P-OGC65 Patterns and timing of recurrence following resection of oesophago-gastric adenocarcinoma

Background Recurrence following resection of oesophago-gastric adenocarcinoma (OGA) is frequent and associated with poor outcomes. Predictors of site, timing and mechanisms driving recurrence is poorly defined, which limits the development of anti-metastatic agents. The aim of this study was to investigate the patterns and timing of recurrence following resection of OGA. Methods Retrospective review of a prospectively maintained resection database from the Glasgow Royal Infirmary oesophago-gastric unit of patients undergoing surgery for OGA. Primary outcomes were recurrence and cancer specific death following surgery. Recurrence patterns were defined as liver, lung, peritoneal, locoregional only and other distant groups. The latter is a heterogenous group that do not include any liver, lung, or peritoneal metastases. Results N = 635 patients were identified having undergone surgical resection of OGA. Of these, n = 262 developed confirmed recurrent disease. Liver metastases (n = 86, 33%) were the most common site of recurrence, followed by peritoneal (n = 35, 13%), lung (n = 33, 13%) locoregional only (n = 51, 20%) and other distant sites (n = 57, 22%). Liver recurrence was associated with significantly worse disease specific (19.1 vs 28.2 months, P < 0.001) and recurrence free survival (P = 0.006). There was no association between site of recurrence and known prognostic clinicopathological factors, including anaerobic threshold (P = 0.810), nodal status (P = 0.088), pathological T-stage (P = 0.357), differentiation (P = 0.195), deprivation index (P = 0.996), perineural (P = 0.475) or lymphovascular (P = 0.422) invasion. Conclusions Liver metastases is the most common site of recurrence following surgery for OGA. Prognostic clinical and pathological factors do not determine the site of recurrence, suggesting that molecular features of the primary tumour determine and promotes recurrence patterns. Further study to delineate the molecular and microenvironment factors driving recurrence patterns is urgently required.

Improving the quality of weekend medical handover on non-receiving medical hospital wards

IntroductionHandover is the system by which the responsibility for immediate and ongoing care is transferred between healthcare professionals and can be an area of risk. The Royal College of Physicians (RCP) has recommended improvement and standardisation of handover. Locally, national training surveys have reported poor feedback regarding handover at Glasgow Royal Infirmary.AimTo improve and standardise handover from weekday to weekend teams.MethodsThe Plan–Do–Study–Act (PDSA) quality improvement framework was used. Interventions were derived from a driver diagram after consultation with relevant stakeholders. Four PDSA cycles were completed over a 4-month period:PDSA cycle 1—Introduction of standardised paper form on three wards.PDSA cycle 2—Introduction of electronic handover system on three wards.PDSA cycle 3—Expansion of electronic handover to seven wards.PDSA cycle 4—Expansion of electronic handover to all non-receiving medical wards.The outcome of interest was the percentage of patients with full information handed over based on a six-point scale derived from the RCP. Data were collected weekly throughout the study period.Results18 data collection exercises were performed including 525 patients. During the initial phase there was an improvement in handover quality with 0/28 (0%) at baseline having all six points completed compared with 13/48 (27%) with standardised paper form and 21/42 (50%) with the electronic system (p<0.001). When the electronic handover form was expanded to all wards, the increased quality was maintained, however, to a lesser extent compared with the initial wards.ConclusionA standardised electronic handover system was successfully introduced to downstream medical wards over a short time period. This led to an in improvement in the quality of handover in the initial wards involved. When expanded to a greater number of wards there was still an improvement in quality but to a lesser degree.

