Clinical Posters 400 – 406
400 A clinical audit regarding administration of VTE prophylaxis in patients undergoing all forms of upper limb surgery and reviewing compliance NICE guidelines
Background Venous thromboembolism (VTE) comprises deep vein thrombosis (DVT) and pulmonaryembolism (PE) and causes up to 32,000 deaths annually in the UK. According to NICE guidance, upper limb surgery is a VTE risk factor, and it is therefore paramount that there is adequate assessment of surgical patients to identify those at most risk. This audit aims to review VTE prevention policy in upper limb surgery and analyse the adherence to NICE guidelines.
Methods 40 patients were independently assessed after healthcare staff had conducted their initial VTE assessment. Any errors in risk factor identification were subsequently highlighted, and any prophylaxis presribed was compared to NICE guidance. The WWL VTE risk assessment tool was also audited against NICE guidance.
Results 8 patients had undocumented risk factors, 2 having an undocumented personal VTE history. These 8 patients were therefore incorrectly treated aslower risk patients. This questions whether the assessment tool is being properly used. When a patient was deemed ‘at risk’, the correct chemical prophylaxis was prescribed. The correct mechanical prophylaxis is being used, yet it is not in use for a long enough period of time. The assessment tool did adhere to NICE guidance.
Conclusion To fully adhere to NICE guidance there is a need for further mechanical prophylaxis pre-operatively and post-operatively until there is no longer an increased VTE risk, as well as wider use of chemical prophylaxis. Performing the VTE assessment alongside the patient could reduce the number of undocumented risk factors.
401 The association between the ‘fat mass and obesity associated gene (FTO)’ and eating behaviours in adults and children: a systematic review
FTO has been recognised as one of the principle candidate genes predisposing to common obesity in humans and numerous weight-associated single nucleotide polymorphisms (SNP) of FTO have been identified. However, understanding of the mechanism of action by which FTO contributes to obesity is limited. The objective of this systematic review is to investigate the hypothesis that weight-associated variants of the FTO gene elicit their effect on adiposity by influencing eating behaviour. To achieve this objective, an exhaustive database search was conducted, with 16 studies selected for analysis after relevance screening in line with PRISMA guidelines and rigid inclusion and exclusion criteria.
The effects of five FTO SNPs were assessed across the 16 studies: rs9939609, rs1421085, rs17817449, rs1121980 and rs9939973. All five of the SNPs were significantly associated with increased adiposity in at least one study. The rs9939609 SNP was significantly related to multiple appetitive behaviours with the potential to predispose to obesity, including: increased energy and fat intake, risky eating behaviour, decreased satiety responsiveness and preference for energy-dense foods.
The effects of the rs9939609 variant on appetite were predominately observed in children. The rs1421085, rs17817449, rs1121980 and rs9939973 variants were not linked to eating behaviour in either children or adults. These results provide insight into one possible mechanism by which FTO may contribute to obesity, specifically in children. One practical application of these results could be to encourage close monitoring of dietary intake in risk-allele carriers of the rs9939609 SNP as a method of obesity prevention.
402 The provision of end of life care in primary care: findings of a national survey
Aim – To provide insight into the experience of GPs providing end-of-life care (EOLC) in the community, particularly the facilitators and barriers to good quality care.Content of Presentation – results of a web-based national survey circulated via Royal College of General Practitioners, NHS, Marie Curie and Macmillan networks to GPs.
Relevance – There are increasing numbers of people living with complex life-limiting conditions in the community. Consideration must be given to improving the organisation and delivery of high quality palliative and EOLC. GPs play a pivotal role.
Outcomes – 516 GPs responded, and were widely distributed in terms of practice location. 97% felt that general practice plays a key role in the delivery of care to people approaching the end of life and their families. Four interdependent themes emerged from the data: Continuity of care; which can be difficult to achieve due to resource concerns including time, staff numbers, increasing primary care workload and lack of funding. Effective multi-disciplinary team working and communication were considered essential. Patient and family factors; challenges included early identification of palliative care needs and recognition of the end of life; opportunity for care planning discussions and the provision support for families to avoid crisis situations. Medical management; achieving effective symptom-control and having access to specialist palliative care services. Expertise and training; the need for training and professional development was recognised to enhance knowledge, skills and attitudes towards EOLC.
Discussion – The findings reveal enduring priorities for policy, commissioning, practice development and research in future primary palliative care.
403 Mirabegron vs tolterodine in overactive bladder syndrome
Aims/Objectives: To conduct a systematic review of randomised controlled trials comparing the efficacy of mirabegron against tolterodine in treating overactive bladder syndrome.
Content of presentation: The poster will include the aims, methods, results and discussion of the study along with data extraction tables and A PRISMA flowchart to display the screening method.
Relevance/impact: OAB affects around 1 in 6 women1, with a significant impact on their quality of life. Tolterodine remains one of the most commonly prescribed OAB treatments in primary care. Mirabegron is a relatively new drug of the β3 receptor agonist class that was approved for use in OAB in 2013. Current NICE guidelines advocate use of mirabegron if anti-muscarinics are contraindicated, ineffective or have unacceptable side effects. If mirabegron has a higher efficacy than tolterodine, it justifies the drug being considered at an earlier stage in treatment.
