GW4

The adrenal glands of 30 dogs with primary adrenal insufficiency (hypoadrenocorticism) were measured ultrasonographically and compared with those of 14 healthy dogs and those of 10 dogs with diseases mimicking hypoadrenocorticism. Thickness and length of the adrenals were measured on abdominal ultrasonography and the results for each group were compared. Dogs with primary hypoadrenocorticism had significantly thinner adrenals compared with the other two groups, and their left adrenal glands were also significantly shorter than those of healthy dogs. Adrenal ultrasonography may be of diagnostic value in dogs with clinical signs suggestive of primary hypoadrenocorticism, as a left adrenal gland measuring less than 3.2 mm in thickness is strongly suggestive of the disease.

BACKGROUND: Critical care transfers between hospitals are time critical high-risk episodes for unstable patients who often require urgent lifesaving intervention. This study aimed to establish the scale, nature and safety of current transfer practice in the South West Critical Care Network (SWCCN) in England. METHODS: The SWCCN database contains prospectively collected data in accordance with national guidelines. It was interrogated for all adult (>15 years of age) patients from January 2012 to November 2017. RESULTS: A total of 1124 inter-hospital transfers were recorded, with the majority (935, 83.2%) made for specialist treatment. The transferring team included a doctor in 998 (88.8%) and nurse in 935 (93.7%) transfers. In 204 (18.1%) transfers, delays occurred, with the commonest cause being availability of transport. Critical incidents occurred in 77 (6.9%). CONCLUSIONS: This is the first published data on the transfer activity of a UK adult critical care network. It demonstrates that current ad-hoc provision is not meeting the longstanding expectations of national guidelines in terms of training, clinical experience and timeliness. The authors hope that this study may inform national conversation regarding the development of National Health Service commissioned inter-hospital transfer services for adult patients in England.

OBJECTIVES: This study aimed to characterise tick species responsible for avian tick infestations in the UK, to analyse various risk factors for tick-related syndrome in tick-infested birds and to test samples for the presence of certain tick-transmitted pathogens. METHODS: Ticks, blood, splenic tissue and tick attachment site tissue from birds with attached ticks were requested from veterinarians and wildlife sanctuaries around the UK. Ticks were identified according to standard keys, and samples were analysed via DNA PCR test for Borrelia burgdorferi sensu lato, Babesia species, Bartonella species and Ehrlichia species. RESULTS: Ixodes frontalis was the most commonly identified tick, and an association of adult female I frontalis with tick-related syndrome in birds was demonstrated. Tick infestation was markedly seasonal. I frontalis was found on 32 species of birds. DNA PCR testing was uniformly negative. Of the birds known to have been treated, 75 per cent (nine of 12) survived. CLINICAL SIGNIFICANCE: Tick-related syndrome is a poorly understood syndrome, with sporadic distribution, both geographically and seasonally. This study confirms I frontalis as the most common cause of this syndrome in the UK and identifies some features of the tick life cycle in this country. The benefit of treatment in affected birds is highlighted. Risk factors for tick-related syndrome are examined and preventive strategies discussed.

Immobilisation of the cervical spine is a common procedure following traumatic injury. This is often precautionary as the actual incidence of spinal injury is low. Nonetheless, stabilisation of the head and neck is an important part of pre-hospital care due to the catastrophic damage that may follow if further unrestricted movement occurs in the presence of an unstable spinal injury. Currently available collars are limited by the potential for inadequate immobilisation and complications caused by pressure on the patient's skin, restricted airway access and compression of the jugular vein. Alternative approaches to cervical spine immobilisation are being considered, and the investigation of these new methods requires a standardised approach to the evaluation of neck movement. This review summarises the research methods and scientific technology that have been used to assess and measure cervical range of motion, and which are likely to underpin future research in this field. A systematic search of international literature was conducted to evaluate the methodologies used to assess the extremes of movement that can be achieved in six domains. 34 papers were included in the review. These studies used a range of methodologies, but study quality was generally low. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect the real-life situations in which cervical spine immobilisation occurs. Latterly, new approaches using virtual reality and simulation have been developed. Coupled with modern electromagnetic tracking technology this has considerable potential for effective application in future research. However, use of these technologies in real life settings can be problematic and more research is needed.

