1,720,969 research outputs found
PTH-32 development of a novel electronic referral grading & triage system
No full textIntroduction: prior to Covid-19, demand for secondary care appointments continued to rise year on year suggesting unsustainable future post-pandemic demand. Now is thus the right time to invest in triage and clinical pathway innovation.Methods: anew fully-integrated digital triage system was built at our institution allowing for document upload and electronic triage. Data pertaining to referral time, triage decision, outpatient appointments and direct-to-test was extracted from the backend to plot empirical cumulative distribution functions, interquartile ranges and allow statistical comparison using the Kruskal-Wallis’ test.Results: we analysed the first 704 luminal Gastroenterology referrals through the new triage system with the following sub-specialty classifications: Iron deficiency anaemia (IDA) – 200, Upper gastrointestinal symptoms (UGI) – 152, Inflammatory bowel disease (IBD) – 116, Irritable bowel syndrome (IBS/Functional) – 95, Lower gastrointestinal symptoms/change in bowel habit alone (LGI/CIBH) – 59, Coeliac – 27, Surgical – 25, Complex Functional – 12, Intestinal failure (IF/Nutrition) – 12, Hepatology – 4. 664 (95%) of referrals were accepted with 179 (27%) being sent direct to test. Of these only 42 (23.5%) had a subsequent clinic appointment booked, vs 436 (90%) for those not going direct to test. In addition, sending patients direct to test increased the proportion of subsequent routine clinic appointments from 55% to 70%. Median timelag from referral to grading was four days with grading taking a single day and appointments occurring 17 days later on average. Direct-to-test was most common amongst patients in the UGI (52.6%) and IBD (50%) sub-cohorts. This was significantly different vs other groups at the (p<0.05) level. [PTH-32 Figure 1 Subspecialty Referrals vs Direct-To-Test Numbers not included].Conclusions: using a system as described here substantially improves data capture and efficiency. Direct to test reduces both need for clinic appointments and the urgency of subsequent appointments. IBD and UGI are the subspecialties most likely to benefit from direct to test approaches. IDA could be another suitable specialty and the plan is to address this in the future
OTU-18 Silence of the LAMS: reducing risk in EUS guided drainage of pancreatic fluid collections
No full textIntroduction and aims: endoscopic ultrasound guided transmural drainage (ETD) followed by endoscopic transluminal necrosectomy (ETN) is the evidence based preferred modality of treatment for symptomatic pancreatic fluid collections (PFC). EUS guided insertion of a lumen apposing metal stent (LAMS) facilitates improved drainage of fluid and improves efficacy of ETN. There is recognised risk associated with the procedure, primarily including bleeding, stent displacement and buried stent. Recent ESGE guidelines on the management of acute necrotising pancreatitis describe the use of imaging prior to drainage and at a 4 week interval, primarily to quantify the solid component in the collection. No definitive imaging protocols are established. In our institution, a protocol was developed to reduce the risk of adverse events associated with drainage. This included pre-intervention arterial phase CT and if identified, prophylactic embolisation of underlying pseudoaneurysm. In addition, all patients underwent CT at 4-5 weeks post stent insertion to determine efficacy of drainage and quantify residual component to determine benefit of long term plastic stents. We sought to assess the impact of the protocol on reducing LAMS associated adverse events.Methods: we evaluated our practice over a two year period between November 2018 and 2020. Prospectively collected data was reviewed retrospectively for the rates of technical success, clinical success and adverse event.Results: a total of 56 ETD procedures were performed on 52 patients. The majority of patients in the cohort were male (70.6%) with a mean age of 58 years. All patients underwent an arterial phase CT prior to ETD. Nine patients (17.3%) required embolisation of a previously unrecognised pseudoaneurysm prior to ETD. All procedures were technically successful (100%). Thirty five (67.3%) patients underwent a single ETN and 10 (19.2%) had multiple ETN procedures. Twenty two (62.8%) patients had a 20mm lumen diameter stent inserted and the remainder 15mm. Forty eight patients (92%) achieved complete resolution of collection with a single stent. Four patients (8%) required either an additional stent (multi-gated approach) or additional percutaneous drain. Stent dislodgement occurred in 4 (7.6%) patients during ETN. The median duration of LAMS placement was 44 days. No procedural or delayed LAMS related complications occurred.Conclusion: appropriate pre-procedural cross-sectional imaging facilitates identification and treatment of underlying pseudoaneurysm in this complex patient group. Post procedure interval imaging enables quantification of the residual collection to determine the benefit of long term plastic stents or additional drainage procedure. Our experience suggests adherence to a rigorous imaging protocol may reduce the risk of complication associated with LAMS deployment
