20 The Junior Doctor Changeover Effect – Does It Exist in General Surgery?

Introduction

Junior doctor changeover has been perceived as a period of increased risk to patients. However, there is a paucity of contemporary evidence into this ‘Changeover Effect’. The aim of this study was to evaluate the presence of an adverse patient effect during periods of junior doctor changeover.

Method

Data were requested on all patients aged 18 years or older admitted acutely under General Surgery in the North England between 2005-16. This included patient characteristics, diagnoses, co-morbidities, procedure codes, mortality and length of stay. Patients were included in the study if they were admitted during the ‘changeover week’; defined as the first day of the changeover followed by the six subsequent days. For junior trainees (FY1-CT2), this is the first Wednesday of August, December and April each year. For higher surgical trainees (ST3-8) the first Wednesday and October. Another week, four weeks prior, was chosen as a historical comparator.

Results

61714 patients were included in this study. Patient characteristics did not vary between the cohorts. There was no difference in 30-day mortality between changeover and non-changeover groups (2.5% vs. 2.6%, p = 0.280) or length of stay (5.3 vs 5.2, p = 0.613). Changeover week was not a predictor of increased mortality (OR 1.06, p = 0.302) following multivariate adjustment. Further analysis of the first junior and higher specialty trainee periods, August and October respectively, showed no significant difference for measured outcomes.

Conclusions

This retrospective cohort study provides contemporary evidence that the ‘changeover effect’ does not exist in acute general surgical admissions in the UK.

113 Ischaemic Bowel in The North of England: Trends in Management Approach And Patient Outcomes

Aim

Bowel ischaemia is the third most common indication for emergency laparotomy in the UK and is associated with high rates of postoperative morbidity and mortality. This study describes changes in incidence, patient characteristics, management approach and outcomes for patients with bowel ischaemia over a fifteen-year period

Method

Data for patients admitted as an emergency, with a diagnosis of bowel ischaemia, to NHS hospitals in the North of England between 2002 and 2016 were collected. This included patient demographics and co-morbidities, operations performed and outcomes. The primary outcome of interest was in-hospital death within 30 days of admission for non-operatively managed patients and 30-day post-operative mortality for those who underwent an operative intervention.

Results

The incidence of bowel ischaemia has increased as a proportion of emergency general surgery admissions by 68% over fifteen years. More patients are undergoing computerised tomography (CT) imaging has (44.0% vs. 70.3%, p<0.001) and more operations are being performed within 48 hours of admission (p<0.001). The number of patients being managed operatively has fallen from 56.7% to 38.7%. Decreased 30-day mortality rates were observed for both operatively (37.5% to 26.7%, p<0.001) and non-operatively (45.7% to 26.8%, p<0.001) managed patients. Mean length of hospital stay has remained relatively unchanged over time.

Conclusions

Ischaemic bowel is becoming increasingly common. Increased usage of CT imaging has likely resulted in decreased rates of operative management due to its ability to accurately characterise intra-abdominal pathology. Improved mortality rates were observed for both operative and non-operative management strategies.

Perspectives of Interstitial Lung Disease Patients and Carers During COVID-19

Aim To gain an understanding of the impact of COVID-19 on the daily life, healthcare needs, mental wellbeing and outlook of patients with Interstitial Lung Disease (ILD) and their caregivers. Methods ILD patients and caregivers were invited to participate in a quantitative survey. Respondents could self-select to then participate in in-depth structured telephone interviews. Survey data was compared to Department of Health COVID-19 public opinion tracker findings for the comparable time period. Results There were 170 survey respones (111 patients and 59 caregivers) and 14 in-depth interview participants. 32% (n=36) of patients and 42% (n=25) of caregivers expressed extreme worry regarding COVID-19 on a 1-10 scale. 83% (n=92) of patients expressed concern about safe hospital access, 33% (n=37) had received a telephone consultation with their clinician, 43% (n=48) reported test delays, 47% (n=52) were exercising less, 23% (n=26) reported worse sleep and 15% (n=17) reported being financially worse off. Carers reported that sleep was worse for 58% (n=34), 42% (n=25) reported being worse off financially, and 40% (n=24) reported a worse diet. Worry (66%, n=39), stress (51%, n=30), anxiety (49%, n=29) were commonly reported by carers. Discussion ILD patients and caregivers reported higher levels of worry regarding COVID-19 compared to the general public. Alternative pathways for quality ILD patient care and interventions to reduce the burden of care on ILD caregivers are required.

