Gastroschisis: Impact of Bedside Closure on Ventilator-Associated Outcomes

Aim In our practice, preformed silos are routine rather than reserved for difficult cases. We aimed to identify whether silo and bedside closure can minimize: general anesthetic (GA) exposure, need for intubation and ventilation, or days intubated for neonates with simple gastroschisis (SG). Methods After approval, patients were identified via the neonatal discharge log (April 2010 to April 2019). Data were collected by case-note review and analyzed with respect to GA, ventilation, and core outcomes. Results Of 104 patients (50 female, mean birth weight 2.43 kg, mean gestational age 36 + 2 weeks), 85 were SG and 19 complex. Silo application was initial management in 70 SG, 57 completed successful bedside closure (by day 4 of life—median). Fifteen SG had initial operative closure.Of the 70 SG managed with silo, 46 (66%) had no GA as neonates. Twelve required GA for line insertion. Thirteen patients with initial silo had closure in theater (7 opportunistic at time of GA for line). Nine required intubation and ventilation out-with the operating theater during neonatal management. Seven had already been intubated at delivery; 3 because of meconium aspiration.One-hundred percent of those treated with operative closure had GA, 1 patient subsequently required surgery for subglottic stenosis. Time to full feeds did not differ between groups. Conclusion Silo and bedside closure allow the majority of SG neonates to avoid GA or intubation in the neonatal period, without increased risk of complication. However, it is important that the nursing expertise required to manage these patients safely is not underestimated.

Phacoemulsification combined with micropulse cyclodiode laser in glaucoma patients: efficacy and safety

Objective To evaluate the safety and efficacy of phacoemulsification combined with Micropulse transscleral cyclophotocoagulation (MP-TSCPC) in glaucoma patients. Methods This is a retrospective case-note review. The participants were adult patients with diagnoses of glaucoma and cataract who required a further reduction in IOP or a reduction in the number of glaucoma drops. All consecutive patients who underwent cataract surgery (CS) combined with MP-TSCPC laser between October 2018 and July 2019 were included in the study. The effect on visual acuity (VA), intraocular pressure (IOP) and number of anti-glaucoma drops were evaluated at 6 and 12 months in addition to any complications that occurred during any time point of the study. Results 42 eyes were included in the study. Mean IOP was reduced from 19.5 ± 5.4 mmHg by 22.5% to 15.1 ± 4.6 at 6 months post-operatively and by 19.5% to 15 ± 6.6 mm Hg at 12 months (p < 0.001 at both time points). The number of anti-glaucoma medications also reduced significantly from 2.8 ± 1.3 to 1.6 ± 1.2 at 6 months and to 2.2 ± 1.3 at 12 months (p < 0.001 at both time points). The success rate was 56% at 6 months and 54% at 12 months. 54.7% of our patients who completed 12 months follow up had an improvement or unchanged vision at the last visits. Conclusion This is the first study evaluating the effect of cataract surgery combined with MP-TSCPC in glaucoma patients. We demonstrated that this led to a reduction in IOP and the number of anti-glaucoma medications at 6 and 12-month postoperatively. The majority of patients had either stable or better vision at 12 months follow-up.

Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review

Background UK adult gender identity clinics (GICs) are implementing a new streamlined service model. However, there is minimal evidence from these services underpinning this. It is also unknown how many service users subsequently ‘detransition’. Aims To describe service users’ access to care and patterns of service use, specifically, interventions accessed, reasons for discharge and re-referrals; to identify factors associated with access; and to quantify ‘detransitioning’. Method A retrospective case-note review was performed as a service evaluation for 175 service users consecutively discharged by a tertiary National Health Service adult GIC between 1 September 2017 and 31 August 2018. Descriptive statistics were used for rates of accessing interventions sought, reasons for discharge, re-referral and frequency of detransitioning. Using multivariate analysis, we sought associations between several variables and ‘accessing care’ or ‘other outcome’. Results The treatment pathway was completed by 56.1%. All interventions initially sought were accessed by 58%; 94% accessed hormones but only 47.7% accessed gender reassignment surgery; 21.7% disengaged; and 19.4% were re-referred. Multivariate analysis identified coexisting neurodevelopmental disorders (odds ratio [OR] = 5.7, 95% CI = 1.7–19), previous adverse childhood experiences (ACEs) per reported ACE (OR = 1.5, 95% CI = 1.1–1.9), substance misuse during treatment (OR = 4.3, 95% CI = 1.1–17.6) and mental health concerns during treatment (OR = 2.2, 95% CI 1.1–4.4) as independently associated with accessing care. Twelve people (6.9%) met our case definition of detransitioning. Conclusions Service users may have unmet needs. Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental ill health and substance misuse during treatment needs optimising. Detransitioning might be more frequent than previously reported.