P58 anonymous electronic IBD patient service feedback
No full textIntroduction: collecting structured patient feedback is challenging, particularly during the pandemic with many virtual appointments. Our electronic IBD-patient feedback covers outpatient (OP), endoscopy and flare-line experiences.Methods: IBD patients provide anonymous feedback at the time-of-service contact. GATHER, a survey platform hosted by our institution, collects anonymous information via QR codes (scan QR codes for surveys), electronic links or handheld tablet. Demographics, disease characteristics and medication were noted in all 3 surveys. The OP survey collated clinic type/modality and feedback on individual health care professionals based on an adapted Royal College of Physicians questionnaire as well as preferences for future appointments. Endoscopy surveys gathered information on referral pathway, endoscopy type, treatment advice, length of wait and pre-test information. Flare line surveys allowed individual feedback on IBD nurses, assessed response time and outcomes. Patients’ attitudes regarding use of our online portal My Medical Record (MyMR) were explored. All surveys allowed sign up for MyMR. Patients could leave individual comments.Results: since September 2021, 425 patients responded. Figure 1 outlines the findings of the surveys. [P58 Figure 1 not included].Conclusion: electronic surveys are well accepted by our IBD patients and provides useful demographic data. It gives patients the option to inform the service of their preferences for future appointments and allows clinicians to get personal patient feedback for appraisals. Furthermore, it provides feedback on new services such as direct access endoscopy service and the acceptability of patient directed online healthcare (MyMR). Patient-centred feedback enables the user to help shape their future local IBD service
Mo1671 a decision-tree classifier to improve the accuracy of magnification endoscopic assessment of lateral spreading tumours
No full textIntroduction: it is well known that when performing endoscopy for depth diagnosis of T1 colorectal cancer (CRC) one sometimes experiences, the difficulty of depth diagnosis, even with magnification. This is especially the case in lesions containing large nodules. It has been reported that the location of submucosal invasion in laterally spreading tumors (LST) varies between granular type (G) and non-granular type (NG).We hypothesize that the contribution of pit pattern diagnosis and JNET classification using magnified endoscopy is different between LST-G and LST-NG.Methods: a total of 647 LSTs in 612 patients with diagnosed tumor in-situ (Tis) or T1 diagnosed by magnified endoscopy using both pit-pattern and JNET classification were analyzed retrospectively.All lesions were either endoscopically or surgically resected at our institution between Jan 2015 and Dec 2017. All endoscopic findings were recorded in the “Japan Endoscopic Database (JED)”. Independent variables included: JNET classification, macroscopic features, endoscopically estimated lesion size for lesions T1b or deeper. The lesions were divided into LST-G or LST-NG. Histological diagnosis was used as the gold standard for assessing the depth of invasion.The lesions were randomly split 50-50 into test and training datasets and a decision tree classifier was trained on each group using the training data. Then the model was deployed on the test set and a receiver operator curve (ROC) was calculated for each model’s performance on the test set.Results: among all the LSTs, mean size of the lesions were 27.5mm. The ratio of macroscopic features was as follows;The number of LST-G’s was 369 and LST-NG’s 278.Lesions of T1b or deeper were included 91 (24.7%) and 76 (37.3%).The AUC of ROC for LST-G’s was 0.892 in the training data set and 0.846 in the test data set. The weighted variable contribution to the algorithm for the diagnosis of T1b or deeper was as follows; Pit pattern: 0.74, JNET: 0.19, macroscopic features: 0.08, and size of the lesion: 0.0.On the other hand, The AUC for LST-NG’s was 0.931 in the training data set and 0.938 in the validation data set. The variable contribution was as follows; Pit pattern: 0.92, JNET: 0.05, size: 0.02 and macroscopic features: 0.0.The decision tree of LST-NG, a combination of endoscopic findings showed 73% to 96% sensitivity for T1b or deeper and 84% to 98% specificity.LST-G demonstrated 86% sensitivity and 54% to 95% specificity. The specificity was lowest for 0-Is or 0-Is+IIc lesions.Conclusion: pit patterns contributed to the diagnosis of T1b or deeper in both LST-G and LST-NG models. In the case of LST-G with 0-Is component, it appears that depth diagnosis difficult regardless of the size of the lesions. Further research is warranted in this area in order to improve things further
PTU-004 hepatocellular carcinoma can be managed safely and effectively in a DGH-setting with superior surveillance-programme survival