Outcomes: Mirabegron 50 mg has higher efficacy in symptomatic relief of OAB than tolterodine across some but not all outcome measures such as frequency of micturition.
Discussion: Although data was provided, the focus of discussion of the RCTs found seemed to be on the efficacy of mirabegron against placebo rather than against tolterodine. Hence, inferences about data significance had to be made by the reviewer themselves. Stringent exclusion criteria, for example, exclusion of papers written in a foreign language, meant that relevant RCTs may be omitted. Although there is uncertainty about whether it should be first-line, mirabegron should certainly be considered early by GPs in treating OAB.
404 Audit on Blood Glucose Control in Geriatric Patients
Amy Christine Chircop
Aim To assess whether diabetic patients are being monitored as per NICE and American Diabetes Association (ADA) guidelines.
Methodology All diabetic patients at a local rehabilitation hospital were included. Fasting & post-prandial blood glucose levels and HbA1c levels were recorded.
Outcomes 68 patients (27.9% male, mean age 78) were included. 33 (48.53%) patients had an Hba1c in the 6 months prior to data collection. 4 (5.9%) patients never had Hba1c level checked. Mean Hba1c value was 7.7%. Only 19 (29.69%) patients had Hba1c level as recommended. 210 blood glucose readings were analysed. 48 (45.71%) pre-meal readings were within range while 57 (54.29%) readings were outside range. 65 (61.90%) post-prandial readings showed glucose levels
Discussion NICE recommend that HbA1c in diabetics should be tested every 3-6 months, with a target of <6.5% or <7% depending on anti-diabetic medications. ADA recommend pre-meal levels of 4.4-7.2mmol/L and post-prandial blood glucose <10mmol/L. Post-prandial hyperglycaemia is an independent risk factor for both micro and macrovascular complications of diabetes, thus inadequate control could impact patient prognosis.
Relevance/Impact Majority of fasting blood glucose readings were not within recommended targets; two thirds of postprandial levels adhered to guidelines. Over half of the patients did not have an Hba1c level checked in the 6 months prior to data collection; only 30% were in line with recommended guidelines. These results show that there is need for tighter glucose control which can be addressed at a primary health care level.
405 ‘Something in the head or all in the mind?’ Mapping social media posts from patients experiencing uncertainty about the care of their headaches
What uncertainties concern patients with headache, if brain scanning seems not to provide a diagnosis, or if they disagree with proposed treatment plans? Doctors receiving brain scan reports that, apparently, ‘rule out’ structural lesions in patients having headache, may make functional diagnoses such as tension headache or migraine. While acceptable to some, other patients remain uncertain about such diagnoses and associated treatments, especially when they have enduring headache, amounting to a chronic pain syndrome. We aimed to identify and understand patients’ uncertainties about headache care using social media posts.
Multiple patient forums were searched for posts concerning uncertainty in headache care. Patients perspectives were classified using an established approach, being mapped into categories relating to initial diagnosis (Analysing) investigations, referral and imaging (Networking) how individuals experienced care with their GP (Negotiating) how teams influenced care (Team-working).Information will be presented that illuminates themes in patient discourses; issues in the consultation including the doctor/patient interaction, patients’ responses to incidental findings, preferences about appropriate care plans and patients assumptions about the underlying nature of pain.
These results give insight into patients concerns and can help GPs to deploy a wider range of skills needed to provide effective care. Understanding issues of potential importance to patients is likely to generate more cooperative consultations. This is less stressful for doctors and may improve their resilience. Analysing social media posts is a novel approach to understanding the patient’s perspective and offers rich insights into patients’ perceptions of their care.
406 Changing presentations of scarlet fever in general practice
Aims The aim of this research is to highlight changes in consultation rates and demographic characteristics of patients diagnosed with scarlet fever which have occurred in recent years. Concerns have been expressed that the condition might be harder to identify in different ethnic groups.
Relevance GPs and primary care teams should be aware of the rising trend in presentations of scarlet fever in order to provide early detection, treatment and advice, as needed. Assessing consultation patterns according to patient characteristics can help GPs to identify at-risk groups, and to differentiate scarlatina, which should be treated with antibiotics, from viral rashes.
Outcomes In 2014 and 2015, there were a total of 56.70 and 52.90 cases of scarlet fever per 100,000 population, respectively, compared to 22.06 cases in 2012 and 21.95 cases in 2013 (these are clinical diagnoses). The ethnicity distribution for those with a diagnosis was similar to those without, with the exception of a slight overrepresentation of mixed ethnicity among scarlet fever cases (5% vs 2%; p<0.001).
Discussion Assessment of GP data can provide important information on management of scarlet fever, given that changes in the circulating strains have not been identified. Whilst our data are not conclusive, they do not suggest under diagnosis in patients with more darkly pigmented skin in whom the rash may be less apparent. Further assessment of GP data, combined with serological testing, can provide important insights into the impact of the current upsurge in scarlet fever, in particular the incidence of complications.