A Systematic Review of Online Patient Resources to Support Shared Decision Making for Laparoscopic Cholecystectomy

BACKGROUND

RCS Eng, the Royal College of Surgeons of England, has published much information with regard to the consenting process. A majority of patients seek health information through online resources as well as discussing with the care givers. Therefore, it is necessary that online material is both of high quality and reliable for patients. We aimed to evaluate the quality and standard of the online patient information on laparoscopic cholecystectomy to help in the consenting process.

METHODS

A search was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sources were assessed using five validated scoring tools: Flesch-Kincaid Reading Ease Score (readability), DISCERN and IPDAS scores (quality of content) and HONcode and the Information Standard Certification (standards of accreditation).

RESULTS

The average readability of all websites was higher than recommended for patient literature. Less than half of the sources had received HONcode or Information Standard accreditation. On grading of quality and content, across validated scoring tools, no source achieved the minimum recommended level.

CONCLUSION

Online patient information related to laparoscopic cholecystectomy is of poor quality. We recommend a multidisciplinary approach to participate in publishing more readable online resources of a higher standard to help patients and clinicians in consent and shared decision making.

Surveillance of Depleted Uranium-exposed Gulf War Veterans: More Evidence for Bone Effects

ABSTRACT

Gulf War I veterans who were victims of depleted uranium (DU) "friendly-fire" incidents have undergone longitudinal health surveillance since 1994. During the spring of 2019, 36 members of the cohort were evaluated with a monitoring protocol including exposure assessment for total and isotopic uranium concentrations in urine and a comprehensive review of health outcomes, including measures of bone metabolism and bone mineral density (BMD) determination. Elevated urine U concentrations were observed in cohort members with retained depleted uranium (DU) shrapnel fragments. In addition, a measure of bone resorption, N-telopeptide, showed a statistically significant increase in those in the high DU subgroup, a finding consistent with a statistically significant decrease in bone mass also observed in this high DU subgroup compared to the low DU subgroup. After more than 25 y since first exposure to DU, an aging cohort of military veterans continues to show few U-related health effects in known target organs of U toxicity. The new finding of impaired BMD in the high DU subgroup has now been detected in two consecutive surveillance visits. While this is a biologically plausible uranium effect, it is not reflected in other measures of bone metabolism in the full cohort, which have largely been within normal limits. However, ongoing accrual of the U burden from fragment absorption over time and the effect of aging further impairing BMD suggest the need for future surveillance assessments of this cohort.

127 A Student Pilot For A Feasibility Study of the Theoretical 3S Trial (SPFT3S): Patient Questionnaire and Demographics

Introduction

There is conflicting evidence on the benefit of statins for primary prevention of cardiovascular disease (CVD) in non-diabetics over 75. Emerging evidence shows they may be ineffective, yet current guidance supports their use in those up to 85. The objectives of this study were to assess patients’ understanding of statins, willingness to participate in a theoretical randomised controlled trial (RCT), where they would be randomised to stop their statin and to compare the trial population with national data.

Methods

The survey took place in 8 GP practices with 4 students involved in questionnaire distribution. A patient search identified those over 75 and on a statin. Patients were excluded if they had a history of CVD or diabetes. 36 patients were identified and completed questionnaires, 5 were removed because they reported exclusion criteria. Demographic data was compared to the UK population from the 2011 census.

Results

Of 31 participants, 71% understood why they took statins, most were unconcerned about side effects and only 1 patient stopped statins due to the media. Opinions on the theoretical “stopping statins trial” were varied. 35% of people responded positively. 29% would not want to take part and 36% of people were unsure. Comparison of our trial population against the national population shows that 903,505 people would be eligible for a UK trial.

Conclusions

The purpose of this exercise was to see if patients would be willing to participate in a trial where 50% stopped taking their statin. Approximately a third said yes and only a third said no. As there are nearly a million people in this population, it suggests a fully funded, larger-scale feasibility study of this theoretical randomised control trial is warranted.

126 A Student Pilot for A Feasibility Study of the Theoretical 3S Trial (SPFT3S): GP and Ethics Committee Members Questionnaire

Introduction

Emerging research suggests that statin use for primary prevention in people without diabetes aged 75 and older has no benefit. This study aims to determine the feasibility of the theoretical Stop Statin Study (3S), a double-blind randomised controlled trial carried out in general practice, which would test this hypothesis. 50% of trial patients would stop taking statins for 5 years in an event driven study. The questionnaires aim to identify the attitudes of general practitioners (GPs) and ethics committee members (ECMs) regarding stopping statins for 5 years in patients aged 75 and older without diabetes or history of cardiovascular disease and their willingness to allow patients to participate in the 3S study.