An 18 year data-linkage study on the association between air pollution and acute limb ischaemia

Summary: Background: There is limited information regarding the effects of air pollutants, such as nitrogen oxides (NOx), nitric oxide (NO2), nitrous oxide (NO) and particulate matter with a diameter smaller than 10 μm (PM10), on acute limb ischaemia (ALI), a peripheral arterial disease (PAD) often with a poor clinical outcome. Patients and methods: We conducted an 18-year retrospective cohort study using routinely collected healthcare records from Ninewells Hospital, Dundee, and Perth Royal Infirmary, in Tayside, Scotland, UK from 2000 to 2017. ALI hospitalisation events and deaths were linked to daily NOx, NO2, NO and PM10 levels extracted from publicly available data over this same time period. Distributed lag models were used to estimate risk ratios for ALI hospitalisation and for ALI mortality, adjusting for temperature, humidity, day of the week, month and public holiday. Results: 5,608 hospital admissions in 2,697 patients were identified over the study period (mean age 71.2 years, ±11.1). NOx and NO were associated with an increase of ALI hospital admissions on days of exposure to pollutant (p=.018), while PM10 was associated with a cumulative (lag 0–9 days) increase (p=.027) of ALI hospital admissions in our study. There was no increase of ALI mortality associated with pollution levels. Conclusions: ALI hospital admissions were positively associated with ambient NOx and NO on day of high measured pollution levels and a cumulative effect was seen with PM10.

Associations between ambient air pollutants and hospital admissions: more needs to be done

Deaths from air pollution in the UK are higher by a factor of 10 than from car crashes, 7 for drug-related deaths and 52 for murders, and yet awareness seems to be lacking in local government. We conducted an 18-year retrospective cohort study using routinely collected health care records from Ninewells Hospital, Dundee, and Perth Royal Infirmary, in Tayside, Scotland, UK, from 2000 to 2017. Hospitalisation events and deaths were linked to daily nitric oxides (NOX, NO, NO2), and particulate matter 10 (PM10) levels extracted from publicly available data over this same time period. Distributed lag models were used to estimate risk ratios for hospitalisation and mortality, adjusting for temperature, humidity, day of the week, month and public holiday. Nitric oxides and PM10 were associated with an increased risk of all hospital admissions and cardiovascular (CV) admissions on day of exposure to pollutant. This study shows a significant increase in all cause and CV hospital admissions, on high pollution days in Tayside, Scotland.

Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients

Introduction Whilst upper extremity deep vein thromboses (UEDVT) account for approximately 5 to 10% of all cases of DVT, rigorous guidelines regarding diagnosis and management of presenting patients remain to be developed. The association of UEDVT with concurrent asymptomatic pulmonary embolism as well as the first presentation of malignancy deems essential rigorous research and clinical guideline development to ensure optimal patient care. Methods This retrospective audit study is the first to provide estimates of UEDVT prevalence in the North-East Deanery main hospital centre, Aberdeen Royal Infirmary (ARI). Results Of the 605 patients attending the ARI Ambulatory Emergency Care (AEC) clinic with clinical suspicion of UEDVT, 38 (6.2%) had a confirmatory diagnosis. Underlying malignancy, presence of PICC line, and cardiovascular co-morbidities were identified as common confounding factors. Subclavian vein with concurrent extension to primarily the cephalic vein thrombosis was identified as the most commonly thrombosed venous territories. Importantly, oncology patients were found to have poorer survival outcomes following an UEDVT, in comparison to patients with other significant co-morbidities (cardiovascular, chronic renal disease, inflammatory bowel disease): HR 5.814 (95%CI 1.15, 29.25), p 0.012. Lastly, genetic associations were drawn between patient genetic status as tested for other co-morbidities and prothrombotic cellular cascades, suggesting rigorous VTE assessment in patients identified with congenital or acquired mutations, namely, in CALR, JAK, MSH 2/6, MYC, and FXN. Conclusions Overall, this study offers the first report of UEDVT presentations in the UK with no restrictions of patient performance status or underlying co-morbidities and provides a rounded clinical picture of patient characteristics, diagnosis, management, and prognostic associations in view of rigorous guideline development.

