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While many phenomena in physics and engineering are formally high-dimensional, their long-time dynamics often live on a lower-dimensional manifold. The present work introduces an autoencoder framework that combines implicit regularization with internal linear layers and $L_2$ regularization (weight decay) to automatically estimate the underlying dimensionality of a data set, produce an orthogonal manifold coordinate system, and provide the mapping functions between the ambient space and manifold space, allowing for out-of-sample projections. We validate our framework's ability to estimate the manifold dimension for a series of datasets from dynamical systems of varying complexities and compare to other state-of-the-art estimators. We analyze the training dynamics of the network to glean insight into the mechanism of low-rank learning and find that collectively each of the implicit regularizing layers compound the low-rank representation and even self-correct during training. Analysis of gradient descent dynamics for this architecture in the linear case reveals the role of the internal linear layers in leading to faster decay of a "collective weight variable" incorporating all layers, and the role of weight decay in breaking degeneracies and thus driving convergence along directions in which no decay would occur in its absence. We show that this framework can be naturally extended for applications of state-space modeling and forecasting by generating a data-driven dynamic model of a spatiotemporally chaotic partial differential equation using only the manifold coordinates. Finally, we demonstrate that our framework is robust to hyperparameter choices.

Dynamical systems with extreme events are difficult to capture with data-driven modeling, due to the relative scarcity of data within extreme events compared to the typical dynamics of the system, and the strong dependence of the long-time occurrence of extreme events on short-time conditions.A recently developed technique [Floryan, D. & Graham, M. D. Data-driven discovery of intrinsic dynamics. Nat Mach Intell $\textbf{4}$, 1113-1120 (2022)], here denoted as $\textit{Charts and Atlases for Nonlinear Data-Driven Dynamics on Manifolds}$, or CANDyMan, overcomes these difficulties by decomposing the time series into separate charts based on data similarity, learning dynamical models on each chart via individual time-mapping neural networks, then stitching the charts together to create a single atlas to yield a global dynamical model. We apply CANDyMan to a nine-dimensional model of turbulent shear flow between infinite parallel free-slip walls under a sinusoidal body force [Moehlis, J., Faisst, H. & Eckhardt, B. A low-dimensional model for turbulent shear flows. New J Phys $\textbf{6}$, 56 (2004)], which undergoes extreme events in the form of intermittent quasi-laminarization and long-time full laminarization. We demonstrate that the CANDyMan method allows the trained dynamical models to more accurately forecast the evolution of the model coefficients, reducing the error in the predictions as the model evolves forward in time. The technique exhibits more accurate predictions of extreme events, capturing the frequency of quasi-laminarization events and predicting the time until full laminarization more accurately than a single neural network., 9 pages, 7 figures

A rapid review of individual and ward-level outcomes following physical activity interventions undertaken within acute inpatient mental health settings

This study aims to extract and characterize structures in fully developed pipe flow at a friction Reynolds number of $\text{Re}_\tau = 12\,400$. To do so, we employ data-driven wavelet decomposition (DDWD) [D.~Floryan and M.~D.~Graham, PNAS 118, e2021299118 (2021)], a method that combines features of proper orthogonal decomposition and wavelet analysis in order to extract energetic and spatially localized structures from data. We apply DDWD to streamwise velocity signals measured separately via a thermal anemometer at 40 wall-normal positions. The resulting localized velocity structures, which we interpret as being reflective of underlying eddies, are self-similar across streamwise extents of 40 wall units to one pipe radius, and across wall-normal positions from $y^+=350$ to $y/R=1$. Notably, the structures are similar in shape to Meyer wavelets. Projections of the data onto the DDWD wavelet subspaces are found to be self-similar as well, but in Fourier space; the bounds of self-similarity are the same as before, except streamwise self-similarity starts at a larger length scale of $450$ wall units. The evidence of self-similarity provided in this study lends further support to Townsend's attached eddy hypothesis, although we note that the self-similar structures are detected beyond the log layer and extend to large length scales.

Because the Navier-Stokes equations are dissipative, the long-time dynamics of a flow in state space are expected to collapse onto a manifold whose dimension may be much lower than the dimension required for a resolved simulation. On this manifold, the state of the system can be exactly described in a coordinate system parameterizing the manifold. Describing the system in this low-dimensional coordinate system allows for much faster simulations and analysis. We show, for turbulent Couette flow, that this description of the dynamics is possible using a data-driven manifold dynamics modeling method. This approach consists of an autoencoder to find a low-dimensional manifold coordinate system and a set of ordinary differential equations defined by a neural network. Specifically, we apply this method to minimal flow unit turbulent plane Couette flow at $\textit{Re}=400$, where a fully resolved solutions requires $\mathcal{O}(10^5)$ degrees of freedom. Using only data from this simulation we build models with fewer than $20$ degrees of freedom that quantitatively capture key characteristics of the flow, including the streak breakdown and regeneration cycle. At short-times, the models track the true trajectory for multiple Lyapunov times, and, at long-times, the models capture the Reynolds stress and the energy balance. For comparison, we show that the models outperform POD-Galerkin models with $\sim$2000 degrees of freedom. Finally, we compute unstable periodic orbits from the models. Many of these closely resemble previously computed orbits for the full system; additionally, we find nine orbits that correspond to previously unknown solutions in the full system.

An overarching challenge in rheology is to develop constitutive models for complex fluids for which we lack accurate first principles theory. A further challenge is that most experiments probing dynamical structure and rheology do so only in very simple flow fields that are not characteristic of the complex deformation histories experienced by material in a processing application. A recently-developed experimental methodology holds potential to overcome this challenge by incorporating a fluidic four-roll mill (FFoRM) into scanning small-angle x-ray scattering instrumentation (sSAXS) [Corona, P. T. et al. Sci. Rep. 8, 15559 (2018); Corona, P. T. et al. Phys. Rev. Mater 6, 045603 (2022)] to rapidly generate large data sets of scattering intensity for complex fluids along diverse Lagrangian flow histories. To exploit this uniquely rich FFoRM-sSAXS data, we propose a machine learning framework, Scattering-Informed Microstructure Prediction under Lagrangian Evolution (SIMPLE), which uses FFoRM-sSAXS data to learn an evolution equation for the scattering intensity and an associated tensorial differential constitutive equation for the stress. The framework incorporates material frame indifference and invariance to arbitrary rotations by data preprocessing. We use autoencoders to find an efficient reduced order model for the scattering intensity and neural network ordinary differential equations to predict the time evolution of the model coordinates. The framework is validated on a synthetic FFoRM-sSAXS data set for a dilute rigid rod suspension. The model accurately predicts microstructural evolution and rheology for flows that differ significantly from those used in training. SIMPLE is compatible with but does not require material-specific constraints or assumptions.

The presence of a tiny amount of polymers (a few parts per million) in a fluid dramatically reduces turbulent drag. For this reason, polymer additives have been proposed to be used in flood remediation: in an open channel at a fixed flow rate, the decrease in friction due to polymer addition is expected to lead to a decrease in water height in the channel. However, in a recent field experiment, a counterintuitive transient increase in water height has been observed far downstream of polymer injection. We numerically investigate the effect of polymer additives on the water height in a long canal using the shallow water equations augmented with an evolution equation for polymer concentration that incorporates turbulent dispersion and polymer degradation. Just downstream of polymer injection, the water height decreases due to the decreased friction at a fixed volumetric flow rate. Further downstream, however, the height can increase, consistent with the experimental observation. We elucidate the mechanism of this unexpected rise in water height in the canal. We also suggest a technique to mitigate the water rise, as this is detrimental for practical applications.

In my view, a certain answer to the question— “Should fishing of a stock of fish be increased or decreased?”—can be obtained only by adequate estimates of recruitment, natural mortality, mortality by fishing and growth rate: that is, estimates of all the vital rates. Until those are obtained the problem is not solved. The necessary estimates are not available at present for either the Icelandic stock of cod or the Arcto-Norwegian stock. This publication is part of Rapport et Proces-Verbaux des Reunions Vol. 136, which includes all contributions to a special scientific meeting on cod. To see all other articles in this volume, please click on the keyword "RPVR Vol. 136".

