoplasty has the potential to make a significant difference to the lives of patients with brain injury by restoring communication., Introduction: Forces capable of causing chyle leak usually result in bowel and pancreatic injury. High index of suspicion required to avoid missing concurrent injuries. Only 10 reported isolated chyle leaks following blunt trauma. Description: A 34-year-old male presented with a blunt injury to the epigastrium after falling onto the handlebar of a bicycle. On examination, he had epigastric tenderness with no evidence of peritonism. CT demonstrated a fluid collection posterior to proximal jejunum, with appearances suggestive of jejunal perforation but no free air was observed. The patient developed worsening generalised abdominal pain 12 hours after admission. Clinical examination revealed 4-quadrant peritonism, prompting an emergency laparotomy. At laparotomy, no free fluid was observed. Retroperitoneally, milk-coloured diffuse fluid infiltration was noted. Inspection of the duodenum, small bowel and pancreas revealed no obvious injury. Drains were placed at the tail and head of the pancreas where largest pooling of fluid. There was an uncomplicated post-operative recovery with discharge at day 6. Discussion: Diagnostic uncertainty intra-operatively prompted an urgent radiological consult on CT imaging, suggesting pancreatic transection. Intra-operative amylase analysis of the retroperitoneal fluid guided surgical management, which would otherwise have proceeded with a distal pancreatectomy and its associated consequences., Introduction: All psychiatrists will encounter patient suicide during their careers, however little has been written about the impact this can have on them, professionally and personally. Aims: To examine the unconscious communications between suicidal patients and psychiatric trainees based on the trainees’ lived experience. To consider how this data could be used to support trainees in their clinical practice, and inform and shape institutional processes, such as serious adverse incident reviews, as well as the training programme. Methods: Semi-structured interviews were carried out with 3 psychiatry trainees and the material analysed using Interpretative Phenomenological Analysis (IPA). Results: Three main themes were identified, namely “A Deep and Painful Wound”, “Strategies for Survival”, and “A Path to Recovery”. They describe how patient suicide affected the participants personally and professionally, how their colleagues and the organisation responded to them and their thoughts about what was helpful and what could be changed in future. Discussion: Losing a patient to suicide can be an extremely distressing, isolating and anxiety provoking experience All trainees felt that the training programme inadequately prepared them for it, and it is important that training organisations address this., Introduction: In 2014, NCEPOD reported hospital patient care for those with tracheostomies and laryngectomies posed significant safety issues. Subsequently Intensive Care Society guidelines stipulated staff exposed to such patients be competent in managing airway emergencies. Medical patients with tracheostomies and laryngectomies are typically cared for by junior doctors yet juniors often express concern in respect to managing such patients, particularly in the emergency setting. Aim: To establish junior doctor training for tracheostomy and laryngectomy patients.Evaluate junior doctor confidence in the acute and nonacute assessment of such patients. Methods: Junior doctors attached to the acute medical and respiratory wards of a local hospital were invited to complete an online survey regarding previous training and their current confidence regarding managing tracheostomy and laryngectomy patients. Results: Twenty-four junior doctors received the survey with 18 respondents. 55.56% reported previous undergraduate training in this area with 44.4% receiving postgraduate training. Despite this, 77.7% of respondents stated they were not confident in conducting routine reviews of patients with trachyectomies or laryngectomies. 66.6% did not feel confident in managing an acutely unwell patient with a tracheostomy/laryngectomy with 66.6% stating they were ill equipped to manage an airway emergency in such patients. Respondents felt simulation (88.8%) and clinical bedside teaching (77.8%) would improve their confidence. Conclusion: Results indicate junior doctors working with tracheostomy and laryngectomy patients demonstrated low confidence, both in the acute and non acute management setting, an issue which may generate significant patient harm. Evidently there is a need for additional training with the authors proposing such training form a formal component of hospital induction., Aim: To determine if students and paediatric trainee doctors level of knowledge meets a non-faculty clinician-determined minimum accepted competency (MAC). Methods: A 30-item multiple-choice (MCQ) paper (MAC exam) was created, formed of questions proposed by practising non-academic consultant paediatricians, which are deemed as ‘must know’ for paediatric trainees prior to commencing clinical work. A ‘passing score’ was determined using the Angoff technique by the paediatric faculty. The paper was given to undergraduate students and also paediatric senior house officers (SHO’s). Student’s performance on the MAC was compared with their performance on their official university examination. Test item analysis and psychometrics were also performed. Results: The passing score was determined at 13/30 (41.2%) 366 undergraduate students participated. Mean score 45.9% (s.d 9.9%, range 23-73%). 