Remission of Suicidal Ideation in Emotionally Unstable Personality Disorder with Flupenthixol

There are currently no licensed pharmacological treatments for Emotionally Unstable Personality Disorder. This case report describes a 50-year-old male who two years previously had been brought to the attention of psychiatric services following an overdose with intention to end his life. He was subsequently diagnosed with Emotionally Unstable Personality Disorder (EUPD) and, following further suicide attempts and trials of mainstream pharmacological treatments, responded to flupenthixol IM 20 mg fortnightly, experiencing complete remission from his suicidal ideation. Clinicians should be aware of EUPD presenting in later life and should consider the role of typical antipsychotics, including flupenthixol, in the treatment of suicidal ideation in patients with EUPD. Age-specific guidance on EUPD management would be of use to clinicians, especially in the management of older patients, as current guidance is based on findings within a narrow age group.

The recognition and nursing management of common oncological emergencies in children

An oncological emergency may be the initial presentation of a cancer, a sign of cancer progression, or a complication of cancer treatment. The most frequently encountered paediatric oncological emergencies include neutropenic sepsis, hyperleukocytosis, brain tumours presenting with raised intracranial pressure, tumour lysis syndrome and superior mediastinal syndrome. These are all life-threatening conditions that require urgent recognition and management. Health professionals working in an emergency department (ED) are likely to be involved in managing these children. This article brings together the current guidance and recommendations for these specific emergencies. It also includes two case studies that demonstrate the challenges health professionals can face while managing these situations. It is important that health professionals have an acute awareness of oncological emergencies. Confidence in recognising the presentations, diagnoses and initial management are essential because these conditions may be life-threatening and time critical.

Steroid use in Pregnancy with Severe COVID-19

Managing women who are pregnant with severe COVID-19 is complex. This paper focuses on the debate surrounding steroid use in this group. Unfortunately, despite international efforts to identify treatments for COVID-19, there is very little research which has focussed specifically on pregnant women. Therefore current guidance is based on consensus and expert opinion, with variation in these guidelines worldwide, and reports that 73% of pregnant women do not receive steroids at all. There is an assumption of a steroid class-effect implicit within the UK guidelines for the mother with COVID-19 which is at odds with established within-class differences for effects on the foetus. This now warrants further discussion given the increasing numbers of pregnant women being admitted to hospital with COVID-19.

Towards using state-of-the-art climate models to help constrain estimates of unprecedented UK storm surges

Our ability to quantify the likelihood of present-day extreme sea level (ESL) events is limited by the length of tide gauge records around the UK, and this results in substantial uncertainties in return level curves at many sites. In this work, we explore the potential for a state-of-the-art climate model, HadGEM3-GC3, to help refine our understanding of present-day coastal flood risk associated with extreme storm surges, which are the dominant driver of ESL events for the UK and wider European shelf seas. We use a 483-year present-day control simulation from HadGEM3-GC3-MM (1/4∘ ocean, approx. 60 km atmosphere in mid-latitudes) to drive a north-west European shelf seas model and generate a new dataset of simulated UK storm surges. The variable analysed is the skew surge (the difference between the high water level and the predicted astronomical high tide), which is widely used in analysis of storm surge events. The modelling system can simulate skew surge events comparable to the catastrophic 1953 North Sea storm surge, which resulted in widespread flooding, evacuation of 32 000 people, and hundreds of fatalities across the UK alone, along with many hundreds more in mainland Europe. Our model simulations show good agreement with an independent re-analysis of the 1953 surge event at the mouth of the river Thames. For that site, we also revisit the assumption of skew surge and tide independence. Our model results suggest that at that site for the most extreme surges, tide–surge interaction significantly attenuates extreme skew surges on a spring tide compared to a neap tide. Around the UK coastline, the extreme tail shape parameters diagnosed from our simulation correlate very well (Pearson's r greater than 0.85), in terms of spatial variability, with those used in the UK government's current guidance (which are diagnosed from tide gauge observations), but ours have smaller uncertainties. Despite the strong correlation, our diagnosed shape parameters are biased low relative to the current guidance. This bias is also seen when we replace HadGEM3-GC3-MM with a reanalysis, so we conclude that the bias is likely associated with limitations in the shelf sea model used here. Overall, the work suggests that climate model simulations may prove useful as an additional line of evidence to inform assessments of present-day coastal flood risk.

Steroid use in Pregnancy with Severe COVID-19

Managing women who are pregnant with severe COVID-19 is complex. This paper focuses on the debate surrounding steroid use in this group. Unfortunately, despite international efforts to identify treatments for COVID-19, there is very little research which has focussed specifically on pregnant women. Therefore current guidance is based on consensus and expert opinion, with variation in these guidelines worldwide, and reports that 73% of pregnant women do not receive steroids at all. There is an assumption of a steroid class-effect implicit within the UK guidelines for the mother with COVID-19 which is at odds with established within-class differences for effects on the foetus. This now warrants further discussion given the increasing numbers of pregnant women being admitted to hospital with COVID-19.