Introduction: In 2014, the General Medical Council introduced the concept of resilience training to the medical school curriculum. Aims: This cross-sectional study assesses resilience, coping mechanisms and professional quality of life in medical students. Methods: Medical students at Queen’s University Belfast (HUB) were invited to participate in an anonymous online survey during 8 weeks (2019), comprising three validated psychological scales: Connor-Davidson Resilience Scale (CD-RISC), Professional quality of life scale (ProQOL V) and BRIEF COPE. Results: 324 HUB students (years 1-5) participated (response rate: 25%). Mean CD-RISC score was 68.5 (SD 11.5) (low for resilience). Mean burnout (BO) was 26.9 (6.0) (worse than population mean: 20), mean compassion satisfaction (CS) was 37.8 (5.8) (similar to population mean: 37) and mean secondary traumatic stress (STS) was 22.3 (5.9) (worse than population mean: 11). Pre-clinical students had higher compassion satisfaction than clinical students (p=0.01). More than a quarter (27.4%) of medical students had high burnout and 21 (8%) had high BO, high STS and low CS. Common coping mechanisms were planning and active coping. Discussion: The high levels of burnout in HUB medical students suggest that they may benefit from interventions to develop resilience and improve professional quality of life.., Problem: The on call weekend team is primarily in place to deal with emergencies, however a large amount of their time is spent performing routine jobs left over from weekdays. Strategy for change: To reduce the number of routine tasks left for weekend staff to complete by 25% by March 2020 Measurement of improvement: Initial discussions with foundation doctors revealed that the most common routine tasks were IV cannula, bloods to be taken and checked, insulin prescriptions. Baseline audit of number of tasks left for weekend staff to complete (4 weeks), then weekly audit, using ward jobs list as reference. We adapted and introduced the known F.R.I.D.A.Y.S. checklist. We used the PSDA model and implemented 3 cycles in order to achieve improvement. Effects of change: Baseline data revealed an average of 25 routine jobs left to be carried out. By end of PDSA cycle 3, there was an average of 10 jobs left. Discussion with juniors and nursing staff revealed that they were happier with less bleeps, nurses were able to complete tasks more timely and overall satisfaction had improved. Discussion: Overall F.R.I.D.A.Y. checklist was a successful tool for reducing weekend routine tasks. When implemented correctly, it reduced the number of routine jobs (40% reduction in our ward), improved communication between team and staff and improved patient safety., Introduction: Studies based on molecular testing of oral/nasal swabs underestimate SARS-CoV-2 infection due to issues with test sensitivity and timing of testing. Aims: To report the presence of SARS-CoV-2 antibodies, consistent with previous infection, and to report the symptomatology of infection in children. Methods: This multicentre cohort study, conducted between 16th April - 3rd July 2020 at 5 UK sites, recruited children aged 2 to 15 years of age. Participants provided blood samples for SARS-CoV-2 antibody testing and data were gathered regarding unwell contacts and symptoms. Results: 992 participants were included in the final analysis. The median age was 10·1 years. There were 68 (6.9%) participants with positive SARS-CoV-2 antibody tests indicative of previous SARS-CoV-2 infection. Of these, 34/68 (50%) reported no symptoms. The presence of antibodies and the mean antibody titre was not influenced by age. Following multivariate analysis 4 independent variables were identified as significantly associated with SARS-CoV-2 infection. These were: known infected household contact; fatigue; gastrointestinal symptoms; and changes in sense of smell or taste. Discussion: The symptoms of SARS-CoV-2 infection in children were subtle but of those reported, fatigue, gastrointestinal symptoms and changes in sense of smell or taste were most strongly associated with antibody positivity., Introduction: Prior to the pandemic there were already difficulties in delivering postgraduate medical education (PGME) with attempts to balance service delivery and training requirements. Social distancing guidelines imposed due to COVID added the final blow to traditional postgraduate teaching. Aims: We wanted to reintroduce a PGME programme that was: - safe - accessible to all - sustainable. Method: We opted to deliver teaching remotely. Numerous platforms were trialled with Zoom being preferred. Initially we focused on one weekly session and with initial positive engagement momentum built and we systematically increased the opportunities available. Results: There is now a comprehensive PGME programme within the Southern Trust with all activities available remotely. There have been up to 50 participants availing of multiple sessions per week across all sites and specialties. Feedback has been positive: - 100% liking remote teaching format - 100% viewing remote delivery as safer alternative. Discussion: For the majority of trainers and trainees this was a new concept requiring adaptability and overcoming barriers. However this innovative approach has been positively received. We recognise that this is a work in progress and seek feedback, evolve with alterations and addition of new elements., Introduction: Faced with a pandemic, educational activities stopped with teaching and training a distant memory. However, we recognised that an appetite for learning persisted and that our commitment to lifelong learning must never stop. EDHEAD was born to put education back on the agenda. Aims: - Offer platform for paediatric healthcare professionals to access everyday clinical problems answered in evidence-based format using 5-minute peer reviewed, quality-assured videos.- Offer leadership and educational opportunities as part of lifelong commitment to learning.- Improve team moral by incorporating technology and humour within educational videos, with video element allowing for social distancing. Method: The EDHEAD team created a ‘wish-list’ of clinical questions. All members of the paediatric team were invited to prepare 5 minute videos based on guidance provided. These were submitted electronically and EDHEAD team peer reviewed, quality assured, edited and uploaded to shared platform. Results: We have had great engagement from multiple team members with the catalogue of videos steadily increasing. Feedback is collated to inform future clips. Discussion: We have created a pandemic-proof approach to education! We plan to share learning and evolve by collaborating with other departments., Introduction: The Academic Foundation Programme (AFP) provides foundation doctors with protected time for the development of the skills and aptitudes required in academic medicine. The NI AFP programme was established in 2008 with 9 AFP posts each year. To date, there has been no analysis of this cohort. Aims: We sought to describe the academic and career outcomes of the Northern Ireland AFP cohort. Methods: Anonymised data regarding AF2 post-holders from 2008-2018 was obtained from HUB and NIMDTA. A structured questionnaire was distributed to this cohort of 99 AFP trainees. Results: 41 males (41.4%) and 58 (58.6%) females completed the AFP with the majority (59.6%) being HUB graduates. The response rate was 44.8%. Of the respondents, 76.9% have presented and 46.2% have published their AFP project with 61.5% applying for a higher degree or academic position. 86.6% agreed that completion of the AFP has enhanced application for future training programmes and 76.9% believe that the AFP has influenced their intended or actual career pathway. Discussion: Our survey shows that participation in the NI AFP programme leads to research outputs, enhanced career opportunities and a clear pathway to academia, Background: Continued medical education (CME) for postgraduate Obstetrics and Gynaecology trainees is normal delivered by the consultant body in a face-to-face capacity, on a bi-monthly basis. Due to COVID-19, these teaching sessions were not able to occur. With the current pandemic it is important that we explore other options for delivering CME to postgraduate trainees including virtual delivery. Aims: To assess the viability of the consultant body delivering a virtual CME programme for obstetrics and gynaecology trainees in Northern Ireland Methods: Survey monkey sent to consultants to find out about their experience with virtual teaching and whether they would be comfortable teaching on a virtual session. Results: 41 consultants completed the virtual teaching survey, 67% had never used video-conferencing to teach doctors. 40% were not confident in sharing presentations and 92.5% in managing break-out sessions. 34 consultants would consider delivering CME if this became the standard teaching platform, with 82% having no objections to the sessions being recorded for trainees unable to attend. Conclusions: Consultants are keen to provide this method of teaching but require further training to deliver. Having consultants teach via zoom improves access to a diverse and rich knowledge base for postgraduate trainees., Background: Obstetrics and Gynaecology trainees in Northern Ireland attend bi-monthly postgraduate continued medical education (CME). COVID-19 restrictions meant these teaching sessions could not occur. Collaborating with senior trainees we developed a virtual postgraduate teaching series via ZOOM. Aims: To assess the viability of virtual CME for obstetrics and gynaecology trainees in Northern Ireland. Methods: Survey monkey sent to participants/non-participants exploring experiences and attitudes towards this teaching series. Results: 33 trainees completed the participant survey, with most attending 1-2 ZOOM teaching sessions. Over 50% had never attended teaching via video conferencing before. 66% of trainees were confident in using video conferencing for learning. 27 participants agreed that pre reading for each topic added to their learning. All participants agreed that CME should be mapped to the current RCOG curriculum. 87% of participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME. 15 trainees completed the non-participant survey, with 93% of trainees stating that work commitments meant that they were unable to attend the ZOOM sessions. Interestingly 2 trainees were unable to work ZOOM. 73% of non-participants agreed that video conferencing from a location of choosing is a more flexible way to approach CME, with 80% stating that if sessions were recorded and they were unable to attend, that they would use the recording for learning. Conclusions: Virtual teaching is an appropriate method to provide the necessary volume and quality of postgraduate medical education., Introduction/Aims: This study explored what is known about training for rare, time-critical procedures in Emergency Medicine. Methods: A scoping review of the published literature was performed, 40 papers were found which discussed aspects of training in rare, time-critical procedures, relating to Emergency Medicine. Results: Gaining experience in rare, time-critical procedures is challenging as trainees have limited exposure during their training. Skills gained decay quickly, so maintenance of skills is difficult. Simulation is widely practised; it is seen as an ethical imperative as skills can be gained and maintained without putting patients at risk of harm. Skills need to be practised frequently to combat skill decay; the optimum frequency of practice has not been established. New educational techniques may help maintain competency if incorporated into educational programmes. Discussion: There are many challenges to gaining and maintaining skills in performance of rare, time-critical procedures in Emergency Medicine. Frequent practice is required, and this should take the form of simulation in the absence of frequent clinical practice. Further research is needed into the best type of simulation for specific time-critical procedures and into what impact simulation training has on clinical outcomes., Introduction: As junior doctors we remember the difficulties with starting out as an FY1. Although Trust induction is comprehensive, in our experience, there is minimal induction covering the intricacies of daily workings of the ward and what life is really like as an FY1. Aim: To provide a peer-to-peer induction programme that is Trust specific but also role specific. We wanted to share invaluable tips gained through experience and ease transition into working life. Method: Four sessions were offered to all incoming FY1s. Given the current climate these were facilitated remotely. Current FY1s were recruited to deliver the sessions. To determine content we asked current FY1s to reflect on what they wished they had known when starting as a doctor and incoming FY1s were surveyed about what they wanted included. Results: Of the incoming FY1s that availed of the sessions 100% found them to be enjoyable, useful and increased their confidence for starting their new roles as junior doctors. Discussion: This initiative highlights the necessity and usefulness of a peer-to-peer element of induction. To improve this for further years we are currently in the process of seeking additional feedback., Introduction: The outbreak of a novel coronavirus in 2020 required significant and rapid changes to standard operating procedures within the psychiatric inpatient unit, in order to protect patients as well as staff. Aims: To develop standard operating procedures (SOPs) for managing Covid-19 positive patients, and to refine these and train staff using simulation based education. Methods: Phase 1 of the simulation exercise involved “run-throughs” of the SOPs with the MDT on a closed ward to identify latent safety threats and issues with equipment and supplies etc. SOPs were refined based on the issues identified and these were used in Phase 2 which focused more on training redeployed staff and managing anxiety. Results: Feedback was obtained using a staff survey. 85% felt that the SOPs had improved after their involvement in the Sim, 87% felt more confident about managing Covid positive patients, and 81% felt less anxious after attending the Sim. Discussion: Simulations are a useful way to test new care pathways and can identify latent safety threats, engage staff in improvement, and provide a forum for raising concerns and managing anxiety., Introduction: There are over 1.2 million chronically lonely people in the UK. Admission to hospital increases the prevalence of loneliness. Loneliness can significantly increase morbidity and mortality. Aims: The aim of this project was to reduce loneliness by an increasing awareness, befriending scheme, posters and a loneliness protocol. Methods: Use of patient surveys with qualitatitive and quantitive data. Open and closed questions used with implementation of a UCLA loneliness scale. Results: Each intervention decreased the median UCla scale, the befriending scheme had the greatest effect on Ucla reduction. Discussion: Due to social distancing policy, there has been a reduction in number and duration of visitors. Patients described loneliness as loss of purpose, days being very long and not feeling close to others. Many felt a shame associated with loneliness. Patients were reluctant to tell hcps about loneliness due to fear of offending staff. Loneliness was seen by many patients as a natural part of growing old. Patients felt face masks reduced ability to engage with Hcps., Problem: Foundation doctors are contacted regularly out of hours to complete routine prescribing tasks that should be completed in normal working hours. Strategy for Change: The “KIWI Checklist” is a communication tool designed to be used at ward level to ensure completion of 4 routine prescribing tasks within normal working hours. These include: rewriting of Kardexes; Insulin Prescribing; Warfarin prescriptions and IV fluid plans. Measure of Improvement: The primary outcome measure for this project was the percentage of bleeps out of hours received by FY1 doctors that were for routine prescribing tasks. Effects of Change: Data was collected over 10 weeks from October 2019- December 2019. The KIWI Checklist was introduced to 2 wards in BCH after week 5. Ward 7N had a reduction in the percentage of bleeps out of hours that were for routine prescribing tasks from 40% to 0% and Ward 9N had a reduction from 70% to 20%. Discussion: A simple checklist at ward level reduces the burden of prescribing out of hours, improving patient safety. Senior medical and nursing leads within have approved the checklist for rollout across a number of divisions in BHSCT., Problem: The need to reduce the number of general surgical inpatients to create capacity in preparation for the COVID-19 pandemic. Strategy for change: Restructuring of our emergency general surgery (EGS) service, including establishing an enhanced ambulatory service, and non-operative management of selected conditions. Measurement of Improvement: Patients referred by the emergency department were prospectively identified over four weeks from the date of reconfiguration (COVID) and compared to patients retrospectively identified from the equivalent period the previous year (Pre-COVID), followed up for 30 days. Data was extracted from handover documents and electronic care records. Effects of Change: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Rates of admission decreased (78.1% to 41.7%) whilst there were increased rates of ambulation (7.1% to 17.3%) and discharge (6% to 22.6%). Duration of admission decreased (6.9 to 4.8 days), and there were fewer operative and endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39), telephone reviews (0 to 39), and use of early CT to facilitate discharge (5% to 34.7%). There were no differences in 30-day readmission or mortality in any group. Discussion: Restructuring of our EGS service in response to COVID-19 facilitated a 62.7% reduction in inpatient bed days (1519 to 567) whilst maintaining patient safety., Problem: Sleep, both in the recommended duration and quality, is a controversial area. However, it is acknowledged that sleep plays an important role in recovery from illness. Hospital wards are loud, busy and bright – an environment not conducive to sleep. Strategy for change: We sought to tackle two issues negatively impacting patient sleep – noise and light. We offered ear plugs (PDSA cycle 1) and ear plugs with an eye mask ( PDSA cycle 2) aiming to improve the amount of sleep on the respiratory ward in BCH by 25% in a 4 month period. Measurement of improvement: We distributed qualitative and quantitative patient surveys prior to our intervention and after. We compared the data from these surveys. Effects of change: PDSA cycle one (ear plugs) showed evidence of a significant improvement in patient sleep – achieving our aim. PDSA cycle two did not show that the use of both ear plugs and eyes masks had a significant impact than ear plugs alone. Discussion: These were simple changes which could reduce consequences of sleep deprivation such as delirium and hasten patient recovery., Problem: No collection of data on morbidity for discussion occurring in the EMSU Strategy for change: Implementation of morbidity function on the excel handover template already in use, before discharging any patient from the handover a prompt would appear for consideration of morbidity discussion. Teaching to all junior staff about the morbidity function on the excel handover was then provided. At the beginning of the placement a core trainee was designated as the responsible person for collection of morbidity data. Measurement of Improvement: From April to June 0 morbidity cases were discussed prior to change, from July to September 49 cases were discussed. The change was sustained with 45 cases discussed from October to December. Discussion: The problem with morbidity collection was compounded by constant rotation of senior staff. Giving the responsibility of improving the morbidity collection and discussion to a core trainee, who was permanently based in the EMSU, empowered them to organise the rest of the team and make a sustained change, provided permanent point of contact for the team on site. The prompt on the excel handover sheet ensured that patients were not removed from the handover without consideration of morbidity status., Problem: Poor handover process in place for postnatal ward; Handover was handwritten via a ward diary. Often due to lack of space, unclear handwriting or no verbal handover taking place – there were a number of antibiotic doses not given for suspected neonatal sepsis, missed clinical reviews of infants amongst other concerns. Strategy for change: Introduced a new typed & printed handover template and face-face handover to occur between each change of shift. Senior member of staff (Registrar/Consultant) met with post-natal ward SHO mid-morning to address any issues. Measurement of Improvement: Staff questionnaires (initial, re-audit x2 over 6 months) to nursing and medical teams and the recording of any incident report forms completed. Effects of Change: No incidents of missed antibiotics/clinical reviews/concerns were recorded after the introduction of the typed, formal face-face handover. Improved staff morale overall amongst staff – clear, face-face handovers were now expected and became the norm. Staff felt more supported as a result of a formal meeting with registrar/consultant midmorning to trouble-shoot any issues. Discussion: As a result of our QI project, babies were better cared for and were placed at less risk. The project has demonstrated that clear communication at all times has the ability to enhance patient care and staff wellbeing., Problem: Central Venous Access devices (CVADs) are common on medical and surgical wards. Complications including blockage and infection are relatively common. These need addressed appropriately to prevent loss of IV access, days without TPN or line sepsis. There is limited training in hospitals, therefore junior doctors can be unsure in dealing with issues that arise. Strategy for Change: To improve junior doctor aptitude and confidence in managing CVADs, a survey was prepared which consisted of two sections. Firstly one which junior doctors’ rated their confidence on a 1-10 scale and a further section which tested technical knowledge of CVADs and their associated guidelines. An education session was then set up with information provided by the Infusional Services team. Measurement of Improvement: The survey was re-taken after the education session to assess areas which improved and areas which still required attention. Effects of Change: Junior Doctor confidence increased 36% overall for all 3 types of CVAD. There was a 57% improvement in the technical knowledge of CVADs and management of complications. Discussion: Both junior doctor confidence rating and technical knowledge greatly improved after the education session. To ensure retention of knowledge we plan to re-audit. Further measures for implementation include easy access to CVAD protocols on the trust intranet., Problem: During the COVID-19 pandemic, surgical service and practice has been adjusted in order to reduce acute surgical admissions. Acute appendicitis accounts for a significant proportion surgical admissions in the UK. Strategy for Change: Intercollegiate general surgery guidance during the COVID-19 pandemic advised appendicitis should be managed conservatively, or with an open appendicectomy if indicated. Our aim was to determine the efficacy and safety of our ambulation service in the conservative management of acute uncomplicated appendicitis. Measurement of Improvement: Data was collected prospectively from 30th March 2020 – 16th August 2020 on all patients presenting with suspected appendicitis. Stable patients with clinically suspected or CT-proven appendicitis were discharged with oral antibiotics as per trust guidance. Readmissions for ambulated patients were recorded. Effects of Change: 190 patients presented with suspected appendicitis (range 5-71years). 49.4% patients were deemed suitable for ambulation on initial assessment, 22% of which had a CT confirmed diagnosis on discharge. 65% of the ambulated patients underwent a telephone review within a 72 hour window. 13.8% of patients represented within a 30 day period, 7.4% of which proceeded to appendicectomy. Discussion: Patients with uncomplicated appendicitis can be safely managed with antibiotics out of hospital, with low representation rates., Reasons for criterion chosen: Belfast’s Rheumatology Department facilitates infusions of biologics on a daily basis. Usual protocol was that patients had routine bloods taken on arrival. We evaluated guidance on drug monitoring, according to British Society of Rheumatology and Summary of Product Characteristics, finding that frequency of blood monitoring was surplus to requirement. We recorded bloods taken and were struck by the unnecessary frequency of blood monitoring. We constructed a proforma of correct frequency of drug monitoring according to the British Society of Rheumatology and Summary of Product Characteristics. A one page poster of guidance. Data Collection: Frequency of blood monitoring checked in a two week period went from 80% to 10% with use of our guidance poster. Conclusion: Difference in cost of blood tests sent, in a two week period, after implementation of monitoring guidance was £1681.29. It is important to continually assess whether current practise is correct or could be updated. This project has demonstrated how reviewing guidance can lead to significant saving. This project will save at least £43,713.54, in one Rheumatology Unit, per year., Problem: No allocated time for morning handover at Lagan Valley Hospital contributes to anxiety among F1 doctors. It can result in the night-F1 staying beyond their shift to handover to each ward individually; leads to unfamiliarity of sick patients and outstanding tasks; and has the potential to compromise patient safety. Strategy for change: We propose designating time each morning at 9am for handover between F1 doctors. It will follow a standardised format including: Sick patients Outstanding investigations Deaths overnight Any other outstanding issues/concerns This qualitative project aims reducing anxiety among F1 doctors; familiarise the day-F1 with patients on their ward and improve patient safety by minimising errors associated with poor handover. Measurement of improvement: Qualitative pre- and postintervention questionnaires were completed by F1 doctors in relation to job satisfaction, confidence and the perceived impact on patient safety. Effects of change: All respondents felt that the proposed F1 handover improved confidence among F1 doctors and minimised disruptions in patient care. Discussion: Shift patterns and lack of a formal handover between doctors can disrupt continuity of patient care compromising patient safety. Formal handover ensures safe transfer of patients between doctors and reduces anxiety among F1 doctors., Problem: Given the COVID-19 pandemic, reduce face-to-face consultations to only complex burns or those necessitating hospital admission to Northern Ireland’s Regional Burns Unit. Strategy for Change: Establish a virtual burns service, using a combination of telephone calls, emails, photography and Microsoft Teams software. Our initial adoption of the system was audited during April and May 2020. Through Plan-Do-Study-Act (PDSA) methodology an electronic tertiary-referral proforma was subsequently created prior to closure of the audit cycle in July 2020. Measurement of Improvement: 1. Reduction in face-to-face consultations 2. Completeness of burns referral data (including: demographic, clinical and initial management) both pre- (April & May 2020) and postintroduction (July 2020) of e-Referral pathway. Effects of Change: From the start of lockdown a significant reduction in face-to-face consultations was observed. Given the increasing use of virtual telephone consultation only 19.5% of the unit’s total referrals (April, May and July) were either reviewed face-to-face in dressing clinic or admitted. Following implementation of the e-Referral pathway an improvement in both the detail and completeness (95%) of patient referral information was achieved. Discussion: Our experience demonstrates that virtual burns care can be safely and rapidly adapted in response to evolving need. The potential role of virtual care post-COVID, in selected patients, is an exciting one., Problem: Hospitalisation is associated with a deterioration in patient oral health. The pharmacy team can advise on management of common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Survey data revealed the King’s College Hospital (KCH) pharmacy team had low confidence in these areas and were unaware of where to access appropriate guidance. Strategy for change: Two teaching sessions on management of oral conditions were planned and delivered to the pharmacy teams at two KCH sites. Health Education England’s (HEE) Dental Factsheets for the Pharmacy Team were distributed to all team members, with reference copies kept in each department. Measurement of Improvement: An online questionnaire was circulated to measure confidence in managing common oral conditions, adverse oral effects of medications, and appropriate antimicrobial prescribing. Effects of change: Confidence in managing all the oral conditions covered showed significant improvement. 75% of participants would consider using HEE’s Dental Factsheets for the Pharmacy Team for further guidance. Discussion: This project enabled and empowered the pharmacy team to take a more active role in improving patient oral health. Future work lies in evaluating the patient impact of these measures., Problem: During the Covid pandemic information for pregnant patients was updated regularly and printed leaflets were often out of date. Strategy for change: Dynamic QR codes were introduced to antenatal clinics across Northern Ireland. Dynamic codes allow for the destination of a code to be changed without changing the printed code. This allows patients to scan the codes on their phones, providing up to date patient information on their device. Measurement of Improvement: The exact number of codes scanned was recorded digitally. A regional staff and patient survey was undertaken. Effects of change: Both staff (82%) and patients (81%) were keen to provide and receive information leaflets via QR codes. Intervention 1 = printed laminated codes used in clinics – 10 scans per day over 4 weeks Intervention 2 = targeted education sessions at clinics – 17.7 scans per day over 3 weeks Intervention 3 = codes included in patient notes – 26.6 scans per day over 3 weeks. Discussion: This 3 cycle QI project was devised due to the challenges created by the Covid pandemic. QR code use has increased with each intervention saving resources and providing patients with up to date information., Problem: Coronavirus Lockdown meant all non-emergency essential services were reduced. Face-to-face epilepsy clinics had to be cancelled. Strategy for change: Instead of cancellations, all scheduled epilepsy clinic reviews were conducted by pre-arranged telephone call. Measurement of Improvement: DNA rates during the virtual clinic review period were compared with face-to-face review clinics during the same 6 month period last year. We found a 37% reduction in non-attendances when using telephone reviews. Qualitative feedback from parents favoured the approach in terms of convenience and stress reduction, but highlighted reservations regarding variable signal quality, and wanting reassurance of a doctor physically seeing their child. Effects of change: Ongoing use of telephone reviews for this stable patient population. Discussion: Successful improvement in attendance rates and positive feedback from patients indicates telephone clinics are an effective form of review. A combination of face-to-face and telephone reviews is likely to be implemented. This raises questions; who is eligible for this review format and how to we decide? Are any other clinics amenable to this pattern? What are the benefits for the clinician and the financial benefits for the NHS?, Introduction: What appears on the skin can be a manifestation of systemic disease; an infectious, autoimmune or malignant process. Not all new inpatient rashes are drug-related. Description of case: We report a 53 year old female inpatient, being treated for decompensated alcoholic liver disease, who developed a widespread, polymorphic rash, with crops of sterile vesicles. Rifaximin had been newly commenced. Drug eruption was a differential. However, histological findings from a skin biopsy were in keeping with herpes virus infection, with background erythema multiforme changes. Subsequent viral PCR confirmed varicella zoster. Dermatology review confirmed a diagnosis of disseminated herpes infection. Aciclovir, potent topical steroid, emollients and anti-histamines were recommended. Discussion: Confirmation of an alternative diagnosis to a drug reaction enabled the patient to continue on necessary medication. Dual pathology may be present. Her confusion and fluctuating cognitive state was proven to be due to encephalopathy on EEG, thought to be explained by hepatic encephalopathy. Herpes encephalitis may have contributed. Immunosuppression puts patients at risk of VZV. This patient had a prolonged ICU admission, and background of chronic alcoholism and poor nutrition. Allow initial presumptive diagnoses to be challenged, with emerging clinical details., Introduction: Spinning is a popular high-intensity training (HIT) exercise which is increasingly reported as a cause of rhabdomyolysis. Rarely, rhabdomyolysis can lead to limb-threatening acute compartment syndrome (ACS) requiring urgent fasciotomy. Description: We describe spinning-induced rhabdomyolysis in three young women, two of whom required emergency bilateral fasciotomies for ACS. None had neurovascular compromise at the time, and all three had a good outcome. Discussion: Patients with exercise-induced rhabdomyolysis present with severe pain, swelling, and weakness of affected muscle groups accompanied with a rise in serum creatinine kinase (CK). Inadequate physical conditioning and increased duration and intensity of exercise are all associated with a higher risk of rhabdomyolysis. Although in itself it is a recognised phenomenon, diagnostic consideration should be given to occult metabolic myopathies in a young patient population. Learning points: Early involvement of senior / experienced surgeons leads to early diagnosis and rapid intervention. Compartment syndrome can occur without neurovascular compromise. The public and exercise instructors should be aware of the risks to new spin-class attendees, and how to mitigate these risks., Introduction: COVID-19 infection can result in a severe viral pneumonia clinically indistinguishable from acute respiratory distress syndrome (ARDS). Mortality rates of mechanically ventilated patients are high and it is suggested that heterogeneity of disease pathophysiology means established therapeutic approaches to ARDS are not applicable in its management. Aim: This case series aims to describe the physiological and outcome data of patients with Covid-19 who were admitted to Intensive Care (ICU) and treated with standardised evidence based guidelines for ARDS. Method: Retrospective case review of all patients admitted to Intensive Care within the Belfast trust with Covid-19 between March and June 2020. Results: 45 patients were included, 37 (82.2%) were male with a mean age of 55. 