240/366 (65.4%) of students achieved the passing score whereas 99% of these students passed their official university exam. However, positive correlation between students result in the MAC exam and results from their official university exams (spearman R=0.44. p, Introduction: The SHO rota (first on call) in most hospitals is staffed mainly by GP specialty trainees or Foundation doctors on rotation. They are required to attend obstetric emergencies whilst on call. This can be a daunting experience as there is limited postgraduate training for non-specialty trainees in O+G. Aims: Improve training, confidence + competence for all non-specialty trainees in managing obstetric emergencies. Methods: An afternoon of simulation based training was held for all junior doctors currently working in O+G within the SEHSCT. Scenarios included shoulder dystocia, PostPartum haemorrhage, maternal collapse and eclampsia. A questionnaire was completed by all delegates pre and post training. Results: All delegates reported a significant increase in confidence to manage obstetric emergencies for all scenarios post training. Discussion: Working within O+G can be a daunting experience for non-speciality trainees covering the SHO rota. This programme has shown that simulation based training in managing obstetric emergencies not only will improve the clinician’s confidence and competence but also will improve patient safety., Problem: The poor compliance to local guidelines for antibiotic prescription in acute cholecystitis and cholangitis. Strategy for change: A 3 week prospective review of antibiotic prescription in all patients admitted with suspected or confirmed acute cholecystitis or ascending cholangitis. 22 patients admitted within audit window, 18% of which received correct antibiotics. Teaching delivered to surgical team on current antibiotic guidelines and appropriate escalation, information posters displayed in ED and wards and guidelines included in trust induction pack. Measurement of Improvement: Following education on correct prescription, further audit period carried out. 25 patients admitted with suspect or confirmed diagnosis, 84% of which received correct antibiotic therapy as per local guidelines. Effects of change: Correct education to surgical and emergency department staff led to an improvement of 66% in compliance to local antibiotic guidelines. Discussion: Acute cholecystitis and cholangitis are some of the most common presentations on the acute surgical ward, with the mainstay of treatment being intravenous or oral antibiotic therapy, IV fluids and analgesia. Correct antibiotic therapy can ultimately lead to improved patient safety and avoid future potential antibiotic resistance., Problem: Preparing accurate discharge documentation is a central aspect of good clinical practice in accordance to guidelines outlined by SIGN. Seeking clarification regarding a patient’s medications, follow up and correct diagnosis is a common, time-consuming frustration for F1 doctors upon discharge. Strategy for change: A commonly used acronym, ‘MFD’ – ‘Medically Fit for Discharge’ was modified to ‘Medications, Follow up, Diagnosis’ as an aide memoire. We aimed to improve the inclusion of ‘MFD’ information in the notes/ kardex by 50%. Measurement of Improvement: F1s completing discharge letters collected ‘MFD’ data from 100 patients. Baseline data was recorded and two PDSA cycles implemented; Cycle 1 – presentation delivered at departmental teaching and Cycle 2 – posters outlining MFD placed at ward level. Effects of change: At baseline, 20% of discharge letters had ‘MFD’ documented without need for further enquiry. Following PDSA cycles 1 & 2, full documentation was 54% and 62% respectively, representing a 210% improvement from baseline. Discussion: The MFD acronym use increased significantly following simple interventions. Follow-up information was the most commonly omitted. Scope for further improvement includes: Qualitative data regarding time improvement for F1s comparison of consultant diagnosis versus immediate discharge summary diagnosis., Problem: For vascular access in haemodialysis (HD) the mantra is ‘arteriovenous fistula first’ as one benefit is a reduction in bacteraemia incidence. However, a significant proportion of the HD population require a central venous catheter (CVC) for dialysis. Thus, the morbidity and mortality associated with CRB is a relevant and preventable problem. Strategy for change: 2009-11: Improved documentation to facilitate prospective monitoring of CRB rates. 