573 DELIRIUM SCREENING QUALITY IMPROVEMENT PROJECT

Introduction Delirium is a common neuropsychiatric syndrome in patients over the age of 65 presenting to medical admissions units yet remains under-diagnosed despite significant associated mortality and morbidity. Our trust's delirium screening tool incorporates a four-step approach, with completion of validated 4AT test warranted in all those over 65 years of age admitted with increased confusion or social withdrawal. Our aim was to measure current uptake of this delirium screening and introduce measures to improve practice. Method We retrospectively collected data from medical records of patients on two Geriatric inpatient wards (42 patients) at the Leicester Royal Infirmary, to determine whether appropriate delirium screening was taking place for at-risk patients on admission. We then introduced two PDSA (plan, do, study, act) cycles: 1. teaching at departmental weekly educational meetings with sending electronic communications to all doctors in medicine highlighting importance of delirium screening; and 2. displaying posters on all admissions wards. A third cycle was planned involving visiting wards to raise awareness, however this was interrupted by the COVID pandemic. Results Initial baseline results showed only 5% (1 of 18) of at-risk patients were fully screened for delirium. Following our first intervention, this increased to 13% (3 of 23). Second intervention involving display of posters led to an increase to 44% (8 of 18) of at-risk patients being screened. Proportions of dementia were comparable across PDSA cycles. Conclusions Education, raising awareness, and display of reminder posters can improve delirium screening uptake of at-risk patients on admission to medical admission units, despite growing pressures associated with the COVID pandemic. Further interventions are planned to improve and maintain awareness and uptake of delirium screening.

185 Vascular Hitch Procedure for Accessory Lower Pole Vessels

Introduction The gold standard procedure for pelvi-ureteric junction obstruction has been the Anderson-Hynes dismembered pyeloplasty; involving the repositioning of the ureter and ureteropelvic anastomosis. However, the Hellstroem 'Vascular Hitch Procedure’ dictates the superior translocation of the accessory vessel and its fixation to the anterior pelvic wall. The latter has an estimated success rate >90%. Method During 2016-2020, at Leicester Royal Infirmary, 16 operations occurred on paediatric patients with pelvi-ureteric junction obstruction. The dismembered pyeloplasty was performed on 5 patients, 9 patients underwent the vascular hitch procedure, and 2 patients are currently awaiting the latter operation. All patients had a pre-operative functional magnetic resonance urography (fMRU) to identify and localise the accessory lower pole vessel. Results The mean hospital stay for the vascular hitch procedure was 1.5 days (range=1-2) in comparison to 4 days (range=3-5) for the dismembered pyeloplasty. The follow-up period ranged from 6 months to 3 years. Overall, it was noted that the patients were asymptomatic, had markedly reduced hydronephrosis on imaging as well as stable renal function noted on the MAG 3 renogram scan. Conclusions The laparoscopic vascular hitch procedure appears to be the superior operation for the management of pelvi-uteric junction obstruction as the patients had notably reduced hospital stay lengths.

514 Audit to Assess Negative Appendicectomy Rate (NAR) in Adult Patients in The Leicester Royal Infirmary (LRI)

Aim: Determine the NAR rate in Leicester Royal Infirmary (LRI) and compare to the national average (20%) Additional objectives: Method This was a retrospective audit which considered all patients admitted over a three-month period to the LRI with suspected appendicitis. Data was collected on patients proceeding to surgery, and then whether their histology was pathological. Results 318 patients were included, of which 80 proceeded to surgery. Objective 1 - NAR of 5% (4/80) Secondary objective 1 Secondary objective 2 - Appendix visualised in 29.3% (48/164) of Ultrasounds Conclusions This audit has demonstrated that both USS and CT have a very low false-positive rate in assessment of appendicitis; however, USS visualises the appendix in less than 30% of cases. I believe the pathway should be altered to remove USS scanning for obese patients where the appendix is difficult to visualise; or in older patients, where there is less concern in using the CT modality.

P198 Efficacy and safety of secukinumab in ankylosing spondylitis: real-world data from Midlands Ankylosing Spondylitis Collaboration (MASC)