42 patient (93.3%) fulfilled ARDS criteria at time of admission. Clinical management was highly compliant with institution evidence-based ARDS guidelines. Median length of ICU stay was 14 days and ICU mortality was 8.9%. Discussion: COVID-19 fits within the spectrum of ARDS and results in similar respiratory physiology. Adherence to established evidence based therapies for ARDS in ICU patients with COVID-19 pneumonia is associated with a low mortality in this cohort., Introduction: We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity. Description: A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft. Discussion: Neonatal limb ischaemia is a rare disease entity with devastating morbidity-including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life long morbidity., Introduction: Sotos syndrome a genetic disorder characterised by delayed neurodevelopment, learning disability, excessive childhood growth and craniofacial abnormalities occurs as a result of a mutation in the NSD1 gene. We present a case series of 5 children with Sotos Syndrome who have been treated for cholesteatoma and review the literature. Case Series: Retrospective case note review of patients cholesteatoma (n = 5 (1 Bilateral)) and Sotos Syndrome between 2012 and 2019. Median age at first surgery was 8 years old (3.5 years – 10.9 years). All children presented with otorrhoea. 4 children (5 ears) had abnormal hearing thresholds (>30dB HL) pre and post operatively. Median follow up is 32 months with 50% risk of recurrence and 25% risk of residual disease at 24 months. PubMed search of the MEDLINE database returned no articles reporting cholesteatoma in children with Sotos Syndrome. Discussion: Cholesteatoma has not previously been reported in Sotos Syndrome. Otolaryngologists should be vigilant for cholesteatoma in children with Sotos Syndrome., Introduction: Bartholin’s glands provide lubrication to the vagina and are a common site for infection. Lifetime incidence is 2-7%. 1,3,4,6 Bartholin’s abscesses cause pain, dyspareunia, incontinence and obstructive voiding symptoms. 1,5 Scarcely reported in literature are simultaneous presentations of Bartholin’s and peri-urethral abscesses. Peri-urethral abscesses typically follow trauma caused by childbirth or surgical interventions. 2,7 Case Study: A 23 year old was admitted in the spinal unit with acute urinary retention, saddle paraesthesia, back pain and a reduction in lower limb power and unusually high inflammatory markers. MRI spine ruled out cauda equina. On vaginal examination a right sided Bartholin’s abscess was detected. Following a Gynaecology review CT abdomen and pelvis demonstrated a peri-urethral abscess deviating the urethra to the left side. Treatment: The abscess was incised and drained at the bedside. She was discharged with an indwelling catheter and oral antibiotics to return in one week for trial removal of catheter which was successful. Outcome and Follow Up: She was clinically well, discharged and no follow up arranged. Discussion: A common gynaecological pathology presented in an atypical way. Although good clinical history and examination findings are key, imaging modalities can be a vital adjunct for patient care., Introduction: Collisions tumours are a rare but well documented phenomenon. They comprise of two histologically distinct tumour types occurring in the same site. The mechanism of which this comes about can be; 1) Two tumours arising with the same organ in close vicinity, 2) One tumour metastasizes into another tumour (tumour to tumour metastasis), 3) Two different tumours metastasize to a different organ, commonly a lymph node. Collision metastasis of two different primary tumours within the same lymph node is extremely rare. Description of Case: The authors report a case of a 74 year old woman found to have collision metastasizes of lobular breast carcinoma and adenocarcinoma of the caecum metastasizing to the same mesenteric lymph node. Discussion: The case is, to the best of the author’s knowledge, the first to describe the metastatic spread of two tumours to a single lymph node involving breast carcinoma and adenocarcinoma of the colon., Introduction: The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern. Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries. Description: We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings. Discussion: Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full skin thickness burns warranting operative intervention., Introduction: Endometrial ablation is an established treatment option for the management of women with Heavy Menstrual Bleeding. Following this procedure, women may still conceive and therefore effective contraceptive methods are recommended. We report 3 cases of unplanned pregnancies following endometrial ablation. Our series demonstrate the spectrum of possible complications and outcomes. Cases: Case 1 is a 43-year-old woman who had an unplanned pregnancy following hydrothermal balloon ablation. Her pregnancy was complicated by Fetal Growth Restriction and Morbidly Adherent Placenta at delivery. Case 2 is a 40-year-old presenting with a missed miscarriage after previous Bilateral Tubal Ligation at C-Section and subsequent Novasure endometrial ablation. She underwent management by Total Abdominal Hysterectomy. Case 3 is a 41-year-old woman who had an unplanned pregnancy after Novasure endometrial ablation but went on to have relatively uncomplicated pregnancy and delivery. Discussion: Pregnancy after endometrial ablation has the potential to increase patient morbidity significantly. According to Bauer et al. there is a 20-fold increased risk of morbidly adherent placenta. The overall risk of termination, ectopic pregnancy or miscarriage was quoted to be about 85% in another study. Consequently, it is important that appropriate contraceptive methods are discussed with patients post-ablation. The risk of failure of contraceptive methods should also be included in the discussion and an appropriate plan made if this occurs., Introduction: This case demonstrates the complexity of diagnosing and treating a tooth associated with a mandibular fracture and fixation. Description of Case: This 19-year-old male patient attended with a history of severe spontaneous pain lower RHS. On examination the LR7 was acutely TTP, heavily restored and associated swelling painful on palpation. Pre-operative radiographs revealed periapical radiolucency associated with apical third LR7 and a radiopaque mini-plate with an associated tracking sinus. The patient was diagnosed with chronic apical periodontitis with an associated draining sinus. Treatment options; - Endodontic treatment at GDP - Specialist endodontic referral - Extraction Treatment was carried out under LA and a recall for review set at 6 months. Discussion: The challenge was the difficulty of diagnosis. It demonstrates how mini-plates can interfere with accurate diagnosing. It is likely that damage was a result of the trauma or surgery (2 years previously). It highlights the potential that all modern endodontics could routinely use 3D imagery, CBCT. Conclusion: It is important to recognise teeth with an associated history of trauma or elective surgery involving mini-plate/screw placement. Thorough radiographic and assessment with monitoring is required to ensure an accurate diagnosis., Introduction: Radial artery pseudoaneurysm is a rare complication of a common procedure such as trans-radial arterial catheterisation. There are multiple risk factors increasing the likelihood of developing pseudoaneurysms, including traumatic insertion of the radial catheter or concomitant infection. Few cases are reported, and no established cause is described in literature. We describe a case of a young patient who developed an iatrogenic pseudoaneurysm post arterial line cannulation. Description of Case: A 36 years old male was admitted with subarachnoid haemorrhage (SAH) due to a ruptured intra-cranial aneurysm. He underwent invasive monitoring with radial arterial line catheter during coil embolization treatment. He underwent the procedure uneventfully but was complicated later by the development of a pseudoaneurysm. Discussion: In our case, the patient had borderline levels of inflammatory markers on blood examinations and no overt signs of local infection. There was a history of multiple attempts at arterial cannulation, and he was also commenced on antiplatelet therapy post coil embolization of the aneurysm. Concurrent use of anticoagulation agents is associated with an increased risk of formation of pseudoaneurysms. Arterial line monitoring is an invaluable aid in assessing the critically ill patient, however pseudoaneurysms is a potential complication with high morbidity even in younger age groups. Atraumatic insertion and careful removal are strongly recommended for its prevention., Introduction: Squamous cell carcinoma arising in a dermoid usually affects elderly persons and usually found in 1% of mature teratomas. It usually has a poor prognosis and quite rare in the middle aged women. Dr Tom Murphy Description of Case: The case report presented is a 49year old lady referred from the GP with a large right ovarian mass with radiology suspecting to be an ovarian teratoma. Underwent a laparoscopic BSO with histology coming back as Stage 2b, CT afterwards showed no metastatic disease, she underwent Laparotomy, TAH, recto sigmoid colectomy, end colostomy, appendectomy, anterior caecal resection, SB resection, omental biopsy, re implantation of urethra, urethral resection, stent Right ureter. Histology post op coming back as Stage 3b. She deteriorated quite rapidly despite measures to improve outcomes, knowing that prognosis is usually poor when disease has spread beyond the ovary. Conclusion: A high index of suspicion should be indicated for women in that age group with a pelvic mass. The length of time from diagnosis to death was 7months and begs the question if any of the surgical interventions were of benefit., Introduction: The aim of this case report aims to discuss the surgical management of deep facial lacerations, specifically for dental trainees transitioning to a position in Maxillofacial Surgery. It covers the important anatomical structures that need assessed and repaired. Description: Assessment of a patient with a full thickness facial laceration with a chainsaw, extending into the oral cavity. On examination the patient had some loss of function to the buccal branch of their facial nerve. Intra-orally the parotid duct was located and checked for patency, ensuring that it was not severed and it did not require stenting. The wound was closed in layers, aiming to reattach severed muscle bellies to maximise post-operative function. Postoperative wound care management was carried out as well as post-operative instruction. Discussion: Dentists entering Dental Core Training typically may find the transition to a maxillofacial surgery post daunting as it is extremely out of their comfort zone. This article aims to highlight some stages which are key to address when assessing facial soft tissue trauma as well as ways in which to manage these., Introduction: Colorectal villous adenomas are common. A rare but important complication of rectal villous adenoma is the electrolyte and water “depletion syndrome” which can be elusive as a diagnosis. If recognised and managed expediently, severe metabolic and renal sequelae can be prevented through appropriate replacement therapy and timely surgery. Case Description: We present a case of an elderly female who gave a 2-year history of progressive chronic watery diarrhoea, necessitating multiple attendances to her GP and several hospital admissions where she had been treated successfully with fluid and electrolyte replacement and a diagnosis of autonomic neuropathy was made. It was only after a thorough examination of the patient including a rectal examination that a large mass was detected and biopsies revealed a giant villous adenoma. She ultimately came to surgical resection with complete resolution of her symptoms Discussion: Villous adenomata have a propensity for secreting large volumes of mucus rich in potassium and sodium and the losses can be so great as to result in cardiovascular, neurological and renal sequelae. Where rare, this case highlights the values in carrying out a thorough clinical assessment., Introduction: Upper ministernotomy(UMS) for Aortic valve surgery is a well-established approach.It has been proven to be a competitive alternative to full sternotomy with improved aesthetic appearance and non-inferior safety. Aims: We present our single centre experience showing short and medium term surgical outcomes of UMS approach for aortic surgery. Methods: Retrospective analysis of patients who undergone UMS Aortic valve procedures over the last five years. Analysis of patients’ demographics, intra-op findings and evaluation of early/medium term outcomes. Data presented as median (interquartile range) or percentages. Results: 231 patients had UMS Aortic valve surgery at our Hospital over 5 years (Sep2014-Sep2019). Mean age: 67 (37-86) years, BMI >30 in 120 (52%). Majority were done in J shape hemi-sternotomy (87%) and through Right fourth ICS (94.4%). Central cannulation was the most favoured approach (99.2%). The aortic valve was replaced in 230 patients, mechanical valve: 37 (16%) and bio-prosthetic valve:193 (84%). Combined aortic surgery was performed in 7 patients(3%),cross clamp time: 60 (33-170) min, CPB time: 108 (51-190) min. 30-day Mortality: 1 (0.4%), conversion to full sternotomy: 11 (4.7%), reoperation for bleeding: 8 (3.4%), ICU stay: 1 (1-20) day, hospital stay: 8 (3-32) days, new onset AF: 8 (3.4%), CVA/TIA in 0.86%, 30-day readmission: 7 (3%). Early follow up echo mean gradient: 9. 7 (3-34) mmhg. Follow up: 2.8±2 years. Discussion: Aortic valve, aortic root and ascending aorta surgery is amenable by mini sternotomy incision with good outcomes taking into consideration careful patient selection. It is essential to respect the learning curve and accepting low threshold for conversion to conventional full sternotomy when required, Introduction: The incidence of cutaneous malignant melanoma (cMM) is increasing; Vitamin D deficiency at presentation is associated with increased tumour thickness and poorer outcomes. Aims: To examine the epidemiological and histopathological characteristics of cMM in Northern Ireland (NI), and to correlate with socioeconomic status (SES) and Vitamin D levels. Methods: A retrospective review was performed from August 2015 - March 2020. Patients were identified from electronic theatre records and a prospectively-collected database; further information was gained from paper and electronic clinical records. SES was determined by the NI Multiple Deprivation Measure 2017. Results: 440 patients presented with cMM; there are some differences in tumour site between the devolved nations. Vitamin D levels were assessed in 27%, of whom 44% had deficient levels. Higher SES correlated with increased incidence of cMM (Correlation coefficient (CC) 0.922). This did not correlate with thicker tumours (CC -0.020). There was only a very weak negative correlation between Vitamin D deficiency and tumour thickness (CC -0.14). Discussion: Despite being included in the NICE guidelines since 2015, almost three-quarters of patients had not had Vitamin D levels assessed. Interestingly, higher SES was related to higher incidence of cMM but with presentation at earlier stage of disease., Introduction: Many developed countries have reported a recent rise in non-tuberculous mycobacterial (NTM) infections but the trend in Northern Ireland (NI) is unknown. This study aimed to characterise the epidemiological profile of mycobacterial species isolated from NI patients between 2007-2019. Methods: All positive mycobacterial culture results reported by the NI Mycobacterial Reference Laboratory between 2007-2019 were analysed by species and specimen site. Annual population data was obtained from the NI Statistics and Research Agency. Results: 2193 mycobacterial isolates were captured in the study period. Mycobacterium tuberculosis (M.tb) isolates remained stable at ~3 per 100,000 population whereas NTM isolates increased from 3.2 to 8.1 per 100,000 between 20072019. Eighteen different species of NTM were identified, five of which accounted for ~75% of isolates. Mycobacterium avium complex (MAC) species accounted for the greatest rise in NTM (1.8 to 4.6 per 100,000), of which over 90% were isolated from pulmonary specimens. Discussion: NTM isolates now outnumber M.tb in NI, with a substantial rise in pulmonary MAC specimens. Clinicians in all specialties will increasingly encounter these poorly understood and drug-resistant organisms. More research into NTM disease is required to tackle this emerging problem., Introduction: The global pandemic has resulted in mass cancellation of elective operations; impacting cancer procedures, waiting times and training opportunities. In the Southern Trust, Craigavon Area Hospital is the designated “COVID site” and Daisy Hill the “Non-COVID site”. Aim: To assess if systems introduced resulted in low postoperative COVID cases in a COVID site compared to a non-COVID site. Method: A prospective audit of elective surgeries performed on COVID site from May-July and non-COVID site AprilJune 2020. Data collected using standardized audit proforma with 30 day follow up. Measures introduced included PPE, a separate ‘clean ward’, routine staff and patient testing, 7 day patient self-isolation prior to surgery and a no visiting policy. Results: 44 elective operations performed in COVID site and 21 in non-COVID site. 2.3 %( 1/44) developed clinical COVID 6 days post-op on COVID site - did not require ICU and alive at 30 days. Zero COVID cases in non-COVID site and zero staff cases across both sites. Discussion: Precautionary methods introduced may have contributed to low numbers of COVID and were enough to enable elective operations to continue on a COVID site. In light of recent rising community COVID cases, a re-audit will be conducted., Introduction: UK guidelines recommend sentinel lymph node biopsy (SLNB) for patients with malignant melanoma >1mm Breslow thickness; those found to have micrometastatic disease are considered for adjuvant therapy. Aims: Service evaluation of the new NI SLNB service, which began in December 2018. Methods: Consecutive patients were identified from a prospectively-collected database. Results: 166 patients were referred to the service. A total of 115 nodal basins were investigated with SLNB. Seventy-three patients were male, 95 were female; mean age at presentation was 58 (range 20 - 87). Commonest primary tumour site in men was trunk/back (47%), and lower limb in women (41%). Eighteen nodal basins were positive for micrometastases, 91 nodal basins were negative, and SLN localisation failed in 6 nodal basins. Average waiting time from referral to outpatient appointment is 2.6 weeks, less than 3-week target; however, the mean time from diagnosis to surgery is breaching the 12-week target. Almost 10% of patients were not suitable for SLNB surgery, either due to co-morbidities or previous surgery. Discussion: Surgical outcomes will be compared to international data, and considerations in starting a new service will be discussed, along with methods to reduce proportion of unsuitable referrals., Introduction: Evidence from emerging studies suggests that oral bacteria and poor oral health may contribute to COPD exacerbations. Interventions to improve oral health such as periodontal therapy may improve lung function, decrease the frequency of COPD exacerbations, hospitalisations and improve quality of life. Aims: The aim of this systematic review was to analyse the association between poor oral health and frequency of COPD exacerbations. Methods: The databases, Pubmed; Embase; Web of Science; CINAHL and Medline were searched up to May 2020, with no language restriction. Eight articles met the inclusion criteria and were included in qualitive synthesis, five articles were included in quantitative analysis. Results: The data from randomised controlled clinical trials showed a significant reduction in frequency of exacerbations following periodontal treatment (RR 0.28; 95% CI 0.090.83, p=0.02). Based on random-effects meta-analysis amongst case control studies, plaque index (OR=1.63, 95% CI 1.15 to 2.31, p=0.01), probing pocket depth (OR=2.03, 95% CI 1.46 to 2.82, p, Introduction: The inflammasome is a protein complex that initiates immune responses to danger signals by releasing cytokines interleukin-1β (IL-1β) and IL-18. Inflammasomes are thought to be involved in multiple sclerosis. Studies have shown that inflammasome activity can promote CNS repair. Aims: To determine if inflammasomes can be stimulated in CNS cells, and whether inflammasome activity promotes oligodendrocyte progenitor cell (OPC) proliferation and/or differentiation. Methods: Mixed glial cultures were generated from wildtype and Il1r1-/- mouse brains. Cells were stimulated with IL-1β to test glial response to inflammasome activity, or with inflammasome triggers to test endogenous inflammasome response in glial cells. Cells were then stained for oligodendrocyte and inflammasome markers. Results: Glial cells mounted an inflammasome response upon danger signal sensing. The formation of putative ASC specks denoted inflammasome activation. IL-1β increased oligodendrocyte lineage cell numbers, promoted OPC differentiation and increased myelin production in vitro, mediated via IL-1 receptor 1., Introduction: Orofacial granulomatosis (OFG) is a chronic granulomatous oral inflammatory disease and can precede gut Crohn’s Disease (CD). Not all OFG patients have, or ever develop, CD. Therefore, whether OFG and oral CD are one and the same disease is a matter of debate. Aim: To use proximity extension assay (PEA) to interrogate phenotypic differences between health and oral inflammatory conditions. Methods: PEA analysis was performed using ProSeek Inflammation and Immune Response panel. Olink Proteomics (Uppsala, Sweden). Saliva samples from 32 patients with OFG were processed and analysed. Controls included saliva samples from 30 healthy volunteers and 28 patients with Oral Lichen Planus (OLP). Results: No significant difference between the proteome of health vs OFG / OLP vs OFG. Significant differences in the levels of 8 proteins between OLP vs OFG (TWEAK, PRDX1, CDSN, LY75, MCP.1, FGF.23, CLEC4G, CX3CL1). Within the OFG group there were two distinct subtypes that correlate with idiopathic OFG and gut CD. Discussion: Analysis of the oral proteome may offer a means of differentiating between different oral inflammatory diseases. More importantly it may help predict those cases of OFG that will progress to gut CD., Introduction: De Quervain tenosynovitis is a disorder of the tendons of first dorsal compartment of wrist that causes pain and functional disability managed by platelet-rich plasma (PRP). Objective: To determine efficacy of intralesional injection of platelet rich plasma in patients of De Quervain’s tenosynovitis Material & Methods: This is a descriptive Case series conducted over 6 months, 100 patients were included. Platelet rich plasma was obtained after centrifugation, received intralesional injection plus oral non-steroidal anti-inflammatory drug. Results: 57 males and 43 females with mean age of 41.26±11.26 years, 53(53%) were diabetic. Efficacy of treatment was seen among 85(85%) patients, whereas Intralesional platelet rich plasma had. No significant association was noticed between gender of patients and efficacy of Intralesional injection of platelet rich plasma (p-value=0.756). Efficacy of Intralesional injection of platelet rich plasma was not dependent on the diabetic status of the patients (p-value=0.556).Efficacy of Intralesional injection of platelet rich plasma was not dependent on duration of start of symptoms of patients. i.e. (p-value=0.978). Conclusion: We conclude that Intralesional injection of platelet rich plasma can be effectively used for de Quervain’s tenosynovitis., Introduction: COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. Aim: We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Methods: Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (, Introduction: Studies estimate that 21% of patients with XLA (X Linked Agamaglobulinemia) have had at least one episode of infectious conjunctivitis. In contrast, conjunctivitis is not a commonly described problem in patients with CVID (Common Variable Immunodeficiency). Aims: We aimed to determine whether the association of XLA and eye infections is unique amongst primary antibody deficiencies. Methods: A retrospective observational study was carried out. Age-matched CVID patients with absent IgA levels were selected as the control group. Results: 29 patients with XLA and 30 patients with CVID were analysed. 12 patients with XLA (41%) had suffered from recurrent conjunctivitis. No patients with CVID had documented episodes of recurrent conjunctivitis. The mean IgG trough levels were 10.78g/L for the cohort with XLA and 10.41g/L for patients with CVID. Discussion: We demonstrate here the common and perhaps unique susceptibility to conjunctivitis in patients with XLA. What is the underlying cause for the increased susceptibility? Since both groups in our study lacked serum IgA, it seems unlikely that absence of IgA antibodies is the culprit. The group with XLA and conjunctivitis averaged higher IgG trough levels, therefore, inadequate trough levels are also unlikely to be responsible., Introduction: Many patients admitted with confirmed COVID-19 were found to have electrolyte disturbances. Aims: In this new era of COVID-19, we aimed to assess how this multisystem disease affects electrolytes & creatinine. In clinical practice, we noted patients were hypokalaemic with dysnatraemias. We explored potential aetiologies for this & assessed correlation with their clinical journey (e.g. prolonged hospitalisation, CPAP, critical care & death). We explored if age correlated. Methods: Records of all COVID-19 positive patients over a 3 month period were analysed. Each patients electronic care record was interrogated. Serum sodium, potassium, urea, creatinine, bicarbonate, chloride were recorded, as well as a peak sodium. Patients were subcategorised into those requiring CPAP, needing critical care admission & those who died. Results/Discussion: 332 inpatients tested positive for COVID-19 between 11/3/2020-17/5/2020. Average age was 69 (55% male). 37% had a sodium >/= 145mmol/L. 20% had a potassium, Introduction: Rapid deployment valves are of increasing popularity amongst surgeons. Aims: To compare conventional bioprosthetic with rapid-deployment valves used in aortic valve replacement. Method: A comparison of pre, intra and post-operative outcomes of 120 patients received a rapid-deployment AVR (RDAVR) between Sep2014-Sep2019, with a propensity matched group of patients who had conventional bioprosthetic AVR (Conv AVR). Results: RDAVR (n=120) was compared with Conv AVR (n=120).Both groups were matched in terms of baseline characteristics. However, RDAVR group included more elderly (>80 years) and females (40 vs 11 p, Introduction and Aim: The aim of this study was to investigate the impact of nasal deviation on the perception of the maxillary dental centreline position as judged by orthodontists, general dental practitioners (GDPs) and lay people. The null hypothesis states that there is no difference in perception of maxillary dental centreline position and smile aesthetics with varying degrees of nasal deviation and dental centreline. Methods: This was a cross sectional study which aimed to assess the impact of variations in the position of both the dental centreline and nose on facial aesthetics. An image of a smiling female was digitally manipulated with varying degrees of nasal deviation and dental centreline position. Multiple regression analysis was undertaken to assess the effect of these changes on the perceptions of attractiveness for each rater group. Results: Nasal deviation to the left by 1.5mm was perceived as more attractive if the dental centreline was also deviated to the left by 1.5mm by GDPs (95% CI, 0.4-13.5), orthodontists (95% CI, 7.6-20.0) and lay people (95% CI, 1.7-15.8). Discussion: Overall, there was a preference for the symmetrical dental centreline and nose position. GDPs and orthodontists were more sensitive to changes associated with the dental asymmetry, whereas lay people were more sensitive to nasal changes., Introduction: In our centre, patients undergoing elective transurethral resection of prostate (TURP) and transurethral resection of bladder tumours (TURBT) require a preoperative group and hold (G+H). Local policies requiring pre-operative G&H were developed as TURP/ TURBT historically had a significant risk of bleeding. However, as intra-operative procedures have improved, the risk of bleeding has reduced [2]. Aims: Investigate the rate of blood transfusion in TURP and TURBT patients. Methods: We conducted a prospective analysis of all patients undergoing TURBT/TURP in a two-month period (19/09/2019-19/11/2019). 44 patients were identified using theatre lab lists and cross-referenced with the electronic labs system to confirm if blood products were issued. Patients requiring transfusion (n=2) were further investigated using patient notes to establish contributing factors and timing of transfusion. Results: 4.5% of those undergoing TURBT/TURP required a transfusion. 0% were intraoperative or emergency transfusions. All transfusions occurred over 48 hours postoperatively. Discussion: Our study found that pre-operative G&Hs do not improve patient outcomes. At a cost of £23.77/sample, there is potential to make significant savings without compromising patient care. Our results are in keeping with larger studies performed in other centres [3]. Pre-operative G&H could be performed selectively on those deemed higher risk at pre-operative assessment. Routine preoperative tests for elective surgery: summary of updated NICE guidance - BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3292 (Published 14 July 2016) Cite this as: BMW 2016;354:i3292 https://www.bmj.com/content/354/bmj.i3292 Rassweiler, J, Teber, D, Kuntz, R. Complications of transurethral resection of the prostate (TURP) – incidence, management and prevention. Eur Urol 2006; 50: 969-980. Smith, H., Falconer, R., Szczachor, J., & Ahmad, S. (2018). Routine preoperative group and save for TURP and TURBT – need and cost effectiveness. Journal of Clinical Urology, 11(1), 33-37., Introduction / Aims: Primary aim of gaining quantitative data on levels of sedentary behaviour among GPs and GPSTs, to identify to what extent GP is a sedentary occupation. Secondary aim of gathering qualitative data regarding barriers and facilitators to reducing sedentary behaviour among GPs and GPSTs. Methods: Sequential, mixed-methods model. Stage 1: Online questionnaire based on the International Sedentary Assessment Tool distributed to GPs and GPSTs throughout Northern Ireland. Stage 2: Accelerometer study. Purposive, varied sample of 20 participants, based on questionnaire responses, comprising individuals with a range of demographic characteristics and sedentary behaviour. Accelerometers will be worn continuously on the middle of the thigh for a period of seven-days. Stage 3: Semi-structured interviews. Purposive, varied sample of 6 participants of the accelerometer study will be asked questions related to sedentary behaviour in the GP setting. Results and Discussion: Quantitative data will be analysed to determine current levels of sedentary behaviour in the GP setting. Qualitative data will be analysed thematically to determine barriers and facilitators to reducing sedentary behaviour in the GP setting. Study has been modified due to Covid-19 pandemic., Introduction: Black and minority ethnic communities are at higher risk of mental health problems. Aims: We explore differences in mental health and the influence of social capital among ethnic minority groups in Great Britain. Methods: Cross-sectional linear and logistic regression analysis of data from Wave 6 (2014-2016) of the Understanding Society databases. Results: In unadjusted models testing the likelihood of reporting psychological distress (i) comparing against a white (British) reference population Indian, Pakistani, Bangladeshi and mixed ethnic minority groups recorded excess levels of distress; and (ii) increasing levels of social capital recorded a strong protective effect (OR=0.94: 95% CI 0.935, 0.946). In a subsequent series of gender-specific incremental logistic models-after adjustment for sociodemographic and socioeconomic factors Pakistani (males and females) and Indian females recorded higher likelihoods of psychological distress, and the further inclusion of social capital in these models did not materially alter these results. Discussion: More research on the definition, measurement and distribution of social capital as applies to ethnic minority groups in Great Britain, and how it influences mental wellbeing is needed.