Method

Questionnaires comprised of 6 questions were designed. 4 students distributed the questionnaire and it was completed by 19 GPs based at 8 practices in the North-East of England. 31 ECMs (12 expert and 19 lay) responded by email.

Results

95% of GPs who completed the survey would agree to their patients participating in the theoretical study with 47% of GPs indicating that their willingness to participate in the study is patient dependent. 95% of GPs would also consider stopping statins in this population group if sufficient research had been carried out or if the guidelines were changed. 42% of GPs have a negative attitude to prescribing statins in this population group. All the ECMs would approve the study, citing over-prescribing and polypharmacy as their reason.

Conclusions

The majority of GPs will participate in the theoretical 3S study, if their patients are willing to participate. There is already a negative perception amongst GPs towards the use of statins in elderly people without disease. The 3S study appears to be feasible from the GP and ethics perspective but would require a larger feasibility study.

Synaptic processes and immune-related pathways implicated in Tourette syndrome

Tourette syndrome (TS) is a neuropsychiatric disorder of complex genetic architecture involving multiple interacting genes. Here, we sought to elucidate the pathways that underlie the neurobiology of the disorder through genome-wide analysis. We analyzed genome-wide genotypic data of 3581 individuals with TS and 7682 ancestry-matched controls and investigated associations of TS with sets of genes that are expressed in particular cell types and operate in specific neuronal and glial functions. We employed a self-contained, set-based association method (SBA) as well as a competitive gene set method (MAGMA) using individual-level genotype data to perform a comprehensive investigation of the biological background of TS. Our SBA analysis identified three significant gene sets after Bonferroni correction, implicating ligand-gated ion channel signaling, lymphocytic, and cell adhesion and transsynaptic signaling processes. MAGMA analysis further supported the involvement of the cell adhesion and trans-synaptic signaling gene set. The lymphocytic gene set was driven by variants in FLT3, raising an intriguing hypothesis for the involvement of a neuroinflammatory element in TS pathogenesis. The indications of involvement of ligand-gated ion channel signaling reinforce the role of GABA in TS, while the association of cell adhesion and trans-synaptic signaling gene set provides additional support for the role of adhesion molecules in neuropsychiatric disorders. This study reinforces previous findings but also provides new insights into the neurobiology of TS.

Research priorities for expanding access to methadone treatment for opioid use disorder in the United States: A National Institute on Drug Abuse Center for Clinical Trials Network Task Force report

In the US, methadone treatment can only be provided to patients with opioid use disorder (OUD) through federal and state-regulated opioid treatment programs (OTPs). There is a shortage of OTPs, and racial and geographic inequities exist in access to methadone treatment. The National Institute on Drug Abuse Center for Clinical Trials Network convened the Methadone Access Research Task Force to develop a research agenda to expand and create more equitable access to methadone treatment for OUD. This research agenda included mechanisms that are available within and outside the current regulations. The task force identified 6 areas where research is needed: (1) access to methadone in general medical and other outpatient settings; (2) the impact of methadone treatment setting on patient outcomes; (3) impact of treatment structure on outcomes in patients receiving methadone; (4) comparative effectiveness of different medications to treat OUD; (5) optimal educational and support structure for provision of methadone by medical providers; and (6) benefits and harms of expanded methadone access. In addition to outlining these research priorities, the task force identified important cross-cutting issues, including the impact of patient characteristics, treatment, and treatment system characteristics such as methadone formulation and dose, concurrent behavioral treatment, frequency of dispensing, urine or oral fluid testing, and methods of measuring clinical outcomes. Together, the research priorities and cross-cutting issues represent a compelling research agenda to expand access to methadone in the US.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design is a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology, enabling local contextual interpretations of the indicators while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia, the Pacific and South Africa has also showed the potential of the WSC Index internationally.