EP.TH.939Is routine CTU necessary in the investigation of haematuria?

Aims Upper tract urothelial cancer’s (UTUC) are rare of which 17% have concurrent BT’s. Whilst CTU is the gold standard imaging for UTUC, its routine use is questionable due to low diagnostic yield.1 There is no consensus in our department regarding the use of CTU in screening haematuria patients, regardless of whether a BT is identified. We therefore sought to investigate the diagnostic yield of CTU. Method Retrospective case-note review of haematuria patients (May-October 2018), screening tests utilised and their diagnostic yield. Results 764 patients (mean age=68) presented with VH (n = 448) or NVH (n = 316). All underwent flexible cystoscopy (FC) and upper tract imaging, (346 = USS; 126=CTU; 257= USS and CTU). BT and UTUC were diagnosed in 69 (9%) and 5 patients (0.7%), respectively. Of the 5 patients with UTUC (VH = 4, NVH=1) 2 had synchronous bladder tumours, both were low grade. All 5 underwent CTU but only 3 had a prior USS, of which USS detected UTUC in 2 of these 3. CTU was performed in 384 patients (VH n = 323, NVH n = 61) yielding only one UTUC diagnosis when other investigations were negative. This patient presented with VH. CTU provided no additional cancer detection in all patients with BT. Conclusions Due to the small sample of synchronous tumours, location or grade of BT is not a predictor of UTUC2. In all patients screened with FC and USS, CTU only detected one additional UTUC. On the basis of these results, CTU screening is not indicated for patients presenting with NVH.

EP.TU.141A 5-year Post Colonoscopy Colorectal Cancer audit with focus on root cause analysis and performance at York Teaching Hospital

Introduction Post colonoscopy colorectal cancer (PC-CRC) is an important benchmark of endoscopy performance. Previous publications have reported significant variations between institutions. We chose to perform the root cause analysis (RCA) and the impact of traditional performance indicators on the likelihood of PC-CRC. Methods A retrospective analysis was performed on all PCCRC at York Hospital. Electronic endoscopic records and case-note review was performed to identify appropriate cases. Root cause analysis was performed on all identified cases. Performance data and annual procedural volumes of endoscopist were recorded. Adjusted PC-CRC/5-year period allowed endoscopist to be divided into good (&lt;4 PC-CRC) and poor performers (³4 PC-CRC). Mann Whitney U test used to compare groups. P-value of &lt; 0.05 deemed significant Results 32 (24 male) patients with a PC-CRC were identified . Median age was 72 (IQR 63-79) years. Table provides PCCRC rate for the 5-year period. Root cause analysis identified that most plausible cause was missed lesions despite adequate bowel preparation (76%). The commonest subtype was non interval C (38%). Three out of 18 endoscopist had a higher 5-year adjusted PC-CRC rate and were poor performers. Median withdrawal times, CIR and ADR did not differ between good and poor performers. Conclusion The overall PC-CRC rate at our institution is within an acceptable rate. We have noted significant variation of performance between endoscopist, the exact reasons for this observation require further examination.

Long-term nitrofurantoin: analysis of complication awareness, monitoring and pulmonary injury cases

BackgroundLong-term nitrofurantoin (NF) treatment can result in pulmonary and hepatic injury. Current guidelines do not outline the type or frequency of monitoring required for detection of these injuries.AimsTo assess (1) awareness of NF complications among prescribers, (2) monitoring practice and (3) to describe the pulmonary sequelae of NF-related complications.Methods(1) Electronic questionnaire to prescribers, interrogating prescribing/monitoring practices and awareness of complications; (2) Case-note review (June-July 2020) of NF monitoring among general practitioners (GPs) in our local clinical commissioning group; (3) Case review of patients diagnosed with nitrofurantoin-induced interstitial lung disease (NFILD) at our interstitial lung disease (ILD) centre (2014-2020).Results125 prescribers of long-term NF responded to the questionnaire (82% GPs; 12% urologists). Many were unaware of the potential for liver (42%) and lung (28%) complications. 41% and 53% never monitored for these, respectively. Only 53% of urologists believed themselves responsible for arranging monitoring, whilst nearly all GPs believed this to be the prescriber’s responsibility (94%). One third of all respondents considered current British National Formulary (BNF) guidelines “not at all sufficient/clear”, with mean clarity scoring of 2.2/5. Amongst NFILD patients (n=46), NF had been prescribed most often (70%) for treatment of recurrent UTI and 59% (n=27) were prescribed for >6 months. Upon withdrawal of the medication 61% displayed resolution (completely/minimal fibrosis), whilst 16% of patients had progressive lung fibrosis.ConclusionNF can cause marked or irreversible lung complications and there is currently a shortfall in awareness and monitoring. Existing monitoring guidelines should be augmented.