Induction of differentiation is a promising therapeutic strategy against acute myeloid leukemia. However, current differentiation therapies are effective only to specific patient populations. To identify novel differentiation agents with wider efficacy, we developed a phenotypic high-throughput screen with a range of genetically diverse cell lines. From the resulting hits, one chemical scaffold was optimized in terms of activity and physicochemical properties to yield OXS007417, a proof-of-concept tool compound, which was also able to decrease tumor volume in a murine in vivo xenograft model.

Aim: Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet results in complications. Early reherniation has been reported in alternative xenografts such as Surgisis®. We wondered whether the matrix or decellularization (decel) process led to failure. We compared diaphragmatic reconstructions using SIS and decel porcine diaphragm (DPD), processed with a comparable decel protocol, to Gore-Tex in a fast-growing rabbit model. Methods: Twenty-three 6-weeks-old rabbits underwent intubation, left subcostal laparotomy and 3*3cm hemi- diaphragmatic excision. Defect closure was with a 3,5*3,5cm patch of (a) Gore-Tex® (n=10), (b) Surgisis® (n=6) or (c) DPD (n=7). Rates of herniation or eventration, uniaxial biomechanical testing, and histology were studied at 90days. Results: Eighteen (78%) rabbits survived to 90days. There was mesh failure in all decellularised matrices (p, Introduction: Children commonly present to Emergency Departments (ED) with a non-blanching rash (NBR) in the context of a feverish illness. The approach to assessment of these children is controversial. Aims: Validate clinical practices guidelines (CPGs) for the management of fever and NBR Methods: Prospective multicentre validation study evaluating the performance of available CPGs for feverish children with NBR. The full protocol has been published and is available at https://rdcu.be/bFEtb. Results: 1423 children were recruited from 37 UK sites between the 11th November 2017 to 30th June 2019. This included 77 children with serious bacterial infections (5.4%) and 17 children (1.2%) with confirmed invasive meningococcal disease (MD). Four CPGs (NICE, NBL, London & Nottingham) were prospectively validated. All four demonstrated 100% Sensitivity for identifying children with MD. NICE guidance demonstrated the lowest specificity 10% recommending that 75.3% of children receive parenteral antibiotics and admission to hospital. The NBL, London and Nottingham CPGs all demonstrated a greater specificity ranging from 28% to 41%. Discussion: NICE guidance for the management of NBR performed poorly in this national validation exercise. The alternative CPGs were 100% sensitive and offered greater specificity. Adopting an alternate CPG would reduce painful interventions, parenteral antibiotic use and hospital admissions. Trial registration - NCT03378258. Retrospectively registered on December 19, 2017.., Introduction: Vascular Ehler-Danlos (vEDS or type IV EDS) is the most dangerous subtype of Ehler-Danlos and is rarer than most EDS subtypes, thought to affect 1-200,000. It is autosomal dominant affecting COL3A1 or COL1A1 genes. Symptoms include those of EDS alongside being easily bruised, visible blood vessels on chest, late miscarriage, unusual facial features and aneurysms/dissections, bowel perforation and uterine perforation. Case: A woman presented with acute onset back pain radiating down her right leg after bending over to pick up a heavy object. History and findings were in keeping with sciatica, she was prescribed analgesia. Discharge was delayed due to a trauma call. On reassessment the patient had deteriorated and was noted to be hypotensive and tachycardia and subsequently transferred to resus. She underwent a CT angiogram revealing a ruptured external-iliac artery. She underwent emergency repair. Discussion: The patient has made a full recovery but had she not remained in the department during the trauma call she may have been sent home. This case serves to highlight the dangers of Ehlers-Danlos syndrome and remind clinicians to be aware of such patients and treat them with caution. This is an example of how younger patients compensate physiologically before acutely deteriorating, Problem: The Renal Association guidelines for management of kidney transplant patients (KTP) recommend yearly review of immunosuppression (IS). Patient survival improves by addressing IS related mortality risk factors (MRF) and carefully reducing IS. In our unit, baseline data showed IS reviews were carried out every 32 months. Strategy for change: With multidisciplinary team (MDT) input driver diagrams were generated to set out aims and objectives. Plan-Do-Study-Act cycles facilitated change which was analysed continuously using statistical process charts. A transplant clinic template letter and MDT review assessments were created which were refined through subsequent cycles. Measurement of Improvement: Percentage KTP with documented IS plan and modification of MRF at each clinicFollowing adoption-adherence to template Effects of change: Over 3 month period percentage KTP with IS review rose from 9% to 85% enacting 29% more changes to IS compared to pre-intervention weekly. Modifiable risk factors addressed rose from 8% to 56%. Adherence once template adopted reached 93%. Project generated other change ideas e.g. information & dermatology leaflets. Discussion: This project demonstrates that by utilising the MDT and introducing a standardised approach increased frequency of IS review, adaptions to IS and addressing MRF. This could potentially be replicated by other transplant teams., Background: The traditional method for arthroscopic training relies on appropriate clinical cases, costs particularly with operative time and has implications for patient safety. The Virtamed ArthroS was released in December 2017 and is the world’s first high-fidelity simulator for ankle arthroscopy. The primary aim of this study was to determine the utility of this arthroscopic simulator for training. Methods: Volunteers were recruited from medical students through to consultants. They performed five arthroscopic procedures under control conditions. A 10-minute demonstration on the setup and operation of the simulator was given prior to testing. Performance was evaluated by obtaining predefined metrics for each procedure within the simulator with photo and video acquisition. A questionnaire was administered to evaluate previous arthroscopic and video gaming experience, levels of stress, usefulness and authenticity. Results: Each arm consisted of a minimum of 5 participants from medical students, foundation level, core trainees, orthopaedic registrars and consultants. All groups demonstrated an improvement in time, economy and safety with 20 minutes exposure, reporting high levels of satisfaction and usefulness. Conclusion(s): The Virtamed ArthroS ankle module provides an authentic simulated experience for all levels of training with demonstrable improvements in performance, anatomy knowledge and reductions in adverse events. In the current climate of reduced working times and increased indicative arthroscopy numbers for completion of training the real-world benefits for orthopaedic trainees is promising., Introduction: Colorectal cancer (CRC) is the 4th most common cancer in the UK and approximately 50% of colorectal cancers demonstrate mutations in TP53. Cdc7 kinase is a protein with essential functions in DNA replication initiation and cell-cycle checkpoint responses. It is up- regulated in malignant cells, especially in the presence of a functional TP53 mutation. Aims: To utilise cdc7i to exploit TP53 mutation in CRC, either alone or in combination with current standard of care (SoC) therapies. Methods and Results: Using in-vitro analyses of a novel cdc7i (LY3177833), CRC cell lines with functional mutations in TP53 have an increased sensitivity to cdc7i. Additionally these cells arrest within S and G2/M phases of the cell cycle. SoC chemotherapy in CRC elicits an S- and G2/M- phase accumulation in cells which lack functional p53, with an increased dependency on DNA replication checkpoints, in which cdc7 is involved. Combinations of LY3177833 and SoC chemotherapy significantly reduced long-term survival in cells lacking functional p53. Discussion: Cdc7i either alone or in combination with SoC in CRC, may represent a potential future treatment option, particularly in TP53 mutant CRC. A phase 1 clinical trial of a novel cdc7i as monotherapy is ongoing., Introduction: INR is one of the most common laboratory tests among hospital inpatients. Coaguchek point of care (POC) system has been introduced as a fast and minimally invasive alternative to standard laboratory INR testing in some hospitals. Aims: To assess the correlation between Coaguchek POC and STAGO lab INR readings. Methods: Prospective study involving all patients on warfarin on a single ward. POC and lab readings were taken at the same time and compared. The product-moment correlation coefficients (PMCC) were calculated for various INR ranges. Results: 73 paired samples were received. 62(86%) POC INR readings were higher than lab readings. When lab INR> 2.0, 17 of 35 (49%) POC INR were higher by more than 1.0. Linear correlation between POC and lab INR was strongest between lab INR 1.0-2.0 (PMCC 0.94) but weakens at higher values. When POC INR is between 2.0-3.0, 13 of 24 (54%) lab INR were also between 2.0-3.0. Discussion: Coaguchek system has been recommended by NICE for outpatient self-monitoring. Our data cast significant doubt in its use in hospital inpatients as lab substitute. Inpatient procedures or medications such as enoxaparin may account for the significant difference., Introduction: Submucous clefts are a variant of cleft palate, usually signified by the presence of a bifid uvula. Patients with a submucous cleft tend to present later than patients with complete cleft defects resulting in late primary repair and potentially irreversible speech and language problems. Aim: To review submucous cleft repairs as the rates were increasing in our unit. Methods: The Northern Ireland cleft lip and palate database was used to identify patients born with a submucous cleft over a 7 year period, 1988-1995, and a further 7 year period 15 years later, 2003-2010, for comparison. The Electronic medical records system and the joint cleft palate clinic database were used to collect the data required. Results: A significant rise in submucous cleft numbers over a 15 year period, from 6 to 25 cases. Average age at primary repair reduced from 6 to 5.2years. The unrepaired rate increased from 17->24%. Significant reduction noted in: total length of hospital inpatient stay from 6.3 to 2.7days and total outpatient appointments from 11.7 to 5.3. Conclusions: This review highlights significant changes in the detection and management of patients with a submucous cleft over a 15 year period. Adequate provision must be made to resource the rising demands of cleft surgery., Introduction: The Cleft Nurse Specialist (CNS) plays a key role in counselling and supporting parents from the diagnosis onwards. Aim: The CNS started in 2012 and we aimed to perform a qualitative study to determine the benefits this brought to the cleft community from the parents’ perspective. Methods: The cleft database was used to locate babies born in 2010/2011 and 2013/2014. Parents were contacted by phone and completed a questionnaire on the care and support they received following the diagnosis. Results: Parents of 38 babies completed the survey. In 2010/2011 only 21% had an antenatal diagnosis compared to 47% in 2013/2014. In 2010/2011 68% were counselled by a surgeon, 42% were seen >1week after birth, with some over a month. In 2013/2014 84% were counselled by the CNS, 53% were seen within 48 hours and 100% within 7 days. Parents in 2013/2014 felt more supported by the cleft team throughout pregnancy and the early days, with home visits being particularly advantageous. Conclusion: The introduction of the CNS to the cleft multidisciplinary team has significantly improved the pathway for parents and is a key link with the wider cleft team., Introduction: The diagnosis of cleft lip and/or palate (CLP) can be a difficult time for expectant parents. Antenatal diagnosis ensures the cleft team can spend time with the parents counselling them regarding potential difficulties their baby may have in the early weeks of life as well as providing a support network. Aim: NHS guidelines target: 75% of babies born with a cleft lip should be diagnosed on antenatal ultrasound. Methods: The regional cleft lip and palate database was reviewed over a 5 year period (2014-2018). Numbers of babies born with CLP and rates of antenatal ultrasound diagnosis were reviewed. Results: Over the 5 year period 168 babies were born in the regional unit with CLP. Those with involvement of the lip (cleft lip only or cleft lip and palate) made up 55% of the cohort (92/168). Overall the rate of antenatal detection over the 5 years was 79% (73/92). The annual rates were; 2014: 75%, 2015: 74%, 2016: 89%, 2017: 77%, 2018: 86% Discussion: Over the past 5 years the antenatal diagnosis rate has remained above the NHS guideline target. We are striving towards 100% in the future to ensure parents are counselled antenatally and have time to adjust to the diagnosis before birth., Introduction: Overactive bladder (OAB) is a prevalent, distressing condition. Approximately 40% women will not respond to routinely offered non-invasive interventions (1). Evidence is accruing for the effectiveness of Transcutaneous- Posterior-Tibial-Nerve-Stimulation (TPTNS) (2). This qualitative study is part of a mixed-methods, randomised, feasibility trial of TPTNS in the home versus hospital setting. Quantitative results will be reported separately (NCT03727711). Aims: To explore experiences of women having TPTNS in home and hospital and discover perceived barriers/ facilitators to self-management. Methods: Identification of a subgroup from the larger trial, with a purposive sample of 8 women from each group. Thematic analysis using the method proposed by Braun and Clarke (Nvivo 12 software used) (3). Results: A total of 16 women were interviewed (8 home, 8 hospital). Mean age: 60 years (range 42-78 years). Data saturation was achieved. TPTNS was described as providing ‘confidence’ in addition to physical benefits. Home treatment was viewed favourably as ‘convenient’, especially if the participant was bound by work commitments. Cost of purchasing the machine was seen as a barrier to future use. Discussion: This analysis highlights the willingness of women to use TPTNS as part of a self-management strategy; treatment at home was favoured among those who were working., Introduction: OASIS is a relatively common complication following childbirth with an increasing overall rate which is possibly due to improved reporting and better recognition. Aims: To determine the risk factors for obstetric anal sphincter injuries (OASIS) and to investigate the mode of delivery and recurrence rate in future pregnancies. Methods: A retrospective cohort study of singleton deliveries in the South Eastern trust between April 2012 and March 2017 (n=59236) Results: The overall OASIS rate was 3.7% (593/59236). There was a significantly increased risk of OASIS with an instrumental delivery (p4kg (p25 (p, Introduction: The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is well recognised. Although typically asymptomatic at presentation, VAI can result in neurological deficit, stroke and death. Depending on injury grade and site, management can range from observation, to medical, endovascular and surgical intervention. Aims: To determine the incidence and clinical features of VAI amongst patients found to have cervical spine fractures presenting to the Royal Victoria Hospital, and to establish current practice regarding VAI management. Methods: A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period was conducted. Results: Sixty-eight patients were found to have acute cervical spine fracture. Of these, five (7.4%) were diagnosed with VAI, all of which resulted from fractures of the upper cervical vertebrae following high-energy trauma. One patient sustained an incomplete spinal cord injury. All five patients underwent repeat CT-angiography, none of which demonstrated injury progression. Three patients were commenced on aspirin therapy, one of whom also underwent posterior cervical stabilisation. Discussion: CT-angiography is recommended following identification of fractures involving the foramen transversarium or Type C/ subluxation-type injuries and should also be considered amongst those sustaining upper cervical fractures., Introduction: Management of Dysplastic naevi (DN) is controversial with opinion divided regarding their significance. A recent systematic review and US multi-centre study evaluated subsequent cutaneous melanoma (CM) risk in patients with DN but a paucity of outcome data remains amongst UK and Irish patients. Aims: To evaluate long-term outcomes of histologically confirmed DN in a Northern Ireland Healthcare Trust and incidence of subsequent CM. Methods: Retrospective study of histologically confirmed DN recorded in Trust Pathology Database between 01.01.2008 - 31.12.2013. Cases analysed for demographics, referral source, site, procedure, margins, severity and development of CM. Results: 248 reports were evaluated in 237 patients (104 male, 133 female). Median (range) age 44 (16,82) and mean follow-up period 7.5 years. 93% of DN were removed by excisional biopsy (93%). The back was commonest anatomical site (39%). The majority of cases had clear histological margins (93%). No patients developed CM at the site of a previously excised DN. 2.53% (6/237) patients developed subsequent CM at separate site. Discussion: This is the first long-term study of outcomes for patients with DN in Northern Ireland. Findings support previous studies suggesting subsequent CM risk is low in patients with histologically confirmed DN without prior history of CM., Introduction: Risk-prediction scoring systems are widely used by surgeons to calculate operative morbidity and mortality. They help to stratify level of post-operative care, enable patients to make a fully informed consent and facilitate surgical audit and comparison of units’ performance. Multiple systems have been used for prediction of patient outcome following abdominal aortic aneurysm repair; not much has been done in patients undergoing MLLA. Aim: Our aim was to evaluate VPOSSUM for accuracy of prediction of early mortality and morbidity following MLLA. Methods: Retrospective case review of MLLA carried out in a regional vascular service between Jan-2014 and Jul-2017. Demographic, pre-operative, operative and post-operative data were collected from patient notes and hospital database. VPOSSUM scores were calculated for every procedure and compared with observed morbidity and mortality using SPSS. Results: 181 patients (male=133, female=48, average age 67.6y) underwent MLLA during this study period. Of these, 20 had re-interventions. Revision to a higher level was required in 7 patients on ipsilateral limb within a mean 14.3 days (range=5-33). 13 patients required MLLA on contralateral limb within a mean 216 days (range=5-648). 7 patients had bilateral MLLA at the same session; these procedures were recorded as a single event. Therefore, total number of events was 201. Receiver-Operator Curve (ROC) showed an area-under-curve (AUC) of 0.833 (95% CI 0.740-0.926) for 30-day mortality, suggesting that VPOSSUM was a good score for predicting patient outcome; but was poor for predicting post-operative morbidity (AUC 0.640 (95% CI 0.556-0.724)). Discussion: VPOSSUM performed well with respect to predicting 30-day mortality in patients following MLLA and could be used to stratify patients’ risk from surgery, thus helping us plan level of post-operative care for this group of patients., Introduction/Aim: Oesophagectomy is a complex procedure and associated with high morbidity and mortality. In an effort to reduce the postoperative morbidity associated with open esophagectomy, laparoscopic-assisted oesophagectomy (LAO) has been introduced and developed in recent years. The aim of this study was to present our experience with LAO and assess surgical and oncological outcome and survival. Methods: 100 patients were identified from a prospectively- filled database from July 2010-2017 at a tertiary referral centre. All underwent MIO performed by a single consultant surgeon. Laparoscopic abdominal and trans-hiatal phase plus mini-thoracotomy was performed. Outcome data was retrieved from hospital, laboratory, GP, NHS Spine and coroner’s records. National average (NA) statistics were obtained from National Oesophago-gastrectomy Cancer Audit (NOGCA) 2016 and 2018. Results: Median age of patients 68y (range=41-80). 85% male, 15% female. Pulmonary complications were most common (pneumonia 34%, pleural effusion 19% and pneumothorax 8%). 5% patients had an anastomotic leak. 30- and 90-day mortality was 1 and 2% respectively, compared to NA of 2.4 and 3.9%. Median length of stay 11.5d compared to NA of 9d. Median number of lymph nodes excised was 17 (range=3-32); 58% patients had adequate number of lymph nodes examined (>15). 3-year survival for Stages 1, 2 and 3 was 86.1, 85.7 and 35.3% respectively, compared with NA of 84, 71, and 34%. Discussion: LAO appears to offer marginal benefit to open surgery and is not inferior in the outcomes measured here. This is consistent with current RCTs and adds to the growing body of evidence supporting minimally-invasive surgery., Introduction: Severe fingernail glue burns arising from the exothermic polymerization reaction of cyanoacrylate with the cellulose in cotton fibres have been documented. However, warnings on nail glue bottles, packaging and websites remain poor. We also consider what the optimal first aid should be for such an injury and suggest the publication of this for nail glue consumers, practitioners and pharmacists. Description of Case: A healthy 18-year-old female spilled nail glue whilst applying her acrylic nail tips. The glue eroded through her jeans to leave a substantial deep partial thickness burn on her left medial thigh. No first aid was given. The burn was managed conservatively with silver-impregnated dressings and regular follow-up. Discussion: Review of literature highlighted that pre-teen and teenage girls are most at risk with the majority of incidents occurring in this age group. They are also at high risk of surgical intervention with 80% requiring excision and splitthickness skin grafting compared to 0% of the young children described. The authors recommend publication of first aid advice including: removal of the source - immediate removal of clothing unless already adherent to skin (soak first) and reducing the temperature of the skin as rapidly as possible to minimize thermal injury by soaking in cool water., We report an unusual case of a nineteen-year-old man with Wolff-Parkinson-White syndrome who successfully underwent accessory pathway catheter ablation but subsequently suffered ST segment myocardial infarction (STEMI) through a previously unrecognised mechanism. Post-ablation, the patient complained of new and severe central chest pain. Electrocardiography suggested inferior STEMI and coronary angiography revealed a distal occlusion of the posterior left ventricular branch of the right coronary artery. Flow was established using a ‘standard’ angioplasty wire and a 2.5mm compliant balloon. Given the vessel’s tendency to recoil, despite using a drug coated balloon, stent insertion was necessary to maintain luminal patency. Intravascular ultrasound revealed an oedematous extrinsic compression at the site of the lesion. Subsequent high sensitivity Troponin T assay and echocardiogram were consistent with posterior myocardial infarction. Immediate ECG changes following catheter ablation have been acknowledged and linked to the proximity of ablation site and coronary arteries. This is the first case of post-ablation STEMI caused by oedematous extrinsic coronary obstruction we have noted in our facility, and we have not found any other report in the literature. We recommend that patients describing new post-procedural chest pain should undergo urgent clinical and ECG assessment to consider ischaemia., Introduction: Aortic dissection is a devastating cause of mortality in patients with connective tissue disorders. Personalised external aortic root support (PEARS) is a pioneering approach that utilises a personalised 3D mesh to prevent aortic root dissection without the need for anticoagulation. Description: We describe a retrospective case series of all PEARS procedures performed to date at the Cardiac Surgical Unit, Belfast. Twelve patients have undergone the PEARS procedure of which 2 had concomitant mitral valve repair (9 males; 3 females; median age: 37 years). All cases had evidence of aortic root dilatation. The procedure was technically successful in all cases. Complications: 6 developed tachyarrhythmias, 3 demonstrated ST changes not in keeping with infarction, 1 developed a right coronary artery pseudoaneurysm requiring reoperation and 1 developed circumflex artery occlusion requiring bypass grafting. There were no deaths. The median total hospital admission was 8.5 days (range: 6 – 118 days). Discussion: Although our experience thus far is limited, we demonstrate that a single centre can safely establish a PEARS programme. Our experience highlights the significant learning curve associated with beating heart dissection. Nevertheless, the PEARS procedure offers young patients the advantage of avoiding lifelong warfarin therapy whilst likely preventing further expansion of aortic root aneurysms., Introduction: Timely diagnosis of osteomyelitis is essential for its successful treatment but it is often difficult to recognise despite extensive radiological workup. Case: We outline a case of recurrent sepsis over a seven year period in a patient injured by a car bomb blast and the use of an innovative imaging technique to localise two culprit foci of osteomyelitis. This was a prolonged and difficult diagnosis due to extensive shrapnel injury and associated inflammation as well as significant anatomical disruption from the blast. Discussion: Sites of inflammation associated with shrapnel injury acted as decoys to the true foci of active infection on Fluorodeoxyglucose (FDG) Positron emission tomography/ Computed Tomography) (PET/CT) and a new technique was required to differentiate these. This involved administering a course of antibiotics between two separate FDG-PET/ CT scans and is known as Subtraction PET. Two sites of osteomyelitis were identified among 20-30 other sites of benign granulomatous inflammation and calcification. These two sites of infection were characterised by a significant drop in tracer uptake on FDG-PET/CT after a course of antibiotics while tracer uptake at the remaining sites remained relatively unchanged. This ultimately guided surgical excision of the sequestra and at follow up of two years, the patient has experienced no further septic episodes., Introduction: Over the new year period we recognised a high number of admissions with complications following cosmetic surgery abroad. We aimed to determine the driving forces behind this and financial impact on the NHS. Cases: 6 patients were admitted to the regional unit after independently organising surgery abroad. Countries visited included; Turkey, Belgium, Poland, Estonia and India. Reasons included; cost and access to procedures not recommended by UK surgeon. Type of surgery included; Breast (5), abdominoplasty (2), liposuction (2), labiaplasty (1) and 50% had multiple procedures. Complications included; necrotic wounds (33%), infected breast implant (33%), VTE investigated (33%), wound infection (17%). Overall, 67% required surgery on the NHS. The estimated total cost was £23,976.82 with an average of £4000/patient. Discussion: This surge in cosmetic complications occurred over the New Year. Complications were seen after a range of surgical procedures. All patients required an inpatient stay and 2/3 required surgery with a significant cost burden to the NHS. Patients are unaware of the risks involved, highlighted by the lack of pre-operative counselling and follow up. In addition, this series has highlighted the risks associated with travelling in the peri-operative period., Introduction: Dysarthria is one of the commonest neurological speech disorders resulting from brain injury. It adversely affects psychosocial functioning and rehabilitation due to the inability to communicate effectively. In the majority of patients, it is irreversible. It may be possible to improve the intelligibility and articulation of speech with a pharyngoplasty procedure. This procedure is more commonly performed in patients with velopharyngeal insufficiency (VPI) and a cleft palate. Methods: Data was collected from the regional plastic surgery unit over a ten-year period. Medical records and speech and language notes were reviewed. Outcomes; speech improvement, complications and need for surgical revision. Results: Six patients had a pharyngoplasty. Either a Hynes or the Jackson variant of a flap pharyngoplasty were performed. The majority were male (5/6). Mean time between injury to surgery; 5-years. Overall, 83% of patients had a clear improvement in speech intelligibility and articulation. One patient experienced self-limiting sleep apnoea and one patient developed obstructive symptoms and required a revision. Discussion: We have shown that surgical intervention is an effective method of improving speech intelligibility and articulation in patients with both traumatic brain injury and following CVA. Although speech and language therapy is the pillar of management, certain patients have the potential to benefit further from surgical intervention. The aim of this paper is to highlight this option and heighten the awareness that a pharyngoplasty has the potential to make a significant difference to the lives of patients with brain injury by restoring communication., Introduction: Forces capable of causing chyle leak usually result in bowel and pancreatic injury. High index of suspicion required to avoid missing concurrent injuries. Only 10 reported isolated chyle leaks following blunt trauma. Description: A 34-year-old male presented with a blunt injury to the epigastrium after falling onto the handlebar of a bicycle. On examination, he had epigastric tenderness with no evidence of peritonism. CT demonstrated a fluid collection posterior to proximal jejunum, with appearances suggestive of jejunal perforation but no free air was observed. The patient developed worsening generalised abdominal pain 12 hours after admission. Clinical examination revealed 4-quadrant peritonism, prompting an emergency laparotomy. At laparotomy, no free fluid was observed. Retroperitoneally, milk-coloured diffuse fluid infiltration was noted. Inspection of the duodenum, small bowel and pancreas revealed no obvious injury. Drains were placed at the tail and head of the pancreas where largest pooling of fluid. There was an uncomplicated post-operative recovery with discharge at day 6. Discussion: Diagnostic uncertainty intra-operatively prompted an urgent radiological consult on CT imaging, suggesting pancreatic transection. Intra-operative amylase analysis of the retroperitoneal fluid guided surgical management, which would otherwise have proceeded with a distal pancreatectomy and its associated consequences., Introduction: All psychiatrists will encounter patient suicide during their careers, however little has been written about the impact this can have on them, professionally and personally. Aims: To examine the unconscious communications between suicidal patients and psychiatric trainees based on the trainees’ lived experience. To consider how this data could be used to support trainees in their clinical practice, and inform and shape institutional processes, such as serious adverse incident reviews, as well as the training programme. Methods: Semi-structured interviews were carried out with 3 psychiatry trainees and the material analysed using Interpretative Phenomenological Analysis (IPA). Results: Three main themes were identified, namely “A Deep and Painful Wound”, “Strategies for Survival”, and “A Path to Recovery”. They describe how patient suicide affected the participants personally and professionally, how their colleagues and the organisation responded to them and their thoughts about what was helpful and what could be changed in future. Discussion: Losing a patient to suicide can be an extremely distressing, isolating and anxiety provoking experience All trainees felt that the training programme inadequately prepared them for it, and it is important that training organisations address this., Introduction: In 2014, NCEPOD reported hospital patient care for those with tracheostomies and laryngectomies posed significant safety issues. Subsequently Intensive Care Society guidelines stipulated staff exposed to such patients be competent in managing airway emergencies. Medical patients with tracheostomies and laryngectomies are typically cared for by junior doctors yet juniors often express concern in respect to managing such patients, particularly in the emergency setting. Aim: To establish junior doctor training for tracheostomy and laryngectomy patients.Evaluate junior doctor confidence in the acute and nonacute assessment of such patients. Methods: Junior doctors attached to the acute medical and respiratory wards of a local hospital were invited to complete an online survey regarding previous training and their current confidence regarding managing tracheostomy and laryngectomy patients. Results: Twenty-four junior doctors received the survey with 18 respondents. 55.56% reported previous undergraduate training in this area with 44.4% receiving postgraduate training. Despite this, 77.7% of respondents stated they were not confident in conducting routine reviews of patients with trachyectomies or laryngectomies. 66.6% did not feel confident in managing an acutely unwell patient with a tracheostomy/laryngectomy with 66.6% stating they were ill equipped to manage an airway emergency in such patients. Respondents felt simulation (88.8%) and clinical bedside teaching (77.8%) would improve their confidence. Conclusion: Results indicate junior doctors working with tracheostomy and laryngectomy patients demonstrated low confidence, both in the acute and non acute management setting, an issue which may generate significant patient harm. Evidently there is a need for additional training with the authors proposing such training form a formal component of hospital induction., Aim: To determine if students and paediatric trainee doctors level of knowledge meets a non-faculty clinician-determined minimum accepted competency (MAC). Methods: A 30-item multiple-choice (MCQ) paper (MAC exam) was created, formed of questions proposed by practising non-academic consultant paediatricians, which are deemed as ‘must know’ for paediatric trainees prior to commencing clinical work. A ‘passing score’ was determined using the Angoff technique by the paediatric faculty. The paper was given to undergraduate students and also paediatric senior house officers (SHO’s). Student’s performance on the MAC was compared with their performance on their official university examination. Test item analysis and psychometrics were also performed. Results: The passing score was determined at 13/30 (41.2%) 366 undergraduate students participated. Mean score 45.9% (s.d 9.9%, range 23-73%). 240/366 (65.4%) of students achieved the passing score whereas 99% of these students passed their official university exam. However, positive correlation between students result in the MAC exam and results from their official university exams (spearman R=0.44. p, Introduction: The SHO rota (first on call) in most hospitals is staffed mainly by GP specialty trainees or Foundation doctors on rotation. They are required to attend obstetric emergencies whilst on call. This can be a daunting experience as there is limited postgraduate training for non-specialty trainees in O+G. Aims: Improve training, confidence + competence for all non-specialty trainees in managing obstetric emergencies. Methods: An afternoon of simulation based training was held for all junior doctors currently working in O+G within the SEHSCT. Scenarios included shoulder dystocia, PostPartum haemorrhage, maternal collapse and eclampsia. A questionnaire was completed by all delegates pre and post training. Results: All delegates reported a significant increase in confidence to manage obstetric emergencies for all scenarios post training. Discussion: Working within O+G can be a daunting experience for non-speciality trainees covering the SHO rota. This programme has shown that simulation based training in managing obstetric emergencies not only will improve the clinician’s confidence and competence but also will improve patient safety., Problem: The poor compliance to local guidelines for antibiotic prescription in acute cholecystitis and cholangitis. Strategy for change: A 3 week prospective review of antibiotic prescription in all patients admitted with suspected or confirmed acute cholecystitis or ascending cholangitis. 22 patients admitted within audit window, 18% of which received correct antibiotics. Teaching delivered to surgical team on current antibiotic guidelines and appropriate escalation, information posters displayed in ED and wards and guidelines included in trust induction pack. Measurement of Improvement: Following education on correct prescription, further audit period carried out. 25 patients admitted with suspect or confirmed diagnosis, 84% of which received correct antibiotic therapy as per local guidelines. Effects of change: Correct education to surgical and emergency department staff led to an improvement of 66% in compliance to local antibiotic guidelines. Discussion: Acute cholecystitis and cholangitis are some of the most common presentations on the acute surgical ward, with the mainstay of treatment being intravenous or oral antibiotic therapy, IV fluids and analgesia. Correct antibiotic therapy can ultimately lead to improved patient safety and avoid future potential antibiotic resistance., Problem: Preparing accurate discharge documentation is a central aspect of good clinical practice in accordance to guidelines outlined by SIGN. Seeking clarification regarding a patient’s medications, follow up and correct diagnosis is a common, time-consuming frustration for F1 doctors upon discharge. Strategy for change: A commonly used acronym, ‘MFD’ – ‘Medically Fit for Discharge’ was modified to ‘Medications, Follow up, Diagnosis’ as an aide memoire. We aimed to improve the inclusion of ‘MFD’ information in the notes/ kardex by 50%. Measurement of Improvement: F1s completing discharge letters collected ‘MFD’ data from 100 patients. Baseline data was recorded and two PDSA cycles implemented; Cycle 1 – presentation delivered at departmental teaching and Cycle 2 – posters outlining MFD placed at ward level. Effects of change: At baseline, 20% of discharge letters had ‘MFD’ documented without need for further enquiry. Following PDSA cycles 1 & 2, full documentation was 54% and 62% respectively, representing a 210% improvement from baseline. Discussion: The MFD acronym use increased significantly following simple interventions. Follow-up information was the most commonly omitted. Scope for further improvement includes: Qualitative data regarding time improvement for F1s comparison of consultant diagnosis versus immediate discharge summary diagnosis., Problem: For vascular access in haemodialysis (HD) the mantra is ‘arteriovenous fistula first’ as one benefit is a reduction in bacteraemia incidence. However, a significant proportion of the HD population require a central venous catheter (CVC) for dialysis. Thus, the morbidity and mortality associated with CRB is a relevant and preventable problem. Strategy for change: 2009-11: Improved documentation to facilitate prospective monitoring of CRB rates. 2011: Antimicrobial catheter locks implementation. 2012: Monthly infection MDT meetings. 2016: Visual CVC score streamlined to increase detection of exit site infection (a CRB precursor). 2016: A ‘DRESS’ survey implementation to ensure exit site covered. 2016: Process for swab result review. Measurement of Improvement: CRB rates are quoted between 0.6 – 6.5/1000 catheter days in international studies. Prior to practice change, our unit CRB incidence was 0.41/1000 catheter days. Present incidence is 0.17/1000 catheter days representing a >50% reduction. Effects of change & Discussion: Introduction of antimicrobial catheter locks produced the most significant impact on CRB rates however; it has been the establishment of a collaborative quality improvement culture within the Ulster Renal Unit that has sustained improvement. Meaning for patients, the chance of getting a CRB is 3.5 times less than the lowest rate quoted in the literature., Problem: The gold standard for diagnosis of acute pulmonary embolism (PE) is radiological investigation with Computed Tomography Pulmonary Angiogram (CTPA). Patients undergoing CTPA examinations receive a full volume CT scan of the chest (lung apices to extreme bases) which, after reviewing literature, is unnecessary and leads to higher than necessary radiation doses to the patient. Strategy for Change: Audit current practice to find out radiation dose to patients having CTPA examinations and ascertain whether important diagnoses would be missed by the introduction of a truncated scan range from aortic arch to base of heart. Measurement of Improvement: Re-audit after the implementation of the truncated scan range to see if there is a significant reduction in radiation dose to the patient. Effects of change: Reducing the scan range form aortic arch to base of heart results in an average dose reduction of 56% to the patient whilst still being able to accurately diagnose acute pulmonary embolus. Discussion: With increasing requests for CTPA studies, using the principle to keep radiation dose ‘as low as reasonably possible’, a reduced scan range can help to reduce radiation dose to patient whilst still maintaining diagnostic accuracy., Problem: No pre or post list briefs were being performed in the RVH trauma theatres Strategy for change: A formal pre-list brief and post-list debrief was implemented into two orthopaedic operating theatres over a 2 week period (January 2019). All operating lists were included (15 lists). A post-implementation survey was performed assessing impact (n=17). Measurement of improvement: The initial audit identified non-adherence to mainland policy of pre and post list briefs. All staff surveyed before introduction of pre-list briefing felt it would improve communication, patient safety, staff morale and theatre efficiency thereby advocating its introduction. Resurveyed staff confirmed improvement of each factor by 65%, 47%, 53% and 53% respectively. Effects of change: Furthermore >75% staff surveyed before introduction of post-list debriefing felt it would aid identification of issues and improve communication, which on resurveying equated to and improvement 59% and 71% respectively. Discussion: Our initial audit highlighted non-adherence of NPSA guidance. This project supports the implementation of pre and post list briefing. They take minimal time and can save significant time overall, reducing delays and identifying issues early., Problem: 25% of N.Ireland’s children are overweight/obese but there has been a lack of specialist services to support children with BMI> 98th centile achieve a healthier weight. Strategy for Change: We launched N.Ireland’s first multidisciplinary paediatric obesity service in May 2019. Children are referred from school nurses, general practitioners and paediatricians. Families are invited to participate in holistic assessment by a paediatrician, physiotherapist, associate psychologist and dietician. Measurement of Improvements: Outcome measures including BMI, 6-minute walk test, grip strength, blood pressure, dietary history and quality-of-life are assessed at baseline, 3,6 and 12 months. Parents/siblings also have their weight/BMI monitored. Personalised family plans are co-produced. Treatments include educational evening classes and/or one-to-one input from dietetics/physiotherapy/ psychology. Effects of Change: Currently 30 children (4-16 years) have attended multidisciplinary assessments and are in the treatment phase. 8 families completed the first 5-week cycle of evening classes. Attendance averaged 73%. 75% (6/8) reduced their BMI including one family who collectively lost >12kg. One child’s BMI increased, and another’s remained static. Discussion: After positive family feedback we have extended our evening programme to 6-weeks, introduced appointment text reminders and developed a more extensive outreach programme with local councils. We are excited to recruit more families and develop a sustainable business plan for this gap in paediatric services., Problem: Paediatric burns referred to Plastic Surgery are often given an appointment within the week to attend Paul Ward (RBHSC) for assessment. Plastics trainees are not always scheduled to work in RBHSC however, and the closest staff are in the Burns Unit (RHV). Trainees there manage the ward, admissions, theatre and clinics and so leaving is difficult. Strategy for change: The aim was to encourage appointments to be made on days where staff work in RBHSC. Weekly rota was not being sent to staff nurses, and there were issues in interpreting it. Interventions: Ensuring rota sent to ward staffTeaching session to Plastics traineesEnsuring ward staff understand rota Measurement of Improvement: Change measured by percentage of days medical staff were required that they were scheduled to be in RBHSC. Effects of change: In February 2019 staff were present on 16% of the days they were required, rising following interventions to 88% in June 2019. Discussion: It is not realistic to achieve 100%, as emergency admissions should not be delayed. However where there is flexibility it is better for patient and staff if assessments can be carried out promptly., Problem: Patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. It is medical professionals’ responsibility to advise patients to adhere to DVLA guidelines. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition. Strategy for change: Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Outcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in % Process: Document in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for. Effects of change: After cycle 3, there was an increase of mean of 25% completeness of driving advice to over 90%. Discussion: This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback., Problem: 50-70% of hospitalised patients without a formal diagnosis of Diabetes Mellitus will develop corticosteroid- induced hyperglycaemia. An audit cycle conducted on an inpatient respiratory ward identified deficiencies in recognising and treating this common, but important complication of steroid therapy- some 90% of clinical episodes failed to comply with national and trust guidance. Strategy for change: A PDSA cycle was employed to address this issue, with focus placed upon 3 key areas: Multi-disciplinary educational seminarsChanges in ward-based documentsEnhancing accessibility of guidelines through poster displays. Measurement of Improvement: Closed loop audit cycle (n=140) of blood sugar monitoring frequency, HBa1c measurement and implementation of appropriate hyperglycaemic therapy compared with national standards. Effects of change: Universal improvements in audited standards with >90% of patients on appropriate monitoring regimes and >50% receiving appropriate hyperglycaemic therapy. Discussion: Corticosteroids are employed by physicians in a variety of clinical circumstances. Corticosteroid-induced hyperglycaemia is a common but often overlooked side effect, with important implications for inpatient morbidity and mortality. National and Hospital Trust guidance is readily accessible but requires multi-disciplinary engagement for effective implementation.