Epilepsy Transition in Ambulatory Care: Experiences and Benefits of an Epilepsy Transition Team

Epilepsy is the fourth most common neurological disorder and affects people of all ages; however, at least 40% of children will continue to have seizures into adulthood. Children and youth with epilepsy (CYE) experience neurologic and extraneurologic changes that can negatively impact self-management skills necessary for optimal adult function. Those with intellectual disability have additional transition challenges. Improving the medical transition process for all CYE is vital and necessary. In this article, we will review some of the biologic, behavioral, psychologic, therapeutic, and social considerations for CYE complicating transition. We will then describe general approaches to transitioning CYE to adult care, specifically methods involving creating a framework with overarching transition aims in place, and share our experience at the Children's Hospital of Philadelphia implementing these approaches. Our comprehensive model for a formal transition policy, team structure, and ongoing assessment supporting CYE transitioning into adult care is a practical program that can be integrated into clinical care. Proper investment in the transition process will translate into measurable, significant long-term benefits for all involved.

Identification of a unique anti-Ro60 subset with restricted serological and molecular profiles

Anti-Ro60 is one of the most common and clinically important serum autoantibodies that has a number of diagnostic and predictive capabilities. Most diagnostic laboratories report this simply as a qualitative positive/negative result. The objective of this study was to examine the clinical and serological relevance of a novel subset of anti-Ro60 in patients who display low levels of anti-Ro60 (anti-Ro60^low ). We retrospectively identified anti-Ro60 sera during a 12-month period at a major immunopathology diagnostic laboratory in Australia. These all were anti-Ro60-precipitin-positive on the diagnostic gold standard counter-immuno-electrophoresis (CIEP). Lineblot immunoassay was used to stratify patients into either anti-Ro60^low or anti-Ro60^high subsets. We compared the medical and laboratory parameters associated with each group. Enzyme-linked immunosorbent assay (ELISA) and mass spectrometry techniques were used to analyse the serological and molecular basis behind the two subsets. Anti-Ro60^low patients displayed less serological activity than anti-Ro60^high patients with less intermolecular spreading, hypergammaglobulinaemia and less tendency to undergo anti-Ro60 isotype-switching than anti-Ro60^high patients. Mass spectrometric typing of the anti-Ro60^low subset showed restricted variable heavy chain subfamily usage and amino acid point mutations. This subset also displayed clinical relevance, being present in a number of patients with systemic autoimmune rheumatic diseases (SARD). We identify a novel anti-Ro60^low patient subset that is distinct from anti-Ro60^high patients serologically and molecularly. It is not clear whether they arise from common or separate origins; however, they probably have different developmental pathways to account for the stark difference in immunological maturity. We hence demonstrate significance to anti-Ro60^low and justify accurate detection in the diagnostic laboratory.

Integrating quality improvement into the ECHO model to improve care for children and youth with epilepsy

OBJECTIVE

Project ECHO (Extension for Community Healthcare Outcomes), a telementoring program, utilizes lectures, case-based learning, and an "all teach-all learn" approach to increase primary care provider (PCP) knowledge/confidence in managing chronic health conditions. The American Academy of Pediatrics (AAP) Epilepsy and Comorbidities ECHO incorporated quality improvement (QI) methodology to create meaningful practice change, while increasing PCP knowledge/self-efficacy in epilepsy management using the ECHO model.

METHODS

Monthly ECHO sessions (May 2018 to December 2018) included lectures, case presentations/discussion, and QI review. Pediatric practices were recruited through the AAP. Practices engaged in ECHO sessions and improvement activities including monthly Plan-Do-Study-Act cycles, team huddles, chart reviews, and QI coaching calls to facilitate practice change. They were provided resource toolkits with documentation templates, safety handouts, and medication side effects sheets. QI measures were selected from the American Academy of Neurology Measurement Set for Epilepsy. The AAP Quality Improvement Data Aggregator was used for data entry, run chart development, and tracking outcomes. Participants completed retrospective surveys to assess changes in knowledge and self-efficacy.

RESULTS

Seven practices participated across five states. Average session attendance was 14 health professionals (range = 13-17). A total of 479 chart reviews demonstrated improvement in six of seven measures: health care transition (45.3%, P = .005), safety education (41.6%, P = .036), mental/behavioral health screening (32.2% P = .027), tertiary center referral (26.7%, not significant [n.s.]), antiseizure therapy side effects (23%, n.s.), and documenting seizure frequency (7.1%, n.s.); counseling for women of childbearing age decreased by 7.8%.

SIGNIFICANCE

This project demonstrated that integrating QI into an ECHO model results in practice change and increases PCP knowledge/confidence/self-efficacy in managing epilepsy.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design as a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology enables local contextual interpretations of the indicators, while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia and the Pacific has also showed the potential of the WSC Index internationally.

A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study)

INTRODUCTION

Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes.

MATERIALS AND METHODS

A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22.

RESULTS

A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity.

DISCUSSION

Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.