No full textIntroduction and aims: HCC is the second commonest cause of cancer-related death worldwide and strongly associated with liver cirrhosis and with a rising incidence. Despite screening most HCC cases present at an intermediate or advanced stage unsuitable for curative surgery. The standard of care for most non-curative cases being actively treated remains transarterial chemo-embolisation TACE and/or ablation (RFA.) Both are specialist procedures normally delivered in tertiary centres. At the Royal Bournemouth Hospital (RBH), a large DGH, specialist HCC treatments are offered to Dorset County following MDT and combined hepatology/IR clinic review. There is an established surveillance programme offered to all suitable at-risk patients. We sought to assess the outcomes of the service with a focus on the benefits of surveillance and the safety of offering tertiary level services in a DGH setting.Methods: we identified all new HCC cases presented in the pan-Dorset Upper GI MDT from Jan 2017 to Dec 2017. We collected demographic data, whether they had been under a surveillance programme and the treatment outcomes including complications and 1- and 12- month mortality.Results: we identified 35 patients (30 M; 5F.) The aetiology was alcohol in 26% (n=9), NASH 43% (n=15), HCV 17% (n=6) and others 9% (n=3.) Cirrhosis was present in 63% (n=22): Child’s A 59% (n=13), Child’s B 32% (n=7) & Child’s C 9% (n=2.). Most cases were referred from RBH 77% (n=27), and 23% from the two other referring hospitals in the County. HCC surveillance detected 43% (n=15) of cases with 57% new presentations. Of the surveillance cases, the majority 87% (n=13) were identified at the centre with the most established surveillance programme but as the largest centre RBH also identified most new presentations 70% (n=14.). More active treatment was offered to the surveillance group at 87% vs 65% of non-surveillance group (p≤0.05.). Curative treatment (transplant, surgery or RFA to small HCC) was suitable in only 14.3% (n=5), all identified by surveillance. TACE was offered to 46% of patients (n=16.) Of the TACE patients, 56% (n= 9) underwent more than 1 procedure. Only 2 patients had decompensation post-TACE, which recovered. Post-TACE survival was 100% at 1 month and 79% at 1 year. These outcomes are comparable to published literature from larger centres. Overall 1-month and 12-month survival for surveillance cases was better than new presentations at 100% and 73% vs 85% and 50% respectively (p≤0.05.)Conclusions: specialist HCC treatment, following combined hepatology/IR review, can be offered safely and effectively in a large DGH setting with mortality and morbidities outcomes comparable to specialist tertiary centres. Our data confirms HCC surveillance allows for earlier cancer detection with more treatment options and improved survival
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
PTH-36 identification & service evaluation of a primary sclerosing cholangitis cohort using natural language processing
No full textIntroduction: primary sclerosing cholangitis (PSC) is a rare and difficult to treat condition. PSC is strongly associated with malignancy, therefore screening and surveillance are paramount. PSC however does not have a unique UK ICD-10 diagnostic code, hence reliable patient cohort identification and thorough service evaluation is challenging. We used natural language processing (NLP) to identify the PSC patient cohort at University Hospital Southampton (UHS) and audited associated outcomes against recently updated British Society of Gastroenterology (BSG) management guidelines.Method: records of all patients with PSC at our institution between 2008-2020 were identified using our NLP methodology. We used fuzzy matching to analyse clinical records, and tokenized and lemmatized key paragraphs to identify key diagnostic patterns and exclude diagnostically uncertain or exclusive sentences. Anonymised discharge summaries, clinic letters, radiology reports, endoscopy records and histology were extracted and digitally trawled to identify the cohort characteristics.Results: we identified 125 patients with PSC followed-up at UHS. 39.2% (49) of these patients were missed in a parallel criterion-based review of case notes.We calculated an age-standardised point prevalence of 12.52 cases per 100,000 patients, 124% higher than typically cited UK figures. Service evaluation revealed high rates of clinic follow-up however lower than recommended rates of screening with colonoscopy and imaging (see Table 1). Introduction of a combined PSC/IBD clinic as a targeted service delivery intervention is addressing this shortfall with significant impact after 1 year. [PTH-36 Table 1 not included].Conclusions: PSC cohorts are difficult to identify due to a lack of a UK clinical code. An NLP based methodology proved highly effective at identifying all cases within our institution, with a 64.5% increase compared to conventional methods. This allowed rapid patient cohort identification and conversion of unstructured data to clinically useful structured data and could be reproduced at other institutions and for other diseases
P117 Machine-learning derived characteristics associated with tapering TNF inhibitors in individuals with rheumatoid arthritis