2011: Antimicrobial catheter locks implementation. 2012: Monthly infection MDT meetings. 2016: Visual CVC score streamlined to increase detection of exit site infection (a CRB precursor). 2016: A ‘DRESS’ survey implementation to ensure exit site covered. 2016: Process for swab result review. Measurement of Improvement: CRB rates are quoted between 0.6 – 6.5/1000 catheter days in international studies. Prior to practice change, our unit CRB incidence was 0.41/1000 catheter days. Present incidence is 0.17/1000 catheter days representing a >50% reduction. Effects of change & Discussion: Introduction of antimicrobial catheter locks produced the most significant impact on CRB rates however; it has been the establishment of a collaborative quality improvement culture within the Ulster Renal Unit that has sustained improvement. Meaning for patients, the chance of getting a CRB is 3.5 times less than the lowest rate quoted in the literature., Problem: The gold standard for diagnosis of acute pulmonary embolism (PE) is radiological investigation with Computed Tomography Pulmonary Angiogram (CTPA). Patients undergoing CTPA examinations receive a full volume CT scan of the chest (lung apices to extreme bases) which, after reviewing literature, is unnecessary and leads to higher than necessary radiation doses to the patient. Strategy for Change: Audit current practice to find out radiation dose to patients having CTPA examinations and ascertain whether important diagnoses would be missed by the introduction of a truncated scan range from aortic arch to base of heart. Measurement of Improvement: Re-audit after the implementation of the truncated scan range to see if there is a significant reduction in radiation dose to the patient. Effects of change: Reducing the scan range form aortic arch to base of heart results in an average dose reduction of 56% to the patient whilst still being able to accurately diagnose acute pulmonary embolus. Discussion: With increasing requests for CTPA studies, using the principle to keep radiation dose ‘as low as reasonably possible’, a reduced scan range can help to reduce radiation dose to patient whilst still maintaining diagnostic accuracy., Problem: No pre or post list briefs were being performed in the RVH trauma theatres Strategy for change: A formal pre-list brief and post-list debrief was implemented into two orthopaedic operating theatres over a 2 week period (January 2019). All operating lists were included (15 lists). A post-implementation survey was performed assessing impact (n=17). Measurement of improvement: The initial audit identified non-adherence to mainland policy of pre and post list briefs. All staff surveyed before introduction of pre-list briefing felt it would improve communication, patient safety, staff morale and theatre efficiency thereby advocating its introduction. Resurveyed staff confirmed improvement of each factor by 65%, 47%, 53% and 53% respectively. Effects of change: Furthermore >75% staff surveyed before introduction of post-list debriefing felt it would aid identification of issues and improve communication, which on resurveying equated to and improvement 59% and 71% respectively. Discussion: Our initial audit highlighted non-adherence of NPSA guidance. This project supports the implementation of pre and post list briefing. They take minimal time and can save significant time overall, reducing delays and identifying issues early., Problem: 25% of N.Ireland’s children are overweight/obese but there has been a lack of specialist services to support children with BMI> 98th centile achieve a healthier weight. Strategy for Change: We launched N.Ireland’s first multidisciplinary paediatric obesity service in May 2019. Children are referred from school nurses, general practitioners and paediatricians. Families are invited to participate in holistic assessment by a paediatrician, physiotherapist, associate psychologist and dietician. Measurement of Improvements: Outcome measures including BMI, 6-minute walk test, grip strength, blood pressure, dietary history and quality-of-life are assessed at baseline, 3,6 and 12 months. Parents/siblings also have their weight/BMI monitored. Personalised family plans are co-produced. Treatments include educational evening classes and/or one-to-one input from dietetics/physiotherapy/ psychology. Effects of Change: Currently 30 children (4-16 years) have attended multidisciplinary assessments and are in the treatment phase. 8 families completed the first 5-week cycle of evening classes. Attendance averaged 73%. 