Giving travel advice in the uncertain age of COVID-19

As restrictions ease and more people holiday overseas, the importance of providing accurate travel health advice increases. Jacqueline Spinks and colleagues provide an overview of current guidance The COVID-19 pandemic has led to a dramatic drop in people travelling to other countries for pleasure; however, now that restrictions across the UK are easing, more people are seeking a break and a long-awaited holiday overseas. Practice nurses are uniquely placed to provide travel advice not just in relation to COVID-19 requirements and restrictions, but also to remind travellers of the importance of being prepared for all other communicable diseases and travel-related hazards. This article aims to provide a summary of the latest and up to date information in England (links to guidance covering the Devolved Administrations of Scotland, Wales and Northern Ireland are found in Box 1 ) and covers a summary of COVID-19, current guidance on travel during the pandemic, information about pre-planning for overseas travel, return from travel and information about being identified as a contact during travel, general travel advice; and ends with links to the most relevant guidance and information available.

SP6.1.5 Morbidity following emergency and elective laparoscopic cholecystectomy for cholecystitis: a retrospective comparative cohort study

Aims A comprehensive comparison of post-operative outcomes between emergency and elective laparoscopic cholecystectomy (LC) for cholecystitis has not been conducted and the relative morbidity associated with emergency LC remains uncertain. Our aim was to evaluate the difference in early post-operative outcomes between emergency and elective LC for patients with cholecystitis. Method LC performed for cholecystitis across three surgical units between January 2015 and January 2020 were analysed retrospectively from multiple regional databases using deterministic records-linkage methodology. Rates of complications, further imaging, re-intervention, prolonged post-operative stay and re-admissions over a 100-day follow-up period were compared between emergency and elective groups using univariate and multivariate analysis. Results LC were performed for cholecysitits in 962 cases (median age, 52 years; M:F, 1:2.7; emergency:elective; 1:3.9). Emergency cholecystectomy had higher rates of complication (15.8% versus 8.8%;p<0.0001), prolonged post-operative stay (40.3% vs. 12.7%;p<0.0001), post-operative imaging and intervention (19.1% vs. 9.4%;p<0.0001) and readmission (11.1% vs. 7.0%;p=0.017). In the multivariate regression analysis, emergency LC was associated with prolonged admission (OR,5.7;p<0.0001), complication (OR,2.97;p<0.0001), post-operative imaging and intervention (OR,2.4;p=0.002) and readmission (OR,1.9; p = 0.06). Conclusions Despite current guidance, an emergency cholecystectomy remains a morbid procedure and we demonstrate increased risks of emergency LC versus elective LC. The increased risk of an emergency LC needs to be weighed up against the risk of further attacks from biliary pathology until elective surgery. Our data indicates that we need to readjust our selection criteria for the ‘emergency cholecystectomy patient’ and identify patients who will specifically benefit from earlier surgery.

TP9.2.9Luminal Investigation Following CT Diagnosed Acute Diverticulitis

The commissioning guide for colonic diverticular disease by the Royal Collage of Surgeons (2014) states that all patients should undergo luminal investigations once an acute attack of diverticulitis has passed. The rational behind this is to ensure a malignant polyp is not missed, however there is mounting evidence and opinion that this may not be necessary. We aim to evaluate how our unit follows the commissioning guide and investigate the number of subsequent polyps and cases of malignancy found. Surgical inpatients with a CT proven diagnosis of acute diverticulitis within a one year period (2018) were included. Their CT scans were reviewed to confirm the diagnosis and electronic records examined to see if luminal investigations were requested, occurred and what the findings were. There were 78 cases of CT confirmed diverticulitis. Of these 11 patients underwent emergency Hartmanns procedure. This left 67 patients in whom investigations were requested in 47. Within the 20 cases were follow up was not requested, 50% had a mitigating factor. 40/47 patients who had investigations booked underwent the requested test. In 6 cases a polyp was found and there were no cases of colorectal cancer. Based on current guidance there is scope to improve the follow up investigations in this population of patients with CT proven diverticulitis. As no colorectal cancers were found this is in keeping with the growing notion that colonoscopy may be reserved for those with complicated diverticulitis on CT or with CT findings on a background of ‘red flag’ symptoms.

EP.TU.201Evaluating and Improving the Management of Tonsilitis in an A+E Department: An Educational Intervention

Aims Tonsilitis is one of the most common presentations to the A+E department. We aimed to assess whether patients presenting with tonsilitis are being managed in-line with current guidance. We then set out to educate A+E staff about tonsilitis management and then assessed for improvement in management. Methods All patients presenting to A+E in one fortnight with a documented diagnosis of tonsilitis were included. We reviewed the notes to assess the choice of treatment in each case and whether a clinical score was used to guide choice of treatment (in accordance with NICE guideline [NG84]). We designed and delivered an educational intervention for A+E staff covering tonsilitis guidelines. The audit was repeated two weeks later. Results Over the study period, 49 patients were included; only 35% (n = 17) had either a clinical score documented or had all components of a score recorded. In total, 39% (n = 19) were treated with antibiotics. Of these, 63% (n = 12) should not have been prescribed an antibiotic and 37% (n = 7) were prescribed an inappropriate antibiotic. At re-audit, (n = 50 cases), 58% (n = 29) had a clinical score documented and 28% (n = 14) were treated with antibiotics. Of these, 29% (n = 4) should not have been prescribed antibiotics and 21% (n = 3) were prescribed an inappropriate antibiotic. Thus, after this teaching session, there was a significant improvement in antibiotic prescribing practices (63% vs 29%, p = 0.026). Conclusions A+E assessment and management of tonsilitis frequently deviated from guidelines, but a single teaching session vastly improved clinical scoring and antibiotic prescribing practices.