No full textBackground/AimsTapering of TNF inhibitor (TNFi) drugs may be considered in some patients to reduce risks and costs. Selecting appropriate patients is not always straightforward and may be influenced by age, sex, comorbidity and disease activity state. We sought to identify predictors for dose tapering in a real-world clinical setting. Algorithmic extraction, selection and analysis of relevant patient sub-cohorts could enable identification of relevant predictors associated with TNFi dose tapering.MethodsOur institution has a Rheumatology Biologics database running prospectively for over 15 years. Our approach for patients with RA receiving TNFi has been to dose-taper by one third and then 50% if remission achieved (defined as DAS28<2.6 on two occasions more than 6 months apart with no corticosteroid use). Prescribing, disease activity scores and demographics were extracted using SQL along with comorbidity coding, pathology results and anthropometric data. Data were anonymised and analysed in Python 3.8 within our institutions’ Trusted Research Environment (TRE). Pandas, NumPy and StatsModels python packages were used for the analysis in Jupyter notebooks. 49 covariates were considered clinically relevant and included in the regression analysis. Recursive feature elimination (RFE) was performed using logistic regression (LR) with threshold p-value of 0.05. The primary outcome was tapering of TNFi, algorithmically identified by a temporal increase in dosing interval or decrease in dosage. To avoid multiple-drug confounding, only the most recent TNFi data was included for each patient.Results663 patients with RA were initiated on TNFi between 5th November 2001 and March 2nd 2020. 491 (74.1%) were female with a mean age of 65.5 (SD ± 14.2) years. 261 (39.4%) received adalimumab, 209 (31.5%) etanercept, 74 (11.2%) infliximab, 82 (12.4%) certolizumab and 37 (5.6%) golimumab. Concurrent methotrexate (MTX) was seen in 34.5% (n = 22), either oral or subcutaneous. There was no change in the likelihood of tapering associated with depression, hypothyroidism, obesity, smoking or seropositivity for RF or anti-CCP. Those taking MTX were more likely to taper their biologics (OR 3.33, 95%CI 1.83-6.09, p = <.000), as were patients who were coded as having type 1 or 2 diabetes (7.4% n = 49, OR 3.23, 95%CI 1.32-8.25, p = 0.011), Higher DAS28 CRP score (OR 0.548, 95%CI 0.38-0.78, p = 0.001), and DAS 28 ESR score (OR 0.71, 95%CI 0.53-0.95, p = 0.021) significantly decreased chance of tapering.ConclusionConcurrent methotrexate use increases likelihood of subsequent tapering in patients with RA receiving TNFi. Unexpectedly, patients with diabetes were also more likely to taper, however due to low numbers of patients in this group and the width of confidence intervals this should be interpreted cautiously. As expected, patients with high disease activity scores were less likely to taper. This algorithm driven approach produced results largely in keeping with clinical intuition, however these methods may aid in future selection of tapering cohorts.</p
Impact of accurate initial discharge planning and in-patient transfers of care on discharge delays: a retrospective cohort study
No full textObjective: to investigate the association between initial discharge planning and transfers of in-patient care with discharge delay. To identify operational changes which could expedite discharge within the Discharge to Assess (D2A) model.Design: retrospective cohort study.Setting: University Hospital Southampton NHS Foundation Trust (UHSFT).Participants: all adults (≥18 years) who registered a hospital spell in UHSFT between 1 January 2021 and 31 December 2022 (n = 258,051 spells). Individuals were followed from hospital admission through to discharge. Data includes demographics, comorbidities, operational information (ward changes, handovers) and discharge information (estimated discharge date, D2A pathway).Main outcome measures: the primary outcome was discharge delay, defined as the number of days between the final estimated discharge date and the actual discharge date. Odds ratio analysis was used to assess the impact of initial discharge planning accuracy (D2A pathway), number of ward moves, and number of in-speciality handovers on the outcome, adjusting for demographic and patient complexity factors.Results: out of 65,491 spells, 10,619 had an initial planned pathway that did not match the final discharge pathway, with 7,790 of these spells (75.1%) recording a discharge delay. Conversely, 10,216 of 54,872 spells (18.6%) where the initial pathway matched the final pathway recorded a discharge delay (adjusted odds ratio 2.72 (95% CI 2.55 – 2.91)). Ward moves and in-specialty handovers were also associated with increased likelihood of discharge delay, with adjusted odds ratio 1.25 (1.23 – 1.28) per ward move and 1.17 (1.14 – 1.20) per in-specialty handover.Conclusions: this study finds a strong association between inaccurate initial discharge plans and in-patient transfers of care with discharge delay, after controlling for patient complexity and acuity. This highlights the need to consider how initial plans, and in-patient transfers affect discharge planning. Given the lead-times for organising onward care, operational inefficiencies are most impactful for patients eventually discharged on pathways with higher planning complexity
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