75% (6/8) reduced their BMI including one family who collectively lost >12kg. One child’s BMI increased, and another’s remained static. Discussion: After positive family feedback we have extended our evening programme to 6-weeks, introduced appointment text reminders and developed a more extensive outreach programme with local councils. We are excited to recruit more families and develop a sustainable business plan for this gap in paediatric services., Problem: Paediatric burns referred to Plastic Surgery are often given an appointment within the week to attend Paul Ward (RBHSC) for assessment. Plastics trainees are not always scheduled to work in RBHSC however, and the closest staff are in the Burns Unit (RHV). Trainees there manage the ward, admissions, theatre and clinics and so leaving is difficult. Strategy for change: The aim was to encourage appointments to be made on days where staff work in RBHSC. Weekly rota was not being sent to staff nurses, and there were issues in interpreting it. Interventions: Ensuring rota sent to ward staffTeaching session to Plastics traineesEnsuring ward staff understand rota Measurement of Improvement: Change measured by percentage of days medical staff were required that they were scheduled to be in RBHSC. Effects of change: In February 2019 staff were present on 16% of the days they were required, rising following interventions to 88% in June 2019. Discussion: It is not realistic to achieve 100%, as emergency admissions should not be delayed. However where there is flexibility it is better for patient and staff if assessments can be carried out promptly., Problem: Patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. It is medical professionals’ responsibility to advise patients to adhere to DVLA guidelines. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition. Strategy for change: Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Outcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in % Process: Document in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for. Effects of change: After cycle 3, there was an increase of mean of 25% completeness of driving advice to over 90%. Discussion: This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback., Problem: 50-70% of hospitalised patients without a formal diagnosis of Diabetes Mellitus will develop corticosteroid- induced hyperglycaemia. An audit cycle conducted on an inpatient respiratory ward identified deficiencies in recognising and treating this common, but important complication of steroid therapy- some 90% of clinical episodes failed to comply with national and trust guidance. Strategy for change: A PDSA cycle was employed to address this issue, with focus placed upon 3 key areas: Multi-disciplinary educational seminarsChanges in ward-based documentsEnhancing accessibility of guidelines through poster displays. Measurement of Improvement: Closed loop audit cycle (n=140) of blood sugar monitoring frequency, HBa1c measurement and implementation of appropriate hyperglycaemic therapy compared with national standards. Effects of change: Universal improvements in audited standards with >90% of patients on appropriate monitoring regimes and >50% receiving appropriate hyperglycaemic therapy. Discussion: Corticosteroids are employed by physicians in a variety of clinical circumstances. Corticosteroid-induced hyperglycaemia is a common but often overlooked side effect, with important implications for inpatient morbidity and mortality. National and Hospital Trust guidance is readily accessible but requires multi-disciplinary engagement for effective implementation.

This randomized clinical trial compares the need for re-treatment of respiratory infection following hospitalization for community-acquired pneumonia among children receiving amoxicillin at high doses vs low doses and at 3-days vs 7-days duration. Question For children with community-acquired pneumonia discharged from an emergency department, observational unit, or inpatient ward (within 48 hours), is subsequent outpatient treatment with oral amoxicillin at a dose of 35 to 50 mg/kg per day noninferior to 70 to 90 mg/kg per day, and is a 3-day course noninferior to 7 days, with regard to the need for antibiotic re-treatment? Findings In this 2 x 2 factorial randomized clinical trial of 814 children requiring amoxicillin for community-acquired pneumonia at hospital discharge, antibiotic re-treatment within 28 days occurred in 12.6% vs 12.4% of those randomized to lower vs higher doses, and in 12.5% vs 12.5% of those randomized to 3-day vs 7-day amoxicillin duration. Both comparisons met the prespecified 8% noninferiority margin. Meaning Among children with community-acquired pneumonia discharged from an emergency department, observational unit, or inpatient ward, further outpatient treatment with oral amoxicillin at a dose of 35 to 50 mg/kg per day was noninferior to a dose of 70 to 90 mg/kg per day and 3 days was noninferior to 7 days with regard to the need for later antibiotic re-treatment. Importance The optimal dose and duration of oral amoxicillin for children with community-acquired pneumonia (CAP) are unclear. Objective To determine whether lower-dose amoxicillin is noninferior to higher dose and whether 3-day treatment is noninferior to 7 days. Design, Setting, and Participants Multicenter, randomized, 2 x 2 factorial