Increasing numbers of reports of clinical falcon herpesvirus infection (Falconid herpesvirus-1; FHV-1) have been seen in the UK since 1996. The aim of this epidemiological study was to investigate the seroprevalence of FHV-1 and owl herpesvirus (Strigid herpesvirus-1; StHV-1) infection in the UK, using virus neutralization tests, and to evaluate the prevalence of herpesvirus infection in captive and wild raptor populations. The results, using the English FHV-1 CVL 32/93 isolate, revealed a seroprevalence of 3.97% (10/252). The seroprevalence for StHV-1 was 12.3% (8/65). Analysis of the data by captivity status, age and species revealed that the family Falconidae showed the highest seroprevalence with 6.7% (5/75), while only one of 104 captive Accipitridae was positive for FHV-1 (0.96%). The incidence of FHV-1 neutralizing antibodies in owls was 5.5% (4/73), representing only wild individuals. Eighty-nine serum samples were additionally tested using two other FHV-1 isolates, the German isolate Merlin 1869/92 and the Dutch isolate Peregrine Z100. The seroprevalences of FHV-1 were 28.1% (25/89) and 32.6% (29/89), respectively. All these samples, however, were negative using the CVL 32/92 isolate.

Mistakes made in healthcare settings and the challenges to staff that arise from them can harm service users, consume time and money, and often receive bad publicity. However, by learning from these mistakes and meeting these challenges, practitioners can improve the quality of the care they provide. This article explores what is meant by mistakes and challenges in the context of health care. It suggests that front line managers are best placed to prevent and learn from mistakes, and thereby improve care for patients.

The Community Urgent Response Environment (CURE) concept is a new technology system developed to support the work of Emergency Care Practitioners with portable pods and packs and mobile treatment units. This paper describes a project to transfer research outputs from an academic setting into practice through collaboration between two universities, two manufacturers and the United Kingdom (UK) National Health Service. An iterative prototyping process was used with 12 Emergency Care Practitioners evaluating prototypes in two user trials by carrying out four clinical scenarios in three simulated environments (confined domestic, less confined public space, and vehicle). Data were collected with video recording, field notes and post-trial debriefing interviews and analysed thematically. The final prototypes (pod/pack 1.3 and vehicle 1.6) have potential to support a new way of working in the provision of non-critical, pre-hospital care. The user trials also identified possible efficiencies through the use of CURE by providing support for a wider range of assessment, diagnosis and treatment.

Background: Hyperemesis gravidarum (HG) is a major health burden affecting between 1-2% of all pregnancies. The sequelae of the condition can be fatal. There is current equipoise as to how best to manage the condition; that is inpatient versus outpatient management. Objective: This study investigated the total length of stay for patients diagnosed with HG, comparing those who were managed as inpatients as opposed to those managed in a day case setting. A case control methodology was utilized. Two tertiary referral centres for HG of similar size and demographic were selected. One preferentially used day case management. The other uses inpatient management. Results: In total 61 day, case managed patients and 91 inpatient managed patients were recruited to the study. Adjusting for readmission, total length of stay was 4.08 days for inpatient managed patients compared to 0.39 days for day case managed patients (p=0.0002). Conclusion: Day case managed patients for HG have a significantly shorter length of stay. There is no predictive value in the reviewed serum biomarkers as to the likelihood of re-admission.