Background/Aims Secukinumab is an interleukin-17 inhibitor has been found to be effective in the treatment of ankylosing spondylitis (AS) in studies, including phase 3 clinical trials, however these are conducted in highly selected patients and it is important to confirm the efficacy and safety in a real world data. Response to secukinumab should be assessed after 16-weeks and continued if there has been sufficient response to treatment according to the BASDAI and spinal VAS scores. Methods This was a multicentre cross-sectional observational study in collaboration with Midland Ankylosing Spondylitis Collaboration. Consecutive baseline and 16th week data of all AS patients on Secukinumab from 2017 to 2019 were collected and analysed to assess treatment response. All data were compiled in excel sheets and analysed using Medcalc calculator. Data were collected from collaborative efforts of the Royal Wolverhampton NHS trust, Queen’s Hospital (Burton on Trent), Leicester Royal Infirmary and Robert Jones and Agnes Hunt hospital. Results Total 92 patients with radiographic AS on standard dose of secukinumab were included at baseline and 88 were followed up till week 16. Mean age was 45.9(SD ± 15) (Median=44years) and 67% were male. Baseline Mean BASDAI was 7 (SD ± 1.7); Mean CRP was 16.6 (SD ± 11.2), Mean VAS was 7.6(SD ± 1.6). There was statistical significant change in BASDAI, VAS and CRP levels at week 16th. ΔBASDAI=2.2 (SD ± 2) (p = 0.002), ΔVAS=3.2 (SD ± 2.1) (p = 0.001), ΔCRP=6.9 (SD ± 17) (p = 0.03). At 16th week, 68% had clinical improvement while 4 patients discontinued therapy (2-colitis, 1-uveitis and 1-patient choice). 10% overall had some adverse effects with most common being upper respiratory tract infection. We also compared patients with previous anti-TNF exposure (TE) to Anti-TNF naïve (TN). 63% were in TE group vs 37% in TN. 69% of TE and 76% of TN showed clinical improvement at week 16.Mean ΔBASDAI was more in TN group vs TE (p = 0.01), however there was no difference in ΔVAS and ΔCRP levels. (p = 0.0 & p = 0.2 respectively). Conclusion This multi-centre retrospective analysis found secukinumab to be clinically effective in 68% of patients with AS. There was significant improvement in BASDAI, VAS and CRP levels at week16. Compared to anti-TNF resistant patients, TNF-Naïve responded better to secukinumab, although both showed good clinical improvement. These findings support the use of secukinumab in the treatment of AS, as a first line therapy or for those who have failed anti-TNF therapy. Safety signals observed in the real-word data set were consistent with those seen in the clinical trials and the Summary of Product Characteristics. Disclosure N. Jain: None. R. Laxminarayan: Honoraria; Honorarium from Novartis, Lilly, Pfizer and Abvie. A. Moorthy: Honoraria; Speaker and conference fee MSD, Novartis, Abbvie. R. Amarasena: None. N. Cleaton: None. G. Kakade: None. A. Gunawardane: None. T. Khan: None. H. Sapkota: None. N. Barkham: Grants/research support; research funding from Novartis, Eli Lilly, UCB.

Back to Blame

The death of Jack Adcock in 2011 made headlines all around the world for many reasons. He was a 6-year-old child, admitted to Leicester Royal Infirmary (LRI) in February 2011 who died of sepsis and pneumonia 11 hours later. The paediatric registrar Dr. Hadiza Bawa-Garba had failed to diagnose his condition, resulting in criminal proceedings and her erasure from the medical register in 2017. This article gives a glimpse of the controversial case, tries to relate this to all medical specialties, and offers some guidance on how to avoid a similar situation developing.

Congenital monocular elevation deficiency associated with a novel TUBB3 gene variant

BackgroundThe genetic basis of monocular elevation deficiency (MED) is unclear. It has previously been considered to arise due to a supranuclear abnormality.MethodsTwo brothers with MED were referred to Leicester Royal Infirmary, UK from the local opticians. Their father had bilateral ptosis and was unable to elevate both eyes, consistent with the diagnosis of congenital fibrosis of extraocular muscles (CFEOM). Candidate sequencing was performed in all family members.ResultsBoth affected siblings (aged 7 and 12 years) were unable to elevate the right eye. Their father had bilateral ptosis, left esotropia and bilateral limitation of elevation. Chin up head posture was present in the older sibling and the father. Bell’s phenomenon and vertical rotational vestibulo-ocular reflex were absent in the right eye for both children. Mild bilateral facial nerve palsy was present in the older sibling and the father. Both siblings had slight difficulty with tandem gait. MRI revealed hypoplastic oculomotor nerve. Left anterior insular focal cortical dysplasia was seen in the older sibling. Sequencing of TUBB3 revealed a novel heterozygous variant (c.1263G>C, p.E421D) segregating with the phenotype. This residue is in the C-terminal H12 α-helix of β-tubulin and is one of three putative kinesin binding sites.ConclusionWe show that familial MED can arise from a TUBB3 variant and could be considered a limited form of CFEOM. Neurological features such as mild facial palsy and cortical malformations can be present in patients with MED. Thus, in individuals with congenital MED, consideration may be made for TUBB3 mutation screening.