noninferiority trial enrolling 824 children, aged 6 months and older, with clinically diagnosed CAP, treated with amoxicillin on discharge from emergency departments and inpatient wards of 28 hospitals in the UK and 1 in Ireland between February 2017 and April 2019, with last trial visit on May 21, 2019. Interventions Children were randomized 1:1 to receive oral amoxicillin at a lower dose (35-50 mg/kg/d; n = 410) or higher dose (70-90 mg/kg/d; n = 404), for a shorter duration (3 days; n = 413) or a longer duration (7 days; n = 401). Main Outcomes and Measures The primary outcome was clinically indicated antibiotic re-treatment for respiratory infection within 28 days after randomization. The noninferiority margin was 8%. Secondary outcomes included severity/duration of 9 parent-reported CAP symptoms, 3 antibiotic-related adverse events, and phenotypic resistance in colonizing Streptococcus pneumoniae isolates. Results Of 824 participants randomized into 1 of the 4 groups, 814 received at least 1 dose of trial medication (median [IQR] age, 2.5 years [1.6-2.7]; 421 [52%] males and 393 [48%] females), and the primary outcome was available for 789 (97%). For lower vs higher dose, the primary outcome occurred in 12.6% with lower dose vs 12.4% with higher dose (difference, 0.2% [1-sided 95% CI -infinity to 4.0%]), and in 12.5% with 3-day treatment vs 12.5% with 7-day treatment (difference, 0.1% [1-sided 95% CI -infinity to 3.9]). Both groups demonstrated noninferiority with no significant interaction between dose and duration (P = .63). Of the 14 prespecified secondary end points, the only significant differences were 3-day vs 7-day treatment for cough duration (median 12 days vs 10 days; hazard ratio [HR], 1.2 [95% CI, 1.0 to 1.4]; P = .04) and sleep disturbed by cough (median, 4 days vs 4 days; HR, 1.2 [95% CI, 1.0 to 1.4]; P = .03). Among the subgroup of children with severe CAP, the primary end point occurred in 17.3% of lower-dose recipients vs 13.5% of higher-dose recipients (difference, 3.8% [1-sided 95% CI, -infinity to10%]; P value for interaction = .18) and in 16.0% with 3-day treatment vs 14.8% with 7-day treatment (difference, 1.2% [1-sided 95% CI, -infinity to 7.4%]; P value for interaction = .73). Conclusions and Relevance Among children with CAP discharged from an emergency department or hospital ward (within 48 hours), lower-dose outpatient oral amoxicillin was noninferior to higher dose, and 3-day duration was noninferior to 7 days, with regard to need for antibiotic re-treatment. However, disease severity, treatment setting, prior antibiotics received, and acceptability of the noninferiority margin require consideration when interpreting the findings.

There has been a drive towards increased digitalisation in healthcare. The aim was to provide a snapshot of current apps, instant messaging, and smartphone photography use in paediatric emergency care. A web-based self-report questionnaire was performed. Individual physicians working in paediatric emergency care recorded their personal practice. One hundred ninety-eight medical doctors completed the survey. Eight percent of respondents had access to institutional mobile devices to run medical apps. Eighty-six percent of respondents used medical apps on their personal mobile device, with 78% using Apple iOS devices. Forty-seven percent of respondents used formulary apps daily. Forty-nine percent of respondents had between 1–5 medical apps on their personal mobile device. Respondents who used medical apps had a total of 845 medical apps installed on their personal device, accounted for by 56 specific apps. The British National Formulary (BNF/BNFc) app was installed on the personal mobile device of 96% of respondents that use medical apps. Forty percent of respondents had patient confidentiality concerns when using medical apps. Thirty-eight percent of respondents have used consumer instant messaging services, 6% secure specialist messaging services, and 29% smartphone photography when seeking patient management advice. Conclusion: App use on the personal mobile devices, in the absence of access to institutional devices, was widespread, especially the use of a national formulary app. Instant messaging and smartphone photography were less common. A strategic decision has to be made to either provide staff with institutional devices or use software solutions to address data governance concerns when using personal devices.What is Known:• mHealth use by junior doctors and medical students is widespread.• Clinicians’ use of instant messaging apps such as WhatsApp is the widespread in the UK and Ireland, in the absence of alternatives.WWhat is New:• Personal mobile device use was widespread in the absence of alternatives, with the British National Formulary nearly universally downloaded to physicians’ personal mobile devices.• A third of respondents used instant messaging and smartphone photography on their personal mobile device when seeking patient management advice from other teams in the absence of alternatives.