Livestock are an important source of livelihoods in agricultural systems in sub-Saharan Africa (SSA), while also being the largest source of national greenhouse gas (GHG) emissions in most African countries. As a consequence, there is a critical need for data on livestock GHG sources and sinks to develop national inventories, as well as conduct baseline measurements and intervention testing to mitigate GHG emissions and meet ambitious national climate goals. Our objective was to review studies on GHG emissions from livestock systems in SSA, as well as soil carbon storage in livestock-dominated systems (i.e., grasslands and rangelands), to evaluate best current data and suggest future research priorities. To this end, we compiled studies from SSA that determined emission factors (EFs) for enteric methane and manure emissions, along with studies on soil organic carbon (SOC) stocks in SSA. We found that there has been limited research on livestock GHG emissions and SOC relative to national ambitions for climate change mitigation in SSA. Enteric methane emission factors (EFs) in low productivity cattle systems may be lower than IPCC Tier 1 default EFs, whereas small ruminants (i.e. sheep and goats) had higher EFs compared to IPCC Tier 1 EFs. Manure EFs were equal to or lower than IPCC Tier 1 EFs for deposited manure (while grazing), manure applied as fertilizer, and manure management. SOC stocks for grasslands and rangelands in SSA show broad agreement with IPCC estimates, but there was a strong geographic bias and many studies did not report soil type, bulk density, or SOC stocks at >30 cm depth. In general, the largest data gaps included information for manure (quantity, quality, management), small ruminants, agropastoral/pastoralist systems, and in general from West Africa. Future research should focus on filling major data gaps on locally appropriate mitigation interventions and improving livestock activity data for developing Tier 2 GHG inventories in SSA. At the science-policy interface, all parties would benefit from enhanced coordination within the research community and between researchers and African governments to improve Tier 2 inventories and harmonize measurement for mitigation in livestock systems in SSA.