Management concern surrounding the supply of goods and services from business to business, and the related attempts to understand the phenomena observed therein, appears to rest upon a broad range of incompatible perspectives, from political science (often limited to considerations of power) to the logistical (akin to manipulation of a great, benign but dynamic jigsaw puzzle). It appears that all perspectives abrade against the difficulties of exchanging information, knowledge and innovation within the relationships between buying and selling organizations and the apparent chronic systemic inefficiency that transactions often represent in this context. This article addresses these concerns, exploring the concept of transparency and the developments necessary for it to be useful in exchanging sensitive information and tacit knowledge in supply relationships. Our central concern is how the understanding of transparency and its commercial importance may change when it is expressed as a manageable element of the relationship between two organizations rather than as a general property of a broader system (e.g. a supply network, industrial sub-sector, geographical cluster) and what utility this differentiation might hold for managers. The conclusion to the article, and the implication for managers, is that transparency might indeed be created and usefully managed within supply relationships but that it would differ fundamentally in meaning from previously posited concepts, with the same name, in different contexts.

<h3>Background</h3> The incidence of malignant pleural effusions (MPE) is increasing and overall prognosis remains poor. In-dwelling pleural catheters (IPCs) relieve symptoms, but increase the risk of pleural infection. We reviewed survival times of cases of pleural infection in patients with IPCs for MPE from 6 UK centres. <h3>Methods</h3> Baseline data were collected for all IPC insertions from 1/1/05 to 31/1/14. Survival times were analysed by underlying tumour. Results were compared with national data, and with data from a cohort of 789 patients with MPE (the LENT cohort). LENT scores were used to calculate individual predicted life expectancy, which was compared with actual survival. <h3>Results</h3> Of 672 IPCs inserted across 6 centres during the study period, 25 patients (3.6%) experienced pleural infection. 19/25 were male,median age 69 (range 35–79). 12/25 had mesothelioma, 8/25 lung cancer, 3/25 breast cancer, 1/25 lymphoma and 1/25 thyroid cancer. 18/25 had a performance status of 0–1, and 19/25 received oncological treatment. Survival with MPE and pleural infection compared favourably with the LENT cohort (see figure 1). Median survival with mesothelioma and pleural infection was 753 days (95% confidence interval 446–1089) compared with 339 days in the LENT cohort (95% CI 267–442) and less than 365 days in nationally reported data. Patients with lung cancer and pleural infection also outlived their LENT counterparts; median survival of 138 days (95% CI 62–479) versus 74 days (95% CI 60–90). Patients with breast cancer had similar survival times (167 vs 192 days). LENT scores were calculated where possible. 9/13 (69%) outlived their predicted life expectancy. 16/25 (64%) developed infection within 90 days of IPC insertion. There was no difference in survival times between patients with early and late infection (p = 0.6). <h3>Discussion</h3> In this series of patients with IPCs, pleural infection was associated with longer survival with mesothelioma and lung cancer, but not breast cancer. Most patients experienced early infection, suggesting this result isn’t simply a result of higher infection rates in patients who survive longer with an IPC <i>in situ</i>. We propose that pleural infection stimulates a local immune response, which acts against tumour. Further studies are planned to investigate this hypothesis further.

The aim of the literature review was to identify and appraise studies that have compared the effectiveness and decision-making of emergency care practitioners with other health professionals. There is no ‘gold standard’ for determining whether the actions of an emergency care practitioner (ECP) results in a patient avoiding attendance at an emergency department (ED) or hospital admission. Consequently, reporting on the cost effectiveness of ECPs is potentially spurious, especially as the cost difference between ED attendance and hospital admission is considerable. Medline and EMBASE databases were searched for publications relevant to the study area. Additional searches were carried out using the online search function offered by the Cochrane Library and the Emergency Medicine Journal. Twenty-nine publications met the inclusion criteria. Nineteen of these papers were considered suitable for background information only. Ten studies were analyzed in further detail and three main themes identified: non-conveyance rates, decision-making and admission avoidance. Studies show that patients assessed by ECPs are less likely to be conveyed to the ED, than when attended by a traditional ambulance response. The Department of Health (DH, 2005) refer to a traditional ambulance service response to a 999 call as sending a double-crewed paramedic ambulance to the patient, provide any necessary life support to stabilize the patient and transport to the ED. The decision-making of ECPs compares favourably with other health professionals when deciding whether a patient can be treated at home, or requires ED attendance or hospital admission. No studies were found that determined whether an ECP is able to accurately decide whether their intervention results in patients avoiding ED attendance or admission. There is a need to evaluate the validity of data collection methods which differentiate between emergency department and admission avoidance as a result of the actions of ECPs.