Efficacy and Safety of Combined Surgeries including Intraocular Direct Cyclophotocoagulation with a 532 nm Laser to Treat Advanced Neovascular Glaucoma

Purpose. The purpose of this study was to assess the efficacy and safety of intraocular direct cyclophotocoagulation (IDCP) using a 532 nm laser with combination treatment in reducing intraocular pressure (IOP) for patients with advanced neovascular glaucoma (NVG) with angle closure. In addition, we sought to determine the success rate and frequency of complications and explore an optimized solution to reduce the number of topical medications and the pain of patients. Methods. A retrospective case note review of all patients undergoing combined treatment including IVR, phaco, PPV, PRP, and IDCP from January 2017 to June 2018. Results. In total, 24 consecutive patients (25 eyes) were reviewed. The mean IOP was significantly decreased from 42.2 ± 8.5 mmHg preoperatively to 15.56 ± 2.0 mmHg ( P < 0.0001 ), and no neovascularization of the iris (NVI) reoccurred at month 18. The number of medications used was reduced from 2.72 ± 0.45 preoperatively to 0.87 ± 0.40 at month 18 ( P < 0.0001 ). Conclusions. During 18 months of follow-up, the combined treatments were safe and had a significant IOP-lowering effect. This study provides a new method of performing IDCP with a 532 nm laser, allowing for the use of internal cyclophotocoagulation without extra equipment.

A service evaluation of the use and outcomes of inpatient detoxification for the treatment of alcohol and opiate dependence within a community addictions service

AimsThe 2012 Health and Social Care Act transferred Addictions commissioning from the NHS to local authorities, leading to cuts of up to 30-50% of budgets and having the greatest impact on inpatient detox services. In a system with such limited capacity, effectively triaging access to detox services and optimising the efficacy of each detox has become increasingly important. NICE offers limited guidelines to assist with making these decisions, focused on assessing the severity of dependence and risk, but provides little detail on specific predictors of success. Our aim is to evaluate the nature of cases referred for inpatient alcohol or opiate detox and their treatment outcomes. This will help develop our understanding of the factors which influence achieving abstinence, and inform future decision-making regarding suitability for inpatient detox and post-detox planning. Conclusions will form part of a review of the local alcohol care pathway guidelines.MethodA retrospective case note review of all inpatient detox admissions between April 2019-March 2020 (n = 113 patients) is being undertaken. Our data collection tool extracts quantitative and qualitative data based on criteria from Alcohol use disorders (NICE, 2017), Opiate detoxification (NICE, 2019) and local pathway guidelines.ResultPreliminary analysis of data from November 2019–March 2020 (43 patients) showed that a clearly documented rationale for inpatient detox was recorded in 95% of cases. 100% of cases had a recorded AUDIT score, whilst SADQ scores were recorded in 50% of cases. 33% of cases were admitted to rehab post detox, and 19% were prescribed anti-craving medication. Abstinence at one year was confirmed in 21% of cases. 28% of clients received a second detox within one year. The rationale for inpatient detoxes in this population is to be reported.ConclusionPreliminary data may highlight an opportunity to improve pre detox decision-making and post detox care, with confirmed abstinence in only 21% of clients at one year after detox. The low proportion of completed SADQ scores before accessing detox could offer an opportunity to improve client assessment, and the small proportion of clients prescribed anti-craving medication highlights an area of post detox care which could also be improved. The main limitation of this study is the lack of linked analysis of outcome to specific predictors, which is something that could be explored in future. It would also be valuable to gain survey data on the experience of accessing detox from a service user perspective.