Introduction: Pancreatitis is a common condition on the acute general surgical take. Common aetiologies in the UK include gallstones, alcohol excess and iatrogenesis. Hypothermia is scarcely documented in literature among the rarer causes of pancreatitis, and whilst little scientific literature exists to support this clinical observation, this case adds to the growing evidence for hypothermia as a clinically relevant risk factor for acute pancreatitis. Discussion: We present the clinical course of a 44 year-old male open water swimmer who was admitted to ICU for mechanical ventilation in view of hypoxic respiratory failure and severe hypothermia (27oC). Following cardiorespiratory stabilisation and uncomplicated extubation, the patient complained of sudden, severe epigastric pain, refractory to strong opiate analgesia. CT images were in keeping with acute pancreatitis. The patient was managed conservatively at ward level and made an uncomplicated recovery prior to discharge. Thorough clinical history and biochemical testing excluded all other typical aetiologies of acute pancreatitis. This case is unique from previous reports in literature, where the relationship between hypothermia and pancreatitis has been more ambiguous. It is essential to be vigilant in hypothermic patients and remember this uncommon link, as diagnostic delay may lead to serious local or systemic complications of pancreatitis., Introduction: Differentiating between a bacterial infection and a self-limiting viral illness is challenging. Adrenomedullin (ADM) has many physiological roles and is reported to rise during severe infection. The novel biomarker Mid-regional proadrenomedullin (MR-proADM) is produced during the synthesis of ADM. It proportionally represents the level of ADM and is easier to measure. Aims: To assess the diagnostic accuracy of MR-pro-ADM in detecting bacterial infection in febrile children presenting to the Royal Belfast Hospital for Sick Children Emergency Department (ED) with a non-blanching rash. Methods: Prospective diagnostic accuracy study. Samples tested using the BRAHMS MR-proADM assay on Samsung LABGEO IB10® analyser. Results: 39 patients underwent MR-proADM testing. In all but 2 patients the MR-proADM was under 0.70nmol/l. The two patients with elevated MR-proADM levels were found to have sepsis and tonsillitis. At 0.70nmol/l cut-off MR-proADM demonstrated a sensitivity of 0.11 (95% Confidence Interval 0.02 to 0.35) and a specificity of 1.0 (95% Confidence Interval 0.80 to 1.0) for bacterial infection. Discussion: MR-proADM is highly specific for bacterial infections but lacks sensitivity. Given the physiological roles of ADM it maybe that MR-proADM is better suited as a prognostic marker of sepsis rather than as a diagnostic marker of bacterial infection., Introduction: In a neonatal emergency, if intubation is indicated, it is imperative the correct equipment is collected promptly. Currently no neonatal intubation equipment guide exists. Aims: This study aimed to develop a Neonatal Intubation Flowchart (NIF) and test effectiveness of NIF 1 and NIF 2. Methodology: A prototype NIF was created (NIF 1). Using a simulation, a control group (n = 21) was compared to an intervention group (n = 24), employing NIF 1. These cohorts consisted of paediatricians, neonatal nurses and midwives. The outcomes measured were Percentage of Correct Equipment (PCE) collected and Time Duration (TD) to collect equipment. An improved NIF 2 was created and the simulation was repeated to an intervention group (n= 28) utilising NIF 2. Results: Between the control, NIF 1 and NIF 2, the PCE results were 59%, 87% and 96% respectively. The TD of the control, NIF 1 and NIF 2 showed a median of 90 seconds (Interquartile Range (IQR): 70.5 - 121.5), 140 seconds (IQR: 99.5 - 182) and 60 seconds (IQR: 53.5 - 73.5). Discussion: The NIF 2 improves intubation equipment collection, within a quicker time. Quicker and effective preparation aids quicker intubation which may limit hypoxic brain injuries., Introduction: There is an urgent need to develop efficacious and tolerable therapies for Mycobacterium avium complex (MAC) pulmonary disease. Mesenchymal stromal cells (MSCs) have known antimicrobial properties against common bacteria but their effect on MAC species is not known. Aims: To determine the effect of MSCs on intracellular and extracellular M. avium. Methods: Human MSCs were infected with M. avium at a multiplicity of infection (MOI) of 2. Human monocyte- derived macrophages (MDMs) were also infected with M. avium at MOI of 2. After 4hrs, MSCs were added at a ratio of 1 MSC: 3 MDMs. After 24hrs and 72hrs, colony counts were performed on supernatants and cell lysates. Results: MSCs reduced total bacterial counts of M. avium by 24% at 24hrs (from 295x103/ml to 225x103/ml, p40% (from 381x103/ml to 209x103/ml, p70% after 72hrs (from 1050x103/ml to 314x 103/ml, p, Introduction: This study uses eye-tracking technology to objectively assess the differences in gaze behaviours between consultant and trainee ophthalmologists before and after a taught search strategy was introduced, while interpreting retinal images. Methods: Nine trainee and 10 consultant ophthalmologists were asked to interpret 6 retinal images before and after watching a 5-minute tutorial that suggested a search strategy. Participants were asked to complete questionnaires of clinical signs seen, appropriate retinopathy grade, and confidence. Eye movements were tracked during each interpretation. Results: Overall, trainees compared to consultants demonstrated more uncertain and unstructured gaze behaviours. Trainees eye gaze metrics compared to consultants included: longer interpretation time, 36.5s(SD=6.2) vs 31.4s(SD=4.2)(P=0.024), a higher visit count, 17.38visits(SD=5.13)vs 12.18visits (SD=2.64)(P=0.01), a higher proportion of fixation, 57.0%(SD=5)vs 50.5%(SD=5) (P=0.05) and a shorter time to first fixation, 0.232s(SD=0.10) vs 0.821sec(SD=0.77)(P=0.001), respectively. The teaching intervention did result in more focused gaze patterns in both groups. Pre-intervention and post- intervention mean proportion fixation on areas of interest were 38.6%(SD=6.8) and 51.8%(SD=13.9) for the trainee group, respectively, and 39.9%(SD=4.1)and 50.9%(SD=9.3) for the consultant group(P=0.01). Conclusions: Consultants used a more systematic and efficient approach than trainees in interpreting images. After the introduction of a suggested search strategy, trainees showed trends towards the eye gaze behaviours of consultants. The implication is that eye tracking may have future use in teaching programmes and objectively assessing different teaching strategies., Introduction: Mycobacterium abscessus is an emerging multi-drug resistant pathogen, which is difficult to treat. There is a need for new antimicrobial strategies. Zafirlukast, a leukotriene receptor antagonist, inhibits growth of Mycobacterium tuberculosis, by inhibiting complexation between DNA and protein Lsr2. Lsr2 is present in M. abscessus. Aims: We aimed to investigate the effect of Zafirlukast on extracellular and intracellular M. abscessus growth. Methods: We examined Zafirlukast’s effect on free growth of M. abscessus, and survival of M. abscessus in infected THP-1 cell line derived macrophages. We measured colony- forming units per millilitre in broth, or supernatants and lysates, at 24 and 72 hours. Also, we investigated whether Zafirlukast reduced inflammation as assessed by interleukin-8 secretion (measured by ELISA) by infected THP-1 derived macrophages. Results were analysed by Kruskal-Wallis and Dunn’s tests. Results: At 24 hours, 100μg/ml Zafirlukast reduced M. abscessus free growth by 62% (p=0.0039), also reduced total M. abscessus growth in THP-1 derived macrophages by 94% (p=0.0062), and finally, reduced interleukin-8 concentration in supernatants from M. abscessus-infected THP-1 derived macrophages by 99% (p=0.0412). Discussion: Data suggest Zafirlukast may reduce growth of M. abscessus and modify M. abscessus-induced inflammation. Further work is required to assess the potential therapeutic role of Zafirlukast in treating M. abscessus infection., Introduction: Sepsis represents a dysregulated host response to infection. Underlying mechanisms are unclear, but deficits in the function of monocytes, central to the innate immune system, are implicated. A heterogeneous condition, recent transcriptomic work has revealed two distinct sepsis-response signature profiles; immunosuppressed and immunocompetent, which are linked to outcome. Aims: We propose that these distinct profiles impact differentially on volunteer monocytes, and hypothesize that there will be differences in their phagocytic activity and phenotype when conditioned in plasma from patients in these two groups. We therefore aimed to validate a functional assay for this purpose using lipopolysaccharide (LPS) to represent ‘septic’ plasma. Methods: CD14+ monocytes were isolated from healthy volunteers, and incubated overnight in media and human plasma +/- 10ng/ml LPS. Surface phenotype and phagocytosis were assessed by flow cytometry. Results: LPS exposure decreased monocyte surface CD14, as previously reported, and PD-1, whilst phagocytosis of E.coli particles and expression of CD86, and expression of PDL-1 increased. Discussion: Our LPS model of ‘septic’ plasma/monocytes demonstrated the ability to alter monocyte phenotype and function, providing a positive control for subsequent analysis of patient samples., Case Study: Small bowel malrotations are a rare congenital abnormality (symptomatic in 1 per 6000 live births 1). The majority of these present as a neonate or in early childhood (adult presentation between 0.0001% and 0.19%2,3). Our case is a patient with a rare form of malrotation, a reverse malrotation, presenting as an adult. An 18-year-old woman presented with 1 week of epigastric pain radiating through to her back. The pain had worsened in the 3 days preceding admission and was associated with vomiting. Bowels had been opened the previous day with no diarrhoea, mucus or blood reported. On examination the patient had a tender epigastrium and RUQ with associated guarding. Biochemical tests were unremarkable; WCC, CRP, LFT and Amylase all grossly normal. CT demonstrated small bowel volvulus and incomplete obstruction with a “whirlpool sign” of the small bowel mesentery. At Laparotomy the transverse colon was found running through the small bowel mesentery, ultimately a Right hemicolectomy with end ileostomy was performed. Discussion: Cases of malrotation are rare and there is often a delay in diagnosis. We hope the discussion generated by this report will improve the diagnosis of intestinal malrotation and therefore improve outcomes for patients., Case study: Ocular cicatricial pemphigoid (OCP) is an autoimmune disease that affects the conjunctiva. It is a subtype of mucous membrane pemphigoid (MMP), a disease that affects the skin and the mucous membranes. Initial signs and symptoms can overlap with other conditions such as pseudomembranous conjunctivitis. OCP is sight threatening and requires systemic steroids and immunosuppression while pseudomembranous conjunctivitis is self-limiting. We present the case of a 72 year-old gentleman with multiple attendances to eye casualty with red eyes. He was initially diagnosed with pseudomembranous conjunctivitis before developing cicatricial conjunctivitis and mouth ulcers. The conjunctival biopsy confirmed the diagnosis of OCP and the patient was started on oral steroid and immunosuppressive therapy. Discussion: The diagnosis of OCP was delayed in our case and affected one eye more than the other. Extra-ocular signs and positive direct immunofluorescence can help differentiate OCP from other cause of chronic conjunctivitis. Early diagnosis is important as immunotherapy takes few weeks to achieve maximal effect. A step-wise approach was used in this case, starting with oral Dapsone and escalating to oral Mycophenolate. Close monitoring of the patient will continue under the joint care of the ophthalmology and rheumatology team., Case Study: A lady who was 7 weeks pregnant presented to the Emergency Department at 4am with her partner. She had been out for dinner with friends at 7pm and developed severe vomiting and diarrhoea from 10pm. Whilst in the waiting room she fainted & was faecally incontinent so was brought into a bed. On examination she was clammy and had generalised abdominal tenderness. Observations were normal except a Heart Rate of 105BPM. Initial haemoglobin on her Venous Blood Gas was 145. The obstetrics registrar was called - he could not see an intrauterine pregnancy. Her VBG was repeated showing a haemoglobin of 85. She was rushed to theatre and had 2 Litres of blood in her abdomen. Discussion: Ectopic pregnancy should be considered in any female who presents with abdominal pain. All women presenting with abdominal pain should have a pregnancy test performed. Pregnant women should also have an ultrasound scan to confirm intrauterine pregnancy. This is a potentially life threatening condition if not managed promptly. This case highlights how it can present with atypical features which mimicked gastroenteritis. It also highlights that initial bloods can be normal. This lady survived., Case Study: This patient had a normal delivery with a postpartum haemorrhage of 800ml. Her haemoglobin was 94g/L on discharge. She was a Jehovah’s Witness and refused transfusion of blood products. She was readmitted day 8 following delivery with sepsis. Ultrasound showed a 9x4cm area of retained placental tissue. Her haemoglobin on readmission was 82g/L. Instead of immediate intervention the patient was reviewed weekly to assess for infection and there was multidisciplinary input including pre-operative counselling, anaesthetic review and completion of an advance directive. She was admitted 8 weeks postpartum for resection of retained tissue. Her haemoglobin was 135g/L and intravenous tranexamic acid bolus and infusions were given prior to the procedure. Hysteroscopy showed adherent placental tissue on the right lateral wall and posterior wall of the uterus. As there was moderate bleeding following tissue resection a urinary catheter with 20ml saline was inserted into the uterus. Discussion: Hysteroscopic resection of retained placental tissue is relatively new however has been supported by the literature and warrants further trials. When compared with uterine curettage it may reduce blood loss and long term complications such as Ashermans syndrome., Case Study: A 35 year old female self-detected a lump in left breast July 2017. Triple assessment confirmed node positive, triple negative, infiltrating ductal carcinoma. No evidence of distant metastases on staging investigations. Completed six cycles of neo-adjuvant chemotherapy 08/01/2018 and left partial mastectomy and ANC 05/02/2018. Presented 5 days post-surgery with headache, photophobia, nausea, vomiting; CT Brain was normal - discharged. Admitted to Oncology 11 days later with ongoing symptoms; Normal examinations; MRI Brain and whole Spine normal; LP – cytology confirmed epithelial cells consistent with metastases from a primary breast carcinoma; Rapid decline with death on 11/05/2018. Discussion: Early breast cancer carries an excellent prognosis when treated with neo-adjuvant chemotherapy and surgery. Commonest sites for metastases include bone, lung, liver, brain and leptomeningeal involvement usually occurring months to years post initial diagnosis. Leptomeningeal metastases alone are very rare especially early in the natural history of the disease. Diagnosis requires a high clinical index of suspicion. Gold standard Investigations include T1-W MRI scan of brain and spine with gadolinium enhancement and CSF analysis. Treatment options are limited with continued debate over the effectiveness of systemic chemotherapy, radiotherapy and intra-thecal chemotherapy. Life expectancy following diagnosis of leptomeningeal metastasis is measured in terms of weeks., Case Study: A 41-year old male athlete presented acutely to the Royal Victoria Hospital emergency department with sustained resting typical angina chest pain 30 minutes following completion of an ultra-triathlon. 12-lead ECG demonstrated hyper acute t waves in precordial leads V3 and V4. Serial high-sensitivity Troponin T assays were elevated at 186 – 330 – 603ng/L respectively. Invasive coronary angiography demonstrated acute LAD dissection and significant thrombus burden with TIMI 3 flow distally. Optical coherence tomography (OCT) confirmed coronary dissection. A 6.0(width)/18 (length) mm Herculink bare metal stent was deployed following catheter thrombectomy, with a successful angiographic result. Following 3 months of dual antiplatelet therapy he remains on life-long Aspirin. At 1 year he has had no further major adverse cardiovascular events (MACE), angina free (CCS class 0) and exercising regularly. Discussion: Spontaneous coronary artery dissection (SCAD) is a rare and clinically challenging cause of acute myocardial infarction most commonly affecting younger patients with low risk of atherosclerotic heart disease. The low incidence of SCAD has resulted in a paucity of information on optimal treatment. Our case highlights a challenging case successfully treated with percutaneous coronary intervention including intra-coronary imaging, and antiplatelet therapy., Introduction: Trauma contributes significantly to adolescent morbidity and mortality. Currently a dearth of literature exists, specific to this field in the UK. This study aims to highlight the epidemiology of UK adolescent trauma. Methods: TARN (Trauma Audit Research Network) records all trauma cases which meet pre-specified criteria. Adolescents were defined as 10-24 years old as per recent literature. TARN data from English sites over a ten-year period (2008-2017) were included in this analysis. Results: TARN recorded 26,330 trauma cases, 5,266 aged between 10-15 years and 21,064 aged between 16-24 years. Median age was 19.4 years (IQR 16.7-21.7 years). There was a 2.2-fold increase in the annual number of cases reported during this period with an increase in the number treated in MTCs (44% 2008 vs 73% 2017). Trauma was more likely to occur between 08.00 and 00:00 (77.4%), at weekends and between April and October. Mortality rate was 4.4% (4.47% in 16-24 year old group and 3.84% in 10-15 year old group). Road traffic collision (RTC) was the leading cause of adolescent trauma (52%). Intentional injuries accounted for 19.8%; 16.2% alleged assault and 3.6% suspected self-harm. Conclusions: There has been an increase in reported adolescent trauma. RTC and intentional injuries, including stabbings are leading aetiologies. Health care professionals need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable group., Background: Informed consent is an integral component of good medical practice. Many have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a ‘core outcome set’ to evaluate interventions designed to improve the consent process for surgery. Part of that process involves reviewing outcomes that have been reported in existing research that reportedly capture the quality of a consent process. Aims: To systematically review all qualitative studies to determine which factors determine the quality of informed consent for surgery as viewed by patients and clinicians. Methods: This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. The study protocol has been registered on the International Prospective Register for Systematic Reviews (PROSPERO ID: CRD42017077101). Results: Searches of the databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2014 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers. These findings were divided into 12 categories and ultimately 6 synthesised findings. These synthesised findings were; trust, knowledge, patient characteristics, situational factors, choice and the model patient. Discussion: This qualitative meta-aggregation is the first to examine the issue of informed consent. The review has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been previously been examined in informed consent research. This review forms the basis for the development of a core outcome set to evaluate interventions designed to improve the consent process for surgery., Introduction: Nowadays most people use the Internet to access health-related information. Aim: To objectively analyse online information regarding vertigo, in terms of quality, readability and reliability. Methods: The term vertigo was searched using the most popular search engines. The top 30 websites were analysed. The readability was assessed using Flesch-Kincaid Reading Ease score (FRES) and Simple Measure of Gobbledygook score (SMOG). The quality and reliability were analysed using DISCERN instrument, JAMA criteria and presence of Health on the Net (HON) Foundation seal. Results: The websites Nhs.uk, Patient.info and NIdirect.gov.uk had the highest readability scores. The average FRES score was 48 which correlates to the reading ability of a college student. Thirteen websites had the HON seal and most websites met 2 out of 4 JAMA criteria. The websites Cks.nice.org, Nhsinform.scot and Menieres.org.uk had the highest DISCERN scores and average DISCERN score was 41. Discussion: On average, information online about vertigo is difficult to read and is of fair quality. The highest ranked websites on search engines are not always the most reliable. Clinicians should be aware of available health information online and advise patients accordingly., Introduction: Studies have shown that disease recurrence after LLETZ is higher in patients with positive resection margins; however rates vary possibly due to technique and extent of margin cautery. We analysed patient records to determine if margin status affected test of cure (TOC) rates. Methods: 100 margin positive LLETZ specimens and 103 margin negative specimens were identified in the WHSCT for high grade CIN (CIN 2/3) from January 2016- June 2017. Case records were examined to determine TOC post excisional therapy. Results: Of 203 patients who had LLETZ for high grade CIN 5% of patients were immunocompromised (n=10).6 cases had co-existing CGIN (4 in margin positive group). 63% of the margin positive group and 68% of the margin negative group had negative TOC (p=0.22). 7% of the margin positive group and 3% of the margin negative group required repeat excision (p=0.09). DNA rates for TOC were 10% and 5% in the margin positive and negative groups, respectively. Discussion: Our results show that after TOC smears post LLETZ for high grade CIN margin status of the LLETZ specimen made no significant difference to the outcome. This is perhaps due in part to the treatment technique involving cautery of the residual margins., Introduction: Burnout in doctors has been widely reported on. However, there is limited information in the literature on resilience in doctors. Despite this, workshops and seminars are offered by organisations for clinicians to attend to improve their personal resilience. These may not benefit doctors if they are already highly resilient individuals. Aims: To measure resilience, professional quality of life and coping mechanisms in doctors. Methods: During a 4-week period all medical staff within a single NHS trust in Northern Ireland were invited to complete an online survey that was made up of three validated psychological tests. Results: 283 doctors across a wide range of specialties and grades responded. Mean resilience was 68.9, higher than population norms. 100 (37%) doctors had high burnout scores. Burnout was positively associated with low resilience, low compassion satisfaction, high secondary traumatic stress and more frequent use of maladaptive coping mechanisms, including self-blame and substance use. Non-clinical issues in the workplace were the main factor perceived to cause low resilience in doctors. Discussion: Despite high levels of resilience, doctors had high levels of burnout and secondary traumatic stress. As doctors already have high resilience, improving personal resilience further may not offer much benefit to professional quality of life., Introduction: Osteoporotic acetabular fractures in the frail elderly patient are associated with high levels of morbidity and mortality. Aims: We describe the results of a coned hemipelvic acetabular reconstruction and total hip replacement as the treatment of these fractures. Methods: We have prospectively monitored a series of fifteen patients (16 cases) with a mean follow-up of 22 (12-42) months. Results: The mean age was 79 (67-87), and mean ASA score 3.3 (3-5). Thirteen had low-energy injuries, two had high-energy injuries. Mean operative time was 94 minutes. There were seven minor post-operative complications. Fourteen of 15 patients were full weight bearing day one post-operatively. Mean length of hospital stay was 13 (5-27) days. Preoperative mobility status was maintained in 8 patients. At one year mean Harris hip score was 73.13, Merle d’Aubigné score 12.7 and mean EQ-5D score 0.59 (data from 10 patients). Mortality at 30 days was 0%, and 7% at 1 year. There have been no thromboembolic events, dislocations or deep infections. Discussion: The coned acetabular prosthesis minimises operative time and bypasses the fracture, creating an immediately stable construct that allows immediate weight bearing. Early results show an acceptable complication rate, satisfactory patient reported outcomes and excellent survivorship., Introduction: FFRCT can determine the functional significance of stenosis and guide safe deferral of invasive angiography, however intermediate prognostic implications have not been assessed. Aims: The study aim was to examine the prognosis of fractional flow reserve derived from coronary computed tomography (FFRCT) in routine clinical practice. Methods: Patients referred for FFRCT analysis with stable chest pain at a single centre between October 2015 and June 2017 were retrospectively included and followed up for rates of vessel related late (>90days) unplanned revascularization, MI, and cardiac mortality. Results: 200 (mean age 62.4±10.0 years) patients were sent for FFRCT analysis. A Cox Regression model was used to determine hazard ratios from FFRCT status. FFRCT+ patients were significantly more likely to undergo invasive angiography (p, Introduction: Skin cancer incidence is rising in Northern Ireland (NI)1. The Department of Health, Social Services and Public Safety’s (DHSSPSNI) ‘Skin Cancer Prevention Strategy and Action Plan (2011-2021)’2, aims to reduce skin cancers by raising awareness of the dangers of ultraviolet radiation. Target groups include children and outdoor sports participants. Aim: We surveyed NI sports clubs to gauge whether such messages are reaching members. Methods: Links to sun-safety material accompanied surveys emailed to 562 clubs (158 complete; 75 partially complete). Results: Amongst 158 complete responders, highest responding clubs included Gaelic football (54%), running/ athletics (10%) and golf (9.5%). 67% were unaware of the DHSSPSNI strategy ;< 6% recall receiving promotional material. The majority of clubs provide no sunscreen; 5% supply free sunscreen and 2.5% offer it for special events. Considering future sun-safety promotion, 129/158 clubs would use the material accompanying the survey. Discussion: Evidence shows that safe-sun and skin cancer education does not always lead to behavioural change3,4. Club-level health policies result in healthier behaviours5, with those connected to regional bodies being more inclined to partake. NI clubs are willing to promote sun-safety. They propose better use of social media to target members, with the literature suggesting improved member websites6. Future campaigns could target governing bodies to encourage member-clubs to promote sun-safe behavior., Introduction: Traditional outcome measures (e.g. mortality, length of hospital stay) may not provide a full depiction of patients’ post-operative state, especially for low-risk interventions such as inguinal hernia repair. Patient reported outcomes (PRO) are becoming increasingly common as primary outcomes in clinical trials. Aims: The aim of this study is to report and summarise the PROs in randomised controlled trials (RCT) comparing laparoscopic versus open inguinal hernia repair techniques. Methods: A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. PubMed, Embase, SCOPUS, Cochrane Library and four clinical trials registries were searched. Identified publications were independently reviewed by two authors. Results: 7,129 records were identified, resulting in 53 RCTs being selected. In total 17,148 patients were identified and 18,004 hernias were repaired. After meta-analysis the laparoscopic group was associated with significantly less post-operative pain, except that reported within 2 weeks post- operatively. Numbness and patient reported satisfaction was also significantly better in the laparoscopic group. Discussion: This study reflects the most up-to-date evidence available for the surgeon to council their patient. It was constrained by the heterogeneity of outcome reporting., Introduction: The recently updated NICE guidelines regarding investigation and treatment of stable ischaemic heart disease advise CTCA for investigation of chest pain and reserve non-invasive ischaemia tests for patients with known coronary artery disease. In practice, choice of investigation often depends on local availability and expertise and options for non-invasive ischaemia testing include DSE, MPI and CMR. This audit aimed to assess safety outcomes and sensitivity/specificity of stress CMR in Northern Ireland. Methodology: A retrospective audit of patients undergoing CMR from 1st Jan 2016 - 1st January 2017 was undertaken. For patients with a positive CMR, findings at angiography were assessed. For patients with a negative study, the electronic care record was reviewed to assess incidence of adverse outcomes including acute coronary syndrome and mortality. Results: In total, 74 patients were included in the audit. Follow-up was undertaken from 14-26 months. Twenty nine (39.2%) had a positive CMR. Of the 45 stress CMR negative patients, no patient had myocardial infarction or mortality during follow-up. Of the 29 CMR positive patients, 20 (68.9%) had invasive angiography, of which 19 (95.0%) had PCI and 1 (5.0%) had bypass surgery. The remaining 9 patients were felt inappropriate for angiography due to comorbidities. Sensitivity was 0.96 for coronary artery disease according to post CMR angiogram. Discussion: Stress CMR correctly identified patients with obstructive coronary disease which required further therapy with a high degree of sensitivity. Patients with negative studies appear to have a low risk of cardiac events in the short to medium term., Introduction: A survey of Emergency Medicine Trainees indicated that the progression from lower into higher specialty training (HST) is a stressful transition. Aims: Our aim was to develop a course which met the needs of our trainees based on the feedback obtained from our survey. Methods: We developed a one day course which simulated a busy night shift. The candidate was required to manage simulated patients and the rest of the department represented on a “board”. It tested their ability to prioritise, delegate, lead and managing other staff, deal with difficult situations and maintain situational awareness. Results: Feedback showed improved confidence in managing staff, giving advice, delegating appropriately, making decisions and dealing with difficult situations. All trainees felt the course would improve patient safety and would recommend the course to other trainees. Discussion: The transition into HST is stressful. Our survey identified that the reasons underpinning this are in relation to leadership & management skills and non-technical skills. We showed how a simulated teaching session could help provide a “safe” environment to learn these skills and provide strategies for overcoming common problems. Overall this improved leadership skills, confidence and patient safety., Introduction: In recent years, clinical negligence claims are a growing reality for dental professionals. Defence organisations report both increasing claim numbers and higher levels of compensation being awarded. Aim: We aim to undertake root cause analysis of negligence claims reported on by a single consultant oral to improve understanding of the root causes and to direct quality improvement activities. Method: Claims were identified between 1993 and 2015 through consultant records and a systematic approach taken to review each case to determine both active and latent factors contributing to the claim. Results: 30 negligence cases were identified with 53% of claimants being male and the most common age group 31-40 (33%). Extractions were the most frequent cause of claims. Other reasons included misdiagnosis, patient injury and complications of treatment. Several latent and active contributing factors were identified for each including organisational (30%), task (97%) and communication (57%) factors amongst others. Discussion This study highlights that the cause for dental negligence claims is often multifactorial. It reinforces an often significant variation in recollection and perception of events by both complainant and dentist. Communication frequently features as a factor although other organisational and task factors also play a significant role. Many root causes identified are preventable or modifiable and therefore measures can be put in place to reduce the impact of these and ultimately risk of negligence and negligence claims., Introduction: Previous literature identifies authenticity and the holistic nature of the long case as advantages; however its unreliability makes it unsuitable for summative assessment. The views of students are not well represented in existing research. Aims: To ascertain the views of medical students on the value of the long case. Methods: A questionnaire and focus groups were used to discover students’ views on a rheumatology long case. Eighty- six percent of 106 students returned questionnaires and 19% attended focus groups. Qualitative thematic analysis was undertaken. SPSS® was used for statistics. Results: There was overwhelming support for the long case (92% in favour). Students reported it provided them with a ‘real’ encounter and ‘integrated’ their learning. There were mixed opinions on the educational value of the long case. Opinions that it was ‘unfair’ were prominent in focus groups. There was frequent mention of practical difficulties completing the case. Views on the importance of feedback were expressed. Discussion: Students used the terms ‘real’, ‘integrated’ and ‘fair/unfair’ when describing the long case which correspond to the academic terms ‘authentic’ ‘holistic’ and ‘reliable’. We may improve students’ experience by minimising practical obstacles and maximising the quality of feedback., Aim: A General Surgery firm of a District General Hospital noted an opportunity to improve knowledge and skills for Foundation Year Doctors caring for surgical patients with Peripherally Inserted Central Catheter lines. Shift pattern demands prevented trainees from attending a single education session. Our aim was to improve confidence and knowledge through education with Trust Specialist Nurses. Methods: An initial questionnaire was circulated amongst Foundation Doctors working in Surgery to determine baseline familiarity and confidence with PICC lines. Following education, the questionnaire was recirculated. Results: Pre-education - 14 responses received. 100% encountered a patient with a PICC. 57% had taken blood from a PICC without formal training. 64% encountered difficulty drawing a blood sample from a PICC. The average level of confidence was 6/10. 100% felt they would benefit from formal training on PICC lines. Following formal education: Average level of confidence was 7/10 – demonstrating a 10% increase. Average rating for quality of teaching was 9/10. Conclusion: This unique, combined medical education and patient safety QI project confirmed issues in Junior Doctor training. Results demonstrated simple education can increase confidence in PICC management. As a result, Doctors can deliver safer care for this group of patients., Introduction: Many surgeons write directly to patients with updates on their care. The readability of this correspondence was not subject to the same standards expected from other patient literature. New guidance on patient correspondence has further highlighted this issue. Aim: To show results from a study we undertook regarding readability in January 2018 and to highlight some of this new guidance. Methods: One hundred consecutive letters written directly to patients from the General Surgery Department, Ulster Hospital in December 2017 were analysed. The Simplified Measure of Gobbledygook (SMOG) was calculated for each letter. Results: The mean SMOG was 11.23. 82% of letters were classified as difficult to read. Discussion: Only 3% of letters included in our initial study were considered ‘easy to read’. Although new guidance does not specify a target age for readability, it does give some advice; this includes words to avoid, sentence length, and avoidance of medical jargon. As part of an ongoing quality improvement project we hope to demonstrate improvement in the readability of patient correspondence., Introduction: Anaemia is a key contributor to poor obstetric outcome including increased mortality from obstetric haemorrhage. It is associated with fetal death and premature delivery and UK antenatal prevalence is 24.4%. Aims: To review the diagnosis, treatment and follow up of antenatal anaemia and determine the incidence of avoidable anaemia and transfusion at delivery. Methods: A proforma based upon national guidelines was completed following a chart review of mothers with antenatal anaemia who delivered in the Ulster hospital over a one- month period. Results: Of the 22 patients haemoglobin was checked at 28 weeks in 86%. Oral iron was prescribed when indicated in 50% of patients, with 1/3 experiencing a significant delay. 13% received dietary counselling and of those applicable only 7% were referred to secondary care. 31% were appropriately followed up with a 45% adequate response to treatment. There was a 4.5% incidence of avoidable red cell transfusion and 41% avoidable anaemia at delivery. Discussion: To summarise, 31% of patients with confirmed anaemia received oral iron at the correct dose resulting in avoidable anaemia and transfusion at delivery. This review represents substandard practice and creates baseline data for a quality improvement project which is ongoing., Aims: To determine the presentation, management, waiting times and conversion to SCC of Oral Epithelial Dysplasia (OED) at the School of Dentistry (SOD). Methods: A retrospective review of cases of OED referred to the SOD between March 2011 and July 2017. Hard copy and electronic patient records were used. Results: Overall 45 patient records were reviewed over the time (24 male and 21 female). Over 84% of patients were aged over 50 on referral. Most lesions were located on the tongue or floor of mouth (82%) with almost half appearing as homogenous white patch lesions (69% asymptomatic). Just under one third were referred on the red flag pathway. Management of lesions varied between monitoring (60%), surgical removal, referral or laser excision. Overall 9 of the 51 lesions were re-biopsied and a diagnosis of OSCC made. No link was made between degree of dysplasia and likelihood of conversion. Discussion: OED occurred most frequently in patients over 50 and appears strongly linked to factors such as excessive alcohol intake and smoking. Characteristics of the presenting lesion vary and as such so does triage grade on referral. Management of lesions varied depending on histopathology, clinical findings and risk factors. 20% of lesions later converted to OSCC. Using these findings we aims to formulate a management protocol for these patients in conjunction with histopathology and our head and neck surgery colleagues which will be applicable to both the oral surgery and oral medicine department in the school of dentistry., As a rheumatology trainee I was aware that for those patients with raynauds syndrome, who were being assessed for an underlying connective tissue disease, there was no facility to perform capillaroscopy. Capillaroscopy is a non-invasive method of examining the nail bed capillaries of patients to assess for any abnormalities. This allows for earlier diagnosis and treatment for those with scleroderma and it also can facilitate discharge of those patients with primary raynauds with normal capillaroscopy findings. My aim was to create a nurse led capillaroscopy clinic for the Belfast Trust by August 2018. I was able to secure funding in order to learn how to perform capillaroscopy in May 2017 and successfully completed a capital funding bid to secure a video capillaroscope for the Belfast Trust. After developing my skills in the procedure I was able to encourage one of our specialist nurses, Donna Torrens, to learn the skill herself. We have now completed 6 capillaroscopy clinics at RVH, reviewing 20 patients (16 Female: 4 Male) who were referred via our online form. For those seen 4 patients were given a connective tissue disease diagnosis, 2 patients had their disease staged, 7 patients were able to be discharged from rheumatology services and the remaining 7 patients require ongoing review due to either abnormal capillaroscopy findings or concerning history. The service shall now continue as a nurse led service., Introduction: The UK National Vascular Registry (NVR) records and publishes outcomes for procedures performed by vascular consultants. It aims to audit and improve vascular patient care. Difficulty in extracting data from patient notes have led to incomplete entries and underreporting of results. Aims: To improve the accuracy of data entry into the NVR for all patients undergoing carotid endarterectomies (CEAs) at a Regional Vascular Centre. Methods: A total of 5 PDSA cycles were completed. Data was collected over four months from consecutive CEA patients. Deficiencies in data entries were analysed. At month two, a new proforma was introduced highlighting the key data components required for the NVR database along with further sections for MDT input and inpatient note keeping. Staff were unaware that notes were being audited. Data completion rates were then compared. Results: There was a significant improvement in completion of NVR entries after pro forma introduction; admission details improved from 48% to 98% completion and demographics from 68% to 99%. Discussion: The proforma has resulted in an improvement in the accuracy and completion of NVR data entries for CEA patients permitting outcome data to be audited to ensure high standards of patient care., Introduction: The current pathway is that these patients are referred to a spinal specialist. This generally requires an ambulance trip, often long since the N. Irish population is covered by a single spinal centre. Aim: We propose treatment can be done locally on selected patients. Methods: Retrospective study of new referrals seen in the spinal clinics at the Royal Victoria hospital between October 2017 and March 2018 - 395 patients. The segmental kyphotic angle was compared between imaging at diagnosis and in clinic. We’ve excluded patients: younger than 65yo; with neoplastic/ metastatic fractures; with associated myopathy/neuropathy; clinic letter not typed (n=2). N = 109 patients Results: 20% discharged at 1st encounter. Spinal bracing fitted on 45% but no patients offered surgical intervention. Mean segmental kyphotic angle increased 5.25°. Discussion: There was a minimally significant increase in the mean segmental kyphotic angle. Surgical intervention was not necessary for any of the patients, being analgesia and physiotherapy the treatment modalities chosen. We believe this patient group can be managed locally and only referred to a specialist if meeting defined criteria. This should be less cumbersome for all., Introduction: Head and neck patients are subject to national requirements to establish a diagnosis by 31 days. Timely communication is key to assisting this. Red flag signposting of letters in medspeech is key step in process. Prior to this project the majority of letters for red flag patients were being dictated as routine and so typing of the dictations could vary between 1 - 4 weeks depending on the secretarial support. One of the issues we faced was clinicians can remove patients from the red flag process and thus think red flag dictation was unnecessary. Aims: To ensure that by start of July 2018, 75% of Red Flag patient Letters are graded correctly in dictation with 100% graded correctly by end of September 2018 Resulting dictations will thus be typed within 24hrs of seeing the patient This complies with the trust’s standard operating procedure, and ensures efficiency within our systems Methods: Baseline data collection to confirm that improvement was required. PDSA 1 Email to OMFS team. PDSA 2 Audit Reminder. PDSA 3 2nd Email to OMFS team. PDSA 4 Notice on Computers. Results: Aim: 75% compliance. Overall steady rise in compliance after every PDSA cycle. Median Prior to first intervention 33% (Week 1-15) Median after PDSA cycle 1= 50% Median after PDSA cycle 2= 49% Median after PDSA cycle 3= 58% Median after PDSA cycle 4= 66% Discussion: Unfortunately we didn’t reach our aim compliance. I feel that we made a substantial improvement in the practises of the staff and that over time we will be able to reach out aim of 75% compliance for red flag dictations., Introduction NI has one BSGE Endocentre established in 2014 with a team of gynaecologists, colorectal and urology surgeons and one nurse. Aims To determine symptoms and QOL outcomes for women with severe endometriosis since Endocentre was established and patient feedback on current services. Methods BSGE endometriosis database was analysed (previous surgery or hormonal therapy, symptoms and pre- and post-surgery quality of life (QOL) measures). Telephone questionnaires about endometriosis services were undertaken. Results 60 patients on database had QOL score (EQUVAS numeric 0-100 score) recorded. 37% used hormonal therapy pre-surgery, 62% had previous surgery for endometriosis. Most common hormonal therapy was COCP (15%) Most prevalent symptom was menstrual pain (81%). Average pre- surgery QOL score was 57, with average scores at 6 months, 12 months and 24 months post-operatively 67, 71 and 57. Telephone questionnaire (17 patients), 88% attended gynaecology before the endometriosis clinic, 35% noticed improvement since then. Feedback was positive (88%). All felt a patient support group would be beneficial. Discussion On average patients had improved QOL scores at 6 months and 12 months post-operatively. Based on patient feedback, the first endometriosis support group in the Northwest is being established, run by charity and the Patient Client Council., Introduction Heart failure symptoms are non-specific therefore diagnosis can be challenging. If suspected, the European Society of Cardiology recommends that natriuretic peptide (NP) levels are measured prior to requesting an echocardiogram, as patients with normal NP levels are unlikely to have heart failure and do not require echocardiography. Aims: To ascertain how often an NT-ProBNP is checked prior to requesting an echocardiogram for left ventricular (LV) function assessment. Methods: We reviewed 44 echocardiogram requests submitted between May-October 2017. We used ECR to see if an NT-Pro BNP had been requested beforehand, and how these results correlated. Results: Of 25 inpatient requests, 23 had an NT-ProBNP checked beforehand, compared with 8 out of 19 outpatients. When analysed by grade, the majority of requests came from general practitioners. No patients with normal NT-ProBNP values were shown to have LV dysfunction. Discussion: In the majority of patients in whom LV dysfunction was suspected, echocardiographic assessment was normal. Therefore, a test which can reliably exclude LV dysfunction has significant potential to reduce unnecessary referrals, which would in turn reduce waiting list pressures, patient anxiety and hospital spending. Recommendations for improvements are discussed., Aim: Evaluating time from admission acute gallstone pancreatitis to cholecystectomy. Method: UK working party guidelines for management of acute pancreatitis. “All patients should undergo definitive management during same admission or within 2 week period.” All coded diagnosis of gallstone pancreatitis Ulster hospital Dundonald admissions 2016. Dataset: Discharge date, ERCP/Surgery, repeat admissions prior to surgery, mode of procedure and 30 day readmission/morbidity/mortality. Results: 51 patients 47 deemed surgically fit. 14.9% had same admission cholecystectomy; 43.5% performed within guideline 2 week period. 96.1% diagnosed MRCP, 2% CT, 2% USS only. 33.3% positive MRCP findings all underwent ERCP Cause of delay: 15% failed or delayed ERCP, 5% required repeat imaging,14% no noted medical/surgical cause 21% Repeat pancreatitis admissions: 27% before ERCP, 36% After ERCP and 36% no evidence of choledocholithasis. 88% performed Laparoscopically, 9.5% lap conversion to open 11% 30 day readmission rate following surgery, 7% with post operative pancreatitis Conclusions: 43.5% had surgery performed within guidelines period. Delays majorly observed due to ERCP availability; however 14% had no medical/surgical reason. Therefore waiting list factors may have had some effect. Delay to surgery is thought to have directly affected rate of readmission with pancreatitis., Introduction: Within the Mater Hospital admission packs there is a 1 page discharge summary sheet for consultants to fill in when patients are fit for discharge. This ensures vital information eg final diagnosis and review information is communicated. This document was however rarely used. Aims: Increase use of IDD by medical consultants to 90% Methods: - Information session for all medical staff about changes and to gather feedback - All medical consultants emailed to ask for support - Layout of page streamlined - Document changed to yellow paper and moved to front of admission pack - GPs surveyed on what is important in a discharge letter Results: 4 PDSA cycles carried out. Before changes implemented (first audit) 8% were filled out from a random sample of 5 per ward. Improved to 36% on first re-audit, 44% second and 52% on the third. A further re-audit 2 years later (March 2018) showed implementation was at 37%. Discussion: Change can be slow! Project overall a success and improving discharge accuracy has obvious benefits for patient care in community as well as making discharge letters a more accurate document for ECR reference., Introduction: Nice Guideline 53 recommends standards for the transition of care between inpatient mental health facilities and community follow-up. GP`s should receive discharge summaries within 7 days. At baseline 0% of letters were completed within this timeframe within the T&F. Aim: Discharge summary should to be completed within 7 days for at least 60% of patients in the T&F hospital, and to achieve this within 12 months. Method: The baseline data for all patients admitted and discharged in the 8 months prior were also gathered prior to any intervention. 5 PDSA Cycles were used to introduce a new discharge trolley to each inpatient ward, a new discharge checklist introduced. The letter itself was restructured in a way that made it easier to read and easier to complete. Results: Changes implemented correlated with an improvement from 0% of letters complete within 7 days to over 80% completed. The mean time taken for community teams receiving letters improved from 51 days to 4 days. Discussion: This project attained sustained improvement. Microsystems meetings at a local level also allowed a time allocated to focus on this project within a QI minded approach., Aim: To reach 90% adherence to DVANI ADHD guidance in East Belfast OPC Background: According DVLA’s guidance, patients with ADHD must notify DVLA/DVANI of their condition. According to DVLA and GMC, it is medical professionals’ responsibility to advise patient to do so. Measures Process: Staff and patient education, use of checklist, information leaflet. Outcome: % of patients per month informed by medical team to notify DVANI of their diagnosis of ADHD Results: Cycle 1 (baseline): 33.3% of patients were advised by medical staff to notify DVANI Cycle 2 (staff educated):56% of patients were advised Cycle 3 (Update existing ADHD checklist to include driving): 75% of patients were advised Cycle 4 (Educate admin staff and update existing checklist): 100% of patients were advised Cycle 5 Questionnaire given to patients and aim to co-produce driving advice leaflet following focus group Conclusion: It is the legal duty of ADHD patients to notify DVANI of diagnosis however it is the responsibility of medical professionals to advise patients to do so. 100% of patients were informed by medical staff to notify DVANI by education and updating the physical health ADHD checklist., Introduction: Angiosarcoma of the breast and anterior chest wall are extremely rare malignant endothelial cell neoplasms that develop either spontaneously or secondary to radiotherapy treatments. To date lack of published data is limiting best practice guidelines. Aims: To describe incidence, management and outcome of breast angiosarcomas within Northern Ireland as part of the national Breast Angiosarcoma Surveillance Study (BRASS). Methods: An electronic chart review of Northern Ireland patients with histologically confirmed breast angiosarcomas between 01/01/2000 and 31/12/2015. Results: Nine cases (all female) were identified with mean age of 57 at diagnosis. Primary angiosarcomas occurred only with younger patients. 77.8% were secondary angiosarcomas (mean time ∼ six years from receiving radiotherapy to diagnosis). None was discussed by the sarcoma multidisciplinary team (MDT). Seven of the nine patients received surgery (five with curative intent). Chemotherapy was offered to those with non-resectable disease and adjuvant radiotherapy followed inadequate margin of resection. Local recurrence was high with poor survival (shortest three months). Patients with > five year survival had no local recurrence. Discussion: Owing to small sample size, a collaborative approach is required to produce valuable data that shapes future studies and practice guidelines. These cases should all be discussed at sarcoma MDT meeting., Introduction: As volunteer doctors in Kiwoko Hospital Uganda we demonstrated a lack of uniformity in antibiotic prescription amongst healthcare professionals for the same diagnoses through clinical audit. The WHO is very clear regarding prudent antibiotic prescription by healthcare professionals and its role in reducing the problem of antimicrobial resistance. Aims: Improving patient safety by ensuring the most appropriate antibiotic is chosen for a given illness. Methods: Based on Uganda Clinical Guidelines 2016 and medications available locally, an accessible antibiotic protocol was devised, printed and placed on four of the wards with education for medical staff. The same exclusion criteria were used as the initial audit and same parameters were measured following introduction of the protocol. In total 228 cases were used. Results and Discussion: An improvement was demonstrated in uniformity of antibiotic prescription with the ‘correct’ choice rising from 17% to 41% following introduction of protocol. The hospital management has introduced the protocol to a number of different clinical areas as a result of the QIP. Anti-microbial resistance is everyone’s responsibility and this intervention resulted in improvement in suitable empirical choice of antibiotic in a low resource setting., Introduction: Challenge: Mental Health Bed Crisis, Bed Occupancy >110%, Reliance on out of Trust beds Safety issues, Difficulties engaging carers, Cost Aims: Decrease bed occupancy to 85% Decrease length of stay by 30% Increase service user/staff satisfaction Methods: Solution: Purposeful Inpatient Admission (PIpA) Based on the Toyota Production System Model Used in healthcare in the Virginia Mason Medical Centre Key features: Patient’s experience central Replaces batched decision making with continuous flow Standardised processes for each step Continuous monitoring of changes/outcomes Formulation and purposeful treatment plan within 72 hours of admission Patient’s journey mapped out on a Visual Control Board Daily report out instead of weekly ward round Daily tasks board Delays immediately identified and escalated Results: ‘Green’ bed status (>5 available beds) for 24 consecutive days 85% Bed occupancy (Royal College of Psychiatrists’ recommendation) >30% reduction in length of stay Reduction in violent incidents No complaints during pilot Increased staff satisfaction Discussion: Conclusion/Next steps Aims met (bed occupancy/length of stay/satisfaction) Sustain improvements in bed occupancy and length of stay Implementation to remaining general adult acute wards.