<h3>Introduction</h3> Chancroid, an ulcerating sexually transmitted infection of the genitals caused by Haemophilus ducreyi, is a rare presentation in the UK. We present a new case identified recently in the South West of England. <h3>Methods</h3> A 26-year-old heterosexual male presented reporting a 2-3 week history of sores to his penis and a swelling in his left groin. A Sierra Leone national, the patient had recently returned to the UK following a six-month stay in the country. He disclosed one regular female sexual partner of 6 months, also from Sierra Leone. Examination of the groin revealed a tender, tense, erythematous mass extending approximately 5-6cm in length, 2cm in width, along the left groin crease. On examination of the penis, three irregularly shaped, wet, and deep-appearing ulcers were present at the coronal sulcus. 7 days later NAAT swabs for H.ducreyi returned a positive result. <h3>Results</h3> The patient returned to clinic for treatment and review following the positive swab. Whilst the ulcers had not changed, the groin buboe had increased in size and discomfort, and had made mobilising difficult. Culture swabs were taken and he was treated with azithromycin 1g PO STAT as per BASHH guidance. At telephone review five days later he reported near complete resolution of symptoms. <h3>Discussion</h3> Although a rare presentation, this case serves to highlight the need to consider a wide differential in patients presenting with genital ulceration not typical of HSV, especially in those whom have recently travelled outside the UK.

:Monitoring anaesthesia in reptiles can be daunting for the RVN, but with increasing numbers of reptiles being seen and treated in practice it is more important than ever for the RVN to understand how to monitor anaesthesia safely in these patients. The usual monitoring tools can be used in reptile anaesthesia, but there are some differences when compared with their use in mammals. Such differences are highlighted here, alongside useful practical information of what to expect during the induction, maintenance and recovery phases of anaesthesia, and how best to monitor an anaesthetised reptile throughout each stage.

<h3></h3> Approximately 89.6% of patients‘ who are going to die in the next 12 months are admitted to hospital at least once. Evidence shows that good communication reduces hospital stays through advance care planning in the last 12 months of life. End of Life and DNAR discussions are part of the F2 curriculum and the development of good communication skills is a central part of clinical training. It is important to note that it is now a legal requirement that doctors involve patients and families in decisions regarding treatment escalation and resuscitation following the Tracey Judgement. A recent audit undertaken at our Trust showed that there is scope for improving the quality of treatment escalation conversations the doctors are having with patients and their families as well as the documentation of these discussions. An initial survey of F2 doctors showed that 92% had previously had TEP discussions with a patient, 77% with a relative and 69% had completed a TEP form. 46% reported not feeling confident having these discussions with main concerns not knowing what to say to initiate the conversation, being unable to answer questions and causing distress to both the patients and their family A SIM course was delivered to improve the communication skills and confidence of F2 doctors allowing them to practice with actors in a safe learning environment. This learning was consolidated by debriefing with consultants in geriatric and palliative medicine. Post course feedback showed all participants enjoyed the course, 90% found it useful for clinical practice and 80% would recommend it to their colleagues. Significantly, all participants feel confident in discussing TEP following the SIM and commented on the detailed feedback. This should lead to an increase in the number of patients who have these documented discussions which we know improves patient care.