Aim: To describe variation in the initial management of children presenting to Emergency Departments (ED) with coins lodged in the oesophagus. To determine the usage of hand-held metal detectors (HHMDs) in EDs, including their role in clinical decision-making, and training in their use. Methods: Online multicentre cross-sectional survey of EDs in the UK and Ireland, with results described using descriptive statistics. Results: Fifty-five (90%) of 61 sites responded. The two main strategies described for lodged oesophageal coins were endoscopic removal or observation with reassessment, dependent on location. For coins in the proximal third of the oesophagus 43/55 (78.2%) referred for endoscopic removal, 6/55 (10.9%) observed and the remaining 10.9% used a variety of methods, including: Foley catheter removal with fluoroscopy, blind Foley catheter removal, referral to paediatric surgery/ENT. Thirty (55%) of 55 used HHMDs, 21/30 (70%) had guidelines for their use, and 3/30 (10%) provided formal training. Twenty (67%) of 30 used the xiphisternum as the anatomical cut-off for assuming safe passage of metallic foreign bodies (FB) beyond the lower oesophageal sphincter. Conclusions: There is considerable variation in the management of oesophageal coins in children, though two dominant strategies were identified. As endoscopy is significantly more invasive than observation, future research should aim to determine whether either is more effective and safer in children. There is a clear division in departmental adoption of HHMDs. However, in those sites using HHMDs there was little formal training in their use, and there are large variations in techniques and their role in clinical decision-making.

Background: No previous studies have validated current clinical practice guidelines for the management of non-blanching rashes in children who have received meningococcal B and C vaccinations. The aim of this study was to evaluate the performance of existing clinical practice guidelines in the diagnosis of invasive meningococcal disease in children presenting with a fever and non-blanching rash in the UK. Methods: The Petechiae in Children (PiC) study was a prospective, multicentre cohort study involving children (aged < 18 years) presenting to 37 paediatric emergency departments in the UK with a fever (≥38°C) and a new-onset non-blanching rash or features suggestive of meningococcal infection. Children with pre-existing haematological conditions (ie, haematological malignancy, idiopathic thrombocytopenic purpura, or coagulopathy) or an existing diagnosis of Henoch-Schonlein purpura were excluded. Invasive meningococcal disease was confirmed by positive culture or a quantitative PCR test for Neisseria meningitidis from either blood or cerebrospinal fluid samples. The primary outcome was the performance of six tailored clinical practice guidelines from participating centres (London, Nottingham, Newcastle–Birmingham–Liverpool, Glasgow, Chester, and Bristol) and two clinical practice guidelines from the National Institutes for Health and Care Excellence (NICE; CG102 and NG51) in identifying children with invasive meningococcal disease, assessed by the sensitivity and specificity of each clinical practice guideline. This study is registered with ClinicalTrials.gov, NCT03378258. Findings: Between Nov 9, 2017, and June 30, 2019, 1513 patients were screened, of whom 1329 were eligible and were included in the analysis. The median age of patients was 24 months (IQR 12–48). 1137 (86%) of 1329 patients had a blood test and 596 (45%) received parenteral antibiotics. 19 (1%) patients had confirmed meningococcal disease. All eight clinical practice guidelines had a sensitivity of 1·00 (95% CI 0·82–1·00) for identifying meningococcal disease. The specificities of NICE guidelines CG102 (0·01 [95% CI 0·01–0·02]) and NG51 (0·00 [0·00–0·00]) for identifying meningococcal disease were significantly lower than that of tailored clinical practice guidelines (p< 0·0001). The best performing clinical practice guidelines for identifying meningococcal disease were the London (specificity 0·36 [0·34–0·39]) and Nottingham (0·34 [0·32–0·37]) clinical practice guidelines. Interpretation: Invasive meningococcal disease is a rare cause of non-blanching rashes in children presenting to the emergency department in the UK. Current NICE guidelines perform poorly when compared with tailored clinical practice guidelines. These findings suggest that UK national guidance could be improved by shifting towards a tailored approach.