Nine hundred million people are infected with the soil-transmitted helminths Ascaris lumbricoides (roundworm), hookworm, and Trichuris trichiura (whipworm). However, low single-dose cure rates of the benzimidazole drugs, the mainstay of preventative chemotherapy for whipworm, together with parasite drug resistance, mean that current approaches may not be able to eliminate morbidity from Trichuriasis. We are seeking to develop new anthelmintic drugs specifically with activity against whipworm as a priority, and previously identified a hit series of dihydrobenzoxazepinone (DHB) compounds that block motility of ex vivo Trichuris muris. Here we report a systematic investigation of the structure-activity relationship of the anthelmintic activity of DHB compounds. We synthesised 47 analogues, which allowed us to define features of the molecules essential for anthelmintic action, as well as broadening the chemotype by identification of dihydrobenzoquinolinones (DBQ) with anthelmintic activity. We investigated the activity of these compounds against other parasitic nematodes, identifying DHB compounds with activity against Brugia malayi and Heligmosomoides polygyrus. We also demonstrated activity of DHB compounds against the trematode Schistosoma mansoni, a parasite that causes schistosomiasis. These results demonstrate the potential of DHB and DBQ compounds for further development as broad-spectrum anthelmintics.Author summaryAround a billion people are infected by the soil transmitted helminths Ascaris, hookworm and whipworm. In the case of whipworm, the benzimidazole drugs, which are distributed to school children in affected areas, have low cure rates. This means that finding an improved treatment for whipworm is a priority. We previously identified five DHB compounds in a screen for new compounds active against whipworm. Here we systematically dissect these molecules, making 47 modified versions of the compounds. This allowed us to define the features of these compounds that are important for activity against whipworm. We also demonstrate activity of DHB compounds against other parasitic nematodes, and against Schistosoma mansoni, a trematode parasite. These results show the potential for further development of DHB compounds as broad-spectrum anthelmintics.

Coronavirus disease 2019 (COVID-19) is caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and can affect multiple organs, among which is the circulatory system. Inflammation and mortality risk markers were previously detected in COVID-19 plasma and red blood cells (RBCs) metabolic and proteomic profiles. Additionally, biophysical properties, such as deformability, were found to be changed during the infection. Based on such data, we aim to better characterize RBC functions in COVID-19. We evaluate the flow properties of RBCs in severe COVID-19 patients admitted to the intensive care unit by usingin vitromicrofluidic techniques and automated methods, including artificial neural networks, for an unbiased RBC analysis. We find strong flow and RBC shape impairment in COVID-19 samples and demonstrate that such changes are reversible upon suspension of COVID-19 RBCs in healthy plasma. Vice versa, healthy RBCs immediately resemble COVID-19 RBCs when suspended in COVID-19 plasma. Proteomics and metabolomics analyses allow us to detect the effect of plasma exchanges on both plasma and RBCs and demonstrate a new role of RBCs in maintaining plasma equilibria at the expense of their flow properties. Our findings provide a framework for further investigations of clinical relevance for therapies against COVID-19 and possibly other infectious diseases.

[Image: see text] Utrophin modulation is a disease-modifying therapeutic strategy for Duchenne muscular dystrophy that would be applicable to all patient populations. To improve the suboptimal profile of ezutromid, the first-in-class clinical candidate, a second generation of utrophin modulators bearing a phosphinate ester moiety was developed. This modification significantly improved the physicochemical and ADME properties, but one of the main lead molecules was found to have dose-limiting hepatotoxicity. In this work we describe how less lipophilic analogues retained utrophin modulatory activity in a reporter gene assay, upregulated utrophin protein in dystrophic mouse muscle cells, but also had improved physicochemical and ADME properties. Notably, ClogP was found to directly correlate with pIC(50) in HepG2 cells, hence leading to a potentially safer toxicological profiles in this series. Compound 21 showed a balanced profile (H2K EC(50): 4.17 μM, solubility: 477 μM, mouse hepatocyte T(1/2) > 240 min) and increased utrophin protein 1.6-fold in a Western blot assay.

Utrophin modulation is a promising therapeutic strategy for Duchenne muscular dystrophy (DMD), which should be applicable to all patient populations. Following on from ezutromid, the first-generation utrophin modulator, we describe the development of a second generation of utrophin modulators, based on the bioisosteric replacement of the sulfone group with a phosphinate ester and substitution of the metabolically labile naphthalene with a haloaryl substituent. The improved physicochemical and absorption, distribution, metabolism, and excretion (ADME) properties, further reflected in the enhanced pharmacokinetic profile of the most advanced compounds, 30 and 27, led to significantly better in vivo exposure compared to ezutromid and alleviation of the dystrophic phenotype in mdx mice. While 30 was found to have dose-limiting hepatotoxicity, 27 and its enantiomers exhibited limited off-target effects, resulting in a safe profile and highlighting their potential utility as next-generation utrophin modulators suitable for progression toward a future DMD therapy.

Helminths, including cestodes, nematodes and trematodes, are a huge global health burden, infecting hundreds of millions of people. In many cases, existing drugs such as benzimidazoles, diethylcarbamazine, ivermectin and praziquantel are insufficiently efficacious, contraindicated in some populations, or at risk of the development of resistance, thereby impeding progress towards World Health Organization goals to control or eliminate these neglected tropical diseases. However, there has been limited recent progress in developing new drugs for these diseases due to lack of commercial attractiveness, leading to the introduction of novel, more efficient models for drug innovation that attempt to reduce the cost of research and development. Open science aims to achieve this by encouraging collaboration and the sharing of data and resources between organisations. In this review we discuss how open science has been applied to anthelmintic drug discovery. Open resources, including genomic information from many parasites, are enabling the identification of targets for new antiparasitic agents. Phenotypic screening remains important, and there has been much progress in open-source systems for compound screening with parasites, including motility assays but also high content assays with more detailed investigation of helminth physiology. Distributed open science compound screening programs, such as the Medicines for Malaria Venture Pathogen Box, have been successful at facilitating screening in diverse assays against many different parasite pathogens and models. Of the compounds identified so far in these screens, tolfenpyrad, a repurposed insecticide, shows significant promise and there has been much progress in creating more potent and selective derivatives. This work exemplifies how open science approaches can catalyse drug discovery against neglected diseases.

Reduced order models (ROMs) that capture flow dynamics are of interest for decreasing computational costs for simulation as well as for model-based control approaches. This work presents a data-driven framework for minimal-dimensional models that effectively capture the dynamics and properties of the flow. We apply this to Kolmogorov flow in a regime consisting of chaotic and intermittent behavior, which is common in many flows processes and is challenging to model. The trajectory of the flow travels near relative periodic orbits (RPOs), interspersed with sporadic bursting events corresponding to excursions between the regions containing the RPOs. The first step in development of the models is use of an undercomplete autoencoder to map from the full state data down to a latent space of dramatically lower dimension. Then models of the discrete-time evolution of the dynamics in the latent space are developed. By analyzing the model performance as a function of latent space dimension we can estimate the minimum number of dimensions required to capture the system dynamics. To further reduce the dimension of the dynamical model, we factor out a phase variable in the direction of translational invariance for the flow, leading to separate evolution equations for the pattern and phase dynamics. At a model dimension of five for the pattern dynamics, as opposed to the full state dimension of 1024 (i.e. a 32x32 grid), accurate predictions are found for individual trajectories out to about two Lyapunov times, as well as for long-time statistics. The nearly heteroclinic connections between the different RPOs, including the quiescent and bursting time scales, are well captured. We also capture key features of the phase dynamics. Finally, we use the low-dimensional representation to predict future bursting events, finding good success.

Acute myeloid leukemia (AML) is the most aggressive type of blood cancer, and there is a continued need for new treatments that are well tolerated and improve long-term survival rates in patients. Induction of differentiation has emerged as a promising alternative to conventional cytotoxic chemotherapy, but known agents lack efficacy in genetically distinct patient populations. Previously, we established a phenotypic screen to identify small molecules that could stimulate differentiation in a range of AML cell lines. Utilising this strategy, a 1,5-dihydrobenzo[e][1,4]oxazepin-2(3H)-one hit compound was identified. Herein, we report the hit validation in vitro, structure-activity relationship (SAR) studies and the pharmacokinetic profiles for selected compounds.

Acute Myeloid Leukaemia (AML) continues to have a poor prognosis, especially in the elderly. One reason for this is that many treatment regimens are not well tolerated by elderly patients. Much current focus is on the development of therapies that can target specific vulnerabilities of AML while having fewer toxic side effects. However, despite much recent progress in developing better drugs, many patients with AML still die within a year of diagnosis, partly due to the fact that it is difficult to identify therapeutic targets that are effective across multiple AML subtypes. One common factor across AML subtypes is the presence of a block in differentiation. Thus screening for compounds that can overcome this block in genetically diverse AML models should allow for the identification of agents that are not dependent on a specific mutation for their efficacy. Here, we used a phenotypic screen to identify novel compounds that stimulate differentiation in several AML cell lines. Lead compounds were shown to decrease tumour burden and to increase survival in vivo. Using multiple complementary target deconvolution approaches, these compounds were revealed to be anti-mitotic tubulin disruptors that cause differentiation by inducing a G2-M mitotic arrest. Together, these results reveal a novel function for tubulin disruptors in causing differentiation of AML cells.

Polymer electrolytes are promising candidates for the next generation lithium-ion battery technology. Large scale screening of polymer electrolytes is hindered by the significant cost of molecular dynamics (MD) simulation in amorphous systems: the amorphous structure of polymers requires multiple, repeated sampling to reduce noise and the slow relaxation requires long simulation time for convergence. Here, we accelerate the screening with a multi-task graph neural network that learns from a large amount of noisy, unconverged, short MD data and a small number of converged, long MD data. We achieve accurate predictions of 4 different converged properties and screen a space of 6247 polymers that is orders of magnitude larger than previous computational studies. Further, we extract several design principles for polymer electrolytes and provide an open dataset for the community. Our approach could be applicable to a broad class of material discovery problems that involve the simulation of complex, amorphous materials., 29 pages, 6 figures + supplementary information

Induction of differentiation is a promising therapeutic strategy against acute myeloid leukemia. However, current differentiation therapies are effective only to specific patient populations. To identify novel differentiation agents with wider efficacy, we developed a phenotypic high-throughput screen with a range of genetically diverse cell lines. From the resulting hits, one chemical scaffold was optimised in terms of activity and physicochemical properties to yield OXS007417, which was also able to decrease tumour volume in a murine in vivo xenograft model.