Chronic obstructive pulmonary disease (COPD) affects thousands of people across the UK. It accounts for a large amount of hospital admissions, which are often seen by the ambulance service during acute exacerbations. Discussion has surrounded the amount of oxygen this type of patient should be receiving during acute exacerbations. Research to provide evidence–based practice for the use of oxygen in the hospital and pre-hospital environment has been ongoing for several years. In 2009 the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) changed their guidance following the British Thoracic Society's (BTS) release of new guidelines in oxygen use in adult patients, thus determining that oxygen should be delivered in a more precise manner. However in light of current evidence could further changes be made in the delivery of oxygen, by using air–driven nebulisation during the delivery of drugs to patients presenting in the pre-hospital environment with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This would allow patients to receive an appropriate amount of oxygen during their transfer to hospital, giving improved care and treatment of patients at risk of hypercapnic respiratory failure. This article will discuss the changes to practice which have already been identified and recommended and also discuss the potential implications these changes may have on patient care.

Background: Neuroprotection during cardiac and aortic arch surgeries has been a topic of extensive concern. Several protocols were developed in the trial to achieve the best neurological outcome; amongst them is nitric oxide (NO) supplementation through extracorporeal membrane oxygenation (ECMO). While NO was shown to influence the neurological outcome when supplemented during cardiac surgeries, a little is known about the cardiac effects. The current study addresses the molecular effects associated with NO supplementation on the myocardium. Methods: Male Sprague Dawley rats (n=20, 450-550gm) were anesthetized and cooled with cardiopulmonary bypass (CPB) to a core temperature of 19±1 o C and maintained in hypothermic cardiac arrest for 30 minutes. Then, rats were rewarmed to a target temperature of 35 o C for 60 min using CPB without (control group, CPB), or with NO 20 ppm supplementation (experimental group). By the end of experiment, hearts were harvested and analyzed. Results: RNA sequencing analysis showed NO supplementation results in the differential expression of more the genes related to lipid metabolism, oxidative phosphorylation, inflammatory signaling, proteasome formation, autophagy, calcium handling, smooth muscle relaxation, and apoptotic response compared to the control group. RT-PCR confirmed the RNA sequencing analysis. The experimental group showed a six-fold increase in inflammatory markers IL-1 and NF-κβ. The control group showed increased expression of α1 and β1 adrenergic receptors, NO treatment has led to normalization of expression and a three-fold increase in β2 receptors expression compared to shams. NO supplementation induced apoptosis in the myocardium, as indicated by a 50% increase in TUNEL-positive nuclei compared to the control group. Conclusions: NO supplementation during cardiac arrest boosts the inflammatory response in the myocardium and is associated with increased apoptosis.

<h3></h3> CTFFR the SWindon Evaluation of Emerging Technology (CTFFR SWEET) <h3>Aims</h3> To see how adding routine CT Fractional Flow Reserve (CTFFR) to CT Coronary Angiography (CTCA) altered the care pathway of patients with chest pain of recent onset. Setting Rapid Access Chest Pain Clinic (RACPC) in a secondary care hospital in the South West of England supported by a well-established CT programme (since 2006). CTFFR was started in July 2018 as part of the NHS ITP programme, CTFFR was requested routinely for patients with CT scans of sufficient quality with visible stenoses of 30-90% in a major epicardial coronary arteries. The NICE cost model for CTFFR predicts a 50% reduction in subsequent angiography and reduced downstream costs. Measurements Patient journey(s), costs, resource use. <h3>Methods</h3> The RACPC database helped identify 2 consecutive 12 month patient cohorts and their initial testing strategy. Using hospital database searches the care of patients undergoing CTCA as a first test was examined in more detail. Codes of all care were obtained to estimate costs. <h3>Results</h3> The initial testing strategy for each cohort is shown in Table 1. Downstream testing, cath lab procedures and revascularisation by cohort that had CTCA as the first test are shown in table 2. Patients who underwent CTCA as a first test had less steps (cath lab, revascularisation, stress imaging) in care following the introduction of CTFFR (Figure 1). CTFFR helped identify patients likely to receive same day PCI, 51/276 patients had images sent for analysis. 41 were analysed successfully. 17 of these patients were scheduled for angiography. Of these there were