572 Closed-Loop Clinical Audit on Blood Results in Urology Department During Ward Rounds

Aim Clinical governance states that blood results should be flagged during ward rounds to enable better assessment of inpatients. As per our institutional Protocol, each patient is assigned a blood sheet which should be updated every day with outstanding bloods flagged with a circle. The aim of the audit was to evaluate the quality of blood result sheets and to discuss results in order to enhance patient care. Method Data was collected from the Urology ward at Glasgow Royal Infirmary continuously during November 2020. We reviewed the flagging of abnormal bloods and whether clear documentation of baseline eGFR was included. Intervention was carried out by series of discussion with the nursing and the medical staff along with display posters throughout the ward and staff rooms. Results Overall, first cycle assessed 65 folders and second assessed 79. We noticed that the flagging of outstanding blood results increased from 70% to 74%. Documentation of baseline eGFR raised from 32% to 44%. Initially, only 73% of results were appropriately placed in the correct patient nursing folder which improved and reached 100% on review. Conclusions The first cycle of the audit demonstrated serious breach of protocols which could delay and affect patient care. The re-audit cycle post intervention illustrated that active efforts on the part of medical and nursing staff can significantly improve the outcomes. However, sustained intervention in the form of audits and induction program is needed to bring a sustainable change in the departmental practice.

6 The Value of Ultrasound in Diagnosing Acute Appendicitis

Aim The diagnosis of acute appendicitis relies on a thorough history and examination and can often be challenging. Ultrasound is widely considered to be the most appropriate first line investigation; however non-diagnostic ultrasounds are not uncommon and do lead to delays in diagnosis and/or definitive treatment by creating a need for further clinical assessment. The purpose of this study was to determine the sensitivity and specificity of ultrasound diagnosis of appendicitis in patient treated at Doncaster Royal Infirmary, and to determine the local negative appendicectomy rate. Method This was a retrospective analysis of 99 patients undergoing appendicectomy, with a prior ultrasound abdomen within one week of the procedure being undertaken. Data was collected from review of patient's hospital medical records (discharge summaries, clinic letters, PACs). Results 99 patient aged 8-76 years were studied. Male to female ratios was 3:1. The sensitivity and specificity of ultrasound was 16% (95% CI - 7% to 29%) and 96% (95% CI - 86% to 99%) respectively with PPV of 80% and NPV of 52%. The accuracy of ultrasound diagnosis was found to be 55% (95% CI 44% to 65%). The negative appendicectomy rate was 48%. Conclusions From our study, ultrasound cannot reliably identify nor exclude appendicitis. Less than 16% of patients who had proven appendicitis (positive histology) had scans that indicated. Almost 50% of the normal/indeterminate scans were false negatives. Furthermore, 20% of positive ultrasound reports were false positives. A collaborative quality improvement project with the imaging department is planned to address these findings.

1674 Training Opportunities and Safe Staffing Levels – Loop Closure Audit

Aim It is not uncommon to find rota gaps at junior doctors’ level across many NHS Trusts within United Kingdom – especially in district general hospitals. In the trauma and orthopaedic department at Huddersfield Royal Infirmary, there were significant rota gaps that frequently relied on locum doctors to provide adequate service coverage. The aim of the audit was to determine whether rota gaps had any impact on safe staffing levels, training of core surgical trainees (CSTs) and costs to the department. Method Retrospective audit - assess daily staffing levels as per rota for three weeks before and after implementation of recommended better utilisation of the department’s Advanced Clinical Practitioners (ACPs) to cover trauma wards. The audit took place over October 2018 – December 2018. Results There were safe staffing levels daily in both audits. Audit 1 demonstrated locum doctors were required to cover 36.6% of ward duties and 42.9% of oncall shifts – costing the department £25, 190. Following implementation of recommendation, where ACPs were rostered to cover trauma, audit 2 reduced the requirements of locum doctors for coverage of ward duties and oncalls to 23.7% and 33.3%, respectively. Protected theatre allocation of CSTs remained less than 1 day/week. The cost of locum doctors in audit 2 was reduced to £17, 050. Conclusions Through better utilisation of the department’s ACPs to cover trauma wards, we managed to significantly reduce cost of locum doctors by £8, 140 over a three-week period. We believe CST theatre allocation will also improve from this intervention.