Duchenne muscular dystrophy is a fatal disease with no cure, caused by lack of the cytoskeletal protein dystrophin. Upregulation of utrophin, a dystrophin paralogue, offers a potential therapy independent of mutation type. The failure of first-in-class utrophin modulator ezutromid/SMT C1100 in Phase II clinical trials necessitates development of compounds with better efficacy, physicochemical and ADME properties and/or complementary mechanisms. We have discovered and performed a preliminary optimisation of a novel class of utrophin modulators using an improved phenotypic screen, where reporter expression is derived from the full genomic context of the utrophin promoter. We further demonstrate through target deconvolution studies, including expression analysis and chemical proteomics, that this compound series operates via a novel mechanism of action, distinct from that of ezutromid.

Genetic approaches for the diagnosis and treatment of inherited muscle diseases have advanced rapidly in recent years. Many of the advances have occurred in the treatment of Duchenne muscular dystrophy (DMD), a muscle wasting disease where affected boys are typically wheelchair bound by age 12 years and generally die in their twenties from respiratory failure or cardiomyopathy. Dystrophin is a 421 kD protein which links F-actin to the extracellular matrix via the dystrophin-associated protein complex (DAPC) at the muscle membrane. In the absence of dystrophin, the DAPC is lost, making the muscle membrane more susceptible to contraction-induced injury. The identification of the gene causing DMD in 1986 resulted in improved diagnosis of the disease and the identification of hotspots for mutation. There is currently no effective treatment. However, there are several promising genetic therapeutic approaches at the preclinical stage or in clinical trials including read-through of stop codons, exon skipping, delivery of dystrophin minigenes and the modulation of expression of the dystrophin related protein, utrophin. In spite of significant progress, the problem of targeting all muscles, including diaphragm and heart at sufficiently high levels, remains a challenge. Any therapy also needs to consider the immune response and some treatments are mutation specific and therefore limited to a subgroup of patients. This short review provides a summary of the current status of DMD therapy with a particular focus on those genetic strategies that have been taken to the clinic.

Duchenne muscular dystrophy (DMD) is a fatal muscle‐wasting disease arising from mutations in the dystrophin gene. Upregulation of utrophin to compensate for the missing dystrophin offers a potential therapy independent of patient genotype. The first‐in‐class utrophin modulator ezutromid/SMT C1100 was developed from a phenotypic screen through to a Phase 2 clinical trial. Promising efficacy and evidence of target engagement was observed in DMD patients after 24 weeks of treatment, however trial endpoints were not met after 48 weeks. The objective of this study was to understand the mechanism of action of ezutromid which could explain the lack of sustained efficacy and help development of new generations of utrophin modulators. Using chemical proteomics and phenotypic profiling we show that the aryl hydrocarbon receptor (AhR) is a target of ezutromid. Several lines of evidence demonstrate that ezutromid binds AhR with an apparent KD of 50 nm and behaves as an AhR antagonist. Furthermore, other reported AhR antagonists also upregulate utrophin, showing that this pathway, which is currently being explored in other clinical applications including oncology and rheumatoid arthritis, could also be exploited in future DMD therapies., Chemical proteomics and phenotypic profiling illustrate the aryl hydrocarbon receptor (AhR) is a target of ezutromid, the first‐in‐class utrophin modulator for the treatment of Duchenne muscular dystrophy. Ezutromid binds to AhR with an apparent K D of 50 nm and functions as an AhR antagonist. Other reported AhR antagonists also upregulate utrophin, showing that this pathway, which is currently being explored in other clinical applications, could also be exploited in future DMD therapies.

The unsteady forces acting on a body depend strongly on the local flow structures such as vortices. A quantitative understanding of the contribution of these structures to the instantaneous overall force is of fundamental significance. In the present study, a threedimensional (3-D) vortex force map (VFM) method, extended from a two-dimensional (2D) one, is used to provide better insight into the complex 3-D flow dynamics. The VFM vectors are obtained from solutions of potential equations and used to build the 3-D VFMs where the critical regions and directions associated with significant positive or negative contributions to the forces are identified. Using the existing velocity/vorticity field near the body, these VFMs can be used to obtain the body forces. A decomposed form of the force formula is also derived to separate the correction term contributed from the uncaptured vortices (close to or far away from the body). The present method is applied to the starting flow of a delta wing at high angle of attack, where leading edge vortices are enhanced and stabilized by an axial flow effect. The analogy between the normal force of a slender delta wing and that of a two dimensional flat plate with a steadily growing span is demonstrated via the VFM analysis. We find, for this application, that the force evolution exhibits some similar behavior to a two dimensional airfoil starting flow and, surprisingly, the force contribution mainly comes from the conical vortex sheet rather than the center core. Moreover, a quantitative understanding of the influence of leading edge vortices (LEVs) in different evolution regimes on the body force is demonstrated.

Using Brofenbrenner’s socio-ecological model as a conceptual framework, the objective of this study was to determine playground users (primary school staff and pupils) perceptions of the barriers and facilitators to a physically active school playground at an intra-personal (individual), inter-personal (social), environmental and policy level. Results from a series of qualitative interactions with children (n = 65) from years five and six (9 to 11 years old), and structured interviews with adult teachers (n = 11) revealed key differences in the child and adult perceptions of the playground and the purpose of break-times. A number of inter-related environmental boundaries and school policies were identified as restrictive to children’s explorations and activity levels during ‘free play’ periods, which centred on resource availability, accessibility and health and safety. Further, traditional playground hierarchies act to promote and prevent physical activity engagement for different groups (e.g. gender and age). Finally, differences between the adult and child perception of the primary school playground were observed. Playground physical activity, during break-times appears to be affected by a number of variables at each level of the socio-ecological model. This study provides an opportunity for primary schools to reflect on primary school playground strategies and practices that are implemented at each level of the socio-ecological model to encourage a more effective use of the playground during school break-times.

Structural misassignments are often seen for complex natural products, but this can also be an issue with seemingly simpler structures. In this paper, we describe how, using a 15N-labelled analogue, we established that the Dimroth rearrangement can occur in imidazo[1,2-a]pyrimidines and result in an incorrect regiochemical assignment of such compounds. These studies supported a rearrangement mechanism involving addition of hydroxide ion followed by ring opening. It was also observed that C(2) and C(3) substituted regioisomers could be readily distinguished using 1H NMR spectroscopy.

Firefly luciferase (FLuc) is a powerful tool for molecular and cellular biology, and popular in high-throughput screening and drug discovery. However, FLuc assays have been plagued with positive and negative artefacts due to stabilisation and inhibition by small molecules from a range of chemical classes. Here we disclose Phase II clinical compound SMT C1100 for the treatment of Duchenne muscular dystrophy as an FLuc inhibitor (KD of 0.40 ± 0.15 µM). Enzyme kinetic studies using SMT C1100 and other non-competitive inhibitors including resveratrol and NFκBAI4 identified previously undescribed modes of inhibition with respect to FLuc’s luciferyl adenylate intermediate. Employing a photoaffinity strategy to identify SMT C1100′s binding site, a photolabelled SMT C1100 probe instead underwent FLuc-dependent photooxidation. Our findings support novel binding sites on FLuc for non-competitive inhibitors.

5-(Ethylsulfonyl)-2-(naphthalen-2-yl)benzo[d]oxazole (ezutromid, 1) is a first-in-class utrophin modulator that has been evaluated in a phase 2 clinical study for the treatment of Duchenne muscular dystrophy (DMD). Ezutromid was found to undergo hepatic oxidation of its 2-naphthyl substituent to produce two regioisomeric 1,2-dihydronaphthalene-1,2-diols, DHD1 and DHD3, as the major metabolites after oral administration in humans and rodents. In many patients, plasma levels of the DHD metabolites were found to exceed those of ezutromid. Herein, we describe the structural elucidation of the main metabolites of ezutromid, the regio- and relative stereochemical assignments of DHD1 and DHD3, their de novo chemical synthesis, and their production in systems in vitro. We further elucidate the likely metabolic pathway and CYP isoforms responsible for DHD1 and DHD3 production and characterize their physicochemical, ADME, and pharmacological properties and their preliminary toxicological profiles.

The rise of antibiotic resistant bacterial species is an international problem. The structure, function and dynamic behaviour of the bacterial cell envelope must be thoroughly understood in order to design novel antimicrobial molecules. This thesis presents the use of molecular dynamics techniques to investigate the function of the Gram-negative outer membrane enzyme LpxR, as well as the subsequent effect of the protein on the dynamics of the outer membrane. LpxR covalently modifies a constituent of the outer membrane, lipopolysaccharide, which can modulate the immune response of the host. Simulations enabled the identification of a putative closed conformation for the protein, as well as a secondary ion binding site. These observations led to the proposition of an evaluated catalytic mechanism for the membrane enzyme.The effect of lipopolysaccharide deacylation on wider membrane properties and dynamics was also investigated. Deacylated lipopolysaccharide induced positive curvature on the membrane when in distinct patches; cardiolipin phospholipids also clustered in areas of the inner leaflet corresponding with the patches of deacylated lipopolysaccharide in the outer leaflet. The application of an electric field to these modified membranes identified structural weaknesses at the interface between deacylated and wildtype lipopolysaccharide. Electroporation of the outer membrane model with OmpA embedded was also performed, and these simulations indicated that the presence of integral proteins may cause localised weakness in the membrane. Finally, the interactions between polymyxin B1, an antimicrobial peptide, and the outer membrane were examined, to gain a further understanding of how the molecule infiltrates the Gram-negative cell envelope. The peptides were observed to permeate through both the outer and inner membrane models, resulting in phospholipid flipflopping, thereby degrading the lipid asymmetry of the outer membrane. Data presented here provide the basis for an updated self-promoted uptake mechanism of cellular infiltration for polymyxin B1.

GPR84 is an orphan G protein-coupled receptor which is expressed on immune cells and implicated in several inflammatory diseases. The validation of GPR84 as a therapeutic target is hindered by the narrow range of available chemical tools and consequent poor understanding of GPR84 pathophysiology. Here we describe the discovery and characterisation of DL-175, a potent, selective, and structurally novel GPR84 agonist and the first to display significantly biased signalling across GPR84-overexpressing cells, primary murine macrophages, and human U937 cells. By comparing DL-175 with reported GPR84 ligands, we show for the first time that biased GPR84 agonists have markedly different abilities to induce chemotaxis in human myeloid cells, while causing similar levels of phagocytosis enhancement. This work demonstrates that biased agonism at GPR84 enables the selective activation of functional responses in immune cells and delivers a high-quality chemical probe for further investigation.

Crop management practices, such as soil tillage and crop residue management, are land management activities with potentially large impacts on carbon (C) cycling and climate at the global scale. Improvements in crop management practices, such as conservation tillage or 'no-till' (NT), have been proposed as climate change mitigation measures because such practices may alter C cycles through increased sequestration of soil C in agricultural soils. Despite their potential importance, regional to global scale data are lacking for many crop management practices, and few studies have evaluated the potential impact of the full range of crop management practices on C cycling and climate at the global scale. However, monitoring of crop management practices is crucial for assessing spatial variations in management intensity and informing policy decisions. Inclusion of crop management practices in Earth system models used for assessing global climate is a key requirement for evaluating the overall effects of different crop management practices on C cycling and their potential to mitigate climate change. Studies in this dissertation seek to address these issues by: (1) evaluating the efficacy of remote sensing methods for monitoring differences in soil tillage and crop residue management practices in Iowa; (2) incorporating soil tillage practices into an Earth system model and assessing the potential for soil C sequestration and climate change mitigation through adoption of NT practices; (3) assessing the historical impact of including the full range of crop management practices (residue harvest, grain harvest, soil tillage, irrigation, and fertilization) on changes in C cycling associated with land use and land cover change (LULCC) to crops in an Earth system model. The remote sensing study found that performance of the minimum Normalized Difference Tillage Index (minNDTI) method for assessing differences in tillage and residue management was below average compared to previous studies, even when using imagery from both Landsat 8 and Sentinel-2A sensors. Accurate assessment of these practices using minNDTI was hindered by issues with image quality and inability to obtain sufficient cloud-free, time series imagery during the critical planting window. Remote sensing research aimed at obtaining regional to global scale data on tillage and residue management practices is likely to continue to face these issues in the future, but further research should incorporate additional sensors and assess the efficacy of the minNDTI method for multiple locations and years. Adoption of NT practices in the Community Land Model, which is the land component of the Community Earth System Model, resulted in a cumulative soil C sequestration of 6.6 – 14.4 Pg C from 2015 – 2100 under a future climate change scenario (Representative Concentration Pathway 8.5), and cumulative soil C sequestration was equal to approximately one year of present-day fossil fuel emissions. Adjusting for areas where NT is already practiced had minor impacts on cumulative soil C storage, reducing gains in soil C from NT adoption by 0.4 – 0.9 Pg C globally. These results indicate that soil C sequestration and potential for climate change mitigation through NT may be more limited than has been anticipated elsewhere. Soil C sequestration via NT adoption was highest in temperate regions of developed countries with high initial soil C contents, indicating these areas should be targeted for NT adoption. Simulating the full range of crop management practices in the Community Land Model resulted in an increase in C emissions due to LULCC of 29 – 38 Pg C compared to scenarios with generic crops and model defaults. Individual crop management practices with the largest impact on LULCC emissions were crop residue harvest (18 Pg C), followed by grain harvest (9 Pg C) and soil tillage (5 Pg C). Although implementation of crop residue harvest and soil tillage was extreme in this study, these results imply that Earth system models may underestimate emissions from LULCC by excluding the full range of crop management practices. Studies in this dissertation corroborate the importance of crop management practices for C cycling and climate, but further research on these management practices is needed in terms of data collection, improving process-level understanding, and inclusion of these practices in Earth system models. Doctor of Philosophy

Purpose: The purpose of this work was to develop, validate, and compare a highly computer-aided method for the segmentation of hot lesions in head and neck 18F-FDG PET scans. Methods: A semiautomated segmentation method was developed, which transforms the segmentation problem into a graph-based optimization problem. For this purpose, a graph structure around a user-provided approximate lesion centerpoint is constructed and a suitable cost function is derived based on local image statistics. To handle frequently occurring situations that are ambiguous (e.g., lesions adjacent to each other versus lesion with inhomogeneous uptake), several segmentation modes are introduced that adapt the behavior of the base algorithm accordingly. In addition, the authors present approaches for the efficient interactive local and global refinement of initial segmentations that are based on the “just-enough-interaction” principle. For method validation, 60 PET/CT scans from 59 different subjects with 230 head and neck lesions were utilized. All patients had squamous cell carcinoma of the head and neck. A detailed comparison with the current clinically relevant standard manual segmentation approach was performed based on 2760 segmentations produced by three experts. Results: Segmentation accuracy measured by the Dice coefficient of the proposed semiautomated and standard manual segmentation approach was 0.766 and 0.764, respectively. This difference was not statistically significant (p = 0.2145). However, the intra- and interoperator standard deviations were significantly lower for the semiautomated method. In addition, the proposed method was found to be significantly faster and resulted in significantly higher intra- and interoperator segmentation agreement when compared to the manual segmentation approach. Conclusions: Lack of consistency in tumor definition is a critical barrier for radiation treatment targeting as well as for response assessment in clinical trials and in clinical oncology decision-making. The properties of the authors approach make it well suited for applications in image-guided radiation oncology, response assessment, or treatment outcome prediction.

We have previously reported the discovery of a series of rhodanine-based inhibitors of the PIM family of serine/threonine kinases. Here we described the optimisation of those compounds to improve their physicochemical and ADME properties as well as reducing their off-targets activities against other kinases. Through molecular modeling and systematic structure activity relationship (SAR) studies, advanced molecules with high inhibitory potency, reduced off-target activity and minimal efflux were identified as new pan-PIM inhibitors. One example of an early lead, OX01401, was found to inhibit PIMs with nanomolar potency (15 nM for PIM1), inhibit proliferation of two PIM-expressing leukaemic cancer cell lines, MV4-11 and K562, and to reduce intracellular phosphorylation of a PIM substrate in a concentration dependent manner.

With the discovery of appreciable room temperature magnetoresistance (MR) in high Curie temperature (Tc) ferrimagnetic double perovskites such as Sr2FeMoO6, research surrounding other materials of this type has expanded. Most ferrimagnetic double perovskites of the formula A2BB′O6 have non-magnetic A-site cations, such as Sr2+, Ca2+ or Ba2+. Replacing non-magnetic cations with magnetic variants offers further possibilities to tune magnetic effects. This thesis focuses on the substitution of non-magnetic A-site cations with relatively small magnetic Mn2+ cations. This substitution is made possible through the use of high-pressure/temperature (P/T) synthesis, and the characterisation of structural and magnetic properties of new phases discovered through these syntheses. The first of these new phases to be reported herein is Mn2FeReO6, which can be described as the Mn analogue of the well-known ferrimagnetic double perovskite Ca2FeReO6. These materials are well ordered with Fe3+/Re5+ on B-sites and crystallise in a P21/n structure. Mn2FeReO6 shows a high Tc of 520 K due to ferrimagnetic Fe/Re magnetic order above RT, and a large saturated magnetisation of 5.0 μB, which peaks at 75 K. Interestingly, the A-site Mn2+ (3d5) magnetic order has the effect of causing a spin reorientation of the Fe/Re sublattice observed by neutron powder diffraction (NPD) at temperatures below ~75 K. This causes the MR to exhibit the expected negative intergrain tunnelling behaviour above the transition and colossal positive behaviour below. Also reported are a series of perovskite related structures with formulae CaxMn2- xFeReO6 (x = 0.5, 1.0, 1.5). Of particular note among these is CaMnFeReO6, which exhibits 1:1 A-site ordering of Ca/Mn and adopts the P42/n space group. This material belongs to a family of newly discovered ‘double double’ perovskites, in which Ca/Mn order in columns pointing along the c-axis and Mn has alternating tetrahedral and square planar coordination environments. MR in this material remains negative down to 20 K, potentially due to the presence of Ca disrupting magnetic interactions between Mn2+ cations and suppressing the spin transition. Alternating coordination environments in the double double perovskite structure type were exploited in the synthesis of Ca(Mn0.5Cu0.5)FeReO6. This material also crystallises in the P42/n structure and is well ordered on B-sites, as evidenced by X-ray powder diffraction. Neutron diffraction yields, in addition to columnar order, a slight preference for Cu to occupy the square planar sites and for Mn to occupy tetrahedral sites. This doping of square planar sites with Cu has the effect of enhancing magnetic properties compared to CaMnFeReO6, increasing the saturated magnetisation, raising the ferrimagnetic ordering temperature of the B-sites from 500 to 560 K, and also having a profound effect on the observed MR effects, as a switch in the sign of the MR is observed in this material through a magnetic transition. Finally, B-site substitution has been experimented with in the synthesis of CaMnMnReO6. This also possesses the combined A and B-site orders observed in CaMnFeReO6 and an unusual magnetic structure, with perpendicular A and B-site magnetism due to frustration, deviating greatly from the magnetic structures of materials with B-site Fe/Re. In summary, this thesis compiles the synthesis and analysis of a series of new double perovskites, double double perovskites and a new ‘triple double’ five-fold cation ordered structure with a general formula of AA′0.5A′′0.5BB′O6. These materials show that new types of structural ordering can be used to increase the number of degrees of freedom available for tuning the interplay between many different magnetic cations in different coordination environments.

Parasitic nematodes infect hundreds of millions of people and farmed livestock. Further, plant parasitic nematodes result in major crop damage. The pipeline of therapeutic compounds is limited and parasite resistance to the existing anthelmintic compounds is a global threat. We have developed an INVertebrate Automated Phenotyping Platform (INVAPP) for high-throughput, plate-based chemical screening, and an algorithm (Paragon) which allows screening for compounds that have an effect on motility and development of parasitic worms. We have validated its utility by determining the efficacy of a panel of known anthelmintics against model and parasitic nematodes: Caenorhabditis elegans, Haemonchus contortus, Teladorsagia circumcincta, and Trichuris muris. We then applied the system to screen the Pathogen Box chemical library in a blinded fashion and identified compounds already known to have anthelmintic or anti-parasitic activity, including tolfenpyrad, auranofin, and mebendazole; and 14 compounds previously undescribed as anthelmintics, including benzoxaborole and isoxazole chemotypes. This system offers an effective, high-throughput system for the discovery of novel anthelmintics., Graphical abstract Image 1, Highlights • A rapid system for quantifying motility and growth of nematodes is described. • The system was validated by quantifying the activity of known anthelmintics. • The Pathogen Box was screened for molecules blocking C. elegans growth. • Compounds with known anthelmintic/anti-parasitic activity were identified. • Fourteen compounds previously undescribed as anthelmintics were discovered.

Introduction The tuna fisheries in the Western and Central Pacific Ocean (WCPO), encompassed by the Convention Area of the Western and Central Pacific Fisheries Commission (WCP-CA) (fig. 1), are diverse. They range from small-scale, artisanal operations in the coastal waters of Pacific states to large-scale, industrial purse seine, pole-and-line and longline operations in the exclusive economic zones (EEZs) of Pacific states and in international waters (high seas). The main species targeted b...

Fisheries in the Pacific: The Challenges of Governance and Sustainability is a multidisciplinary book, which examines various aspects of coastal and oceanic fisheries in Pacific waters. These interrelated fisheries sectors are critical for regional food security and also represent a reserve of food resources for the rest of the world. The introduction and eight chapters highlight that both these sectors raise major economic and ecological issues while revealing significant social changes, political asymmetries and alliances, geostrategic rationales, developments in legislation, customary dynamics, and conservation challenges. Through complementary approaches and interpretations of both quantitative and qualitative data, this book aims to contribute to a better understanding of the current situation of fisheries in the Pacific. It also responds to the compelling need to establish a constructive and ongoing dialogue on the matter between social scientists and environmental scientists, based in Europe and in the Pacific Islands, and between these experts and the various stakeholders and policy-making institutions involved in the Pacific region.

The research question being asked by this project is which tool is the most effective at dead forensics and which is the most effective at live forensics when working on time-sensitive cases that involve a Microsoft Surface Book? The Microsoft Surface series of products is an example of one of the new products containing a non-removable solid-state storage drive. These laptop computers are becoming very popular and offer something that most other tablets do not, a full size USB port capable of transferring data on and off the device. This port can allow connectivity of many different device and most simultaneously with the help of a hub. This port can finally allow investigators access to the internal storage of the device. Many techniques were attempted in order to recover data, however due to time constraints this project only tested a few open source techniques along with some commercially developed software. This project examined multiple tools, along with the knowledge and resources needed to perform data recovery. It was found that the Microsoft Surface Book has some form of encryption being utilized at all times even if the user has not enabled BitLocker. The only way this project was able to successfully recover data from the computer was by utilizing FTK Imager on a live system while logged into a profile. This new knowledge will help digital investigators to more effectively gather data both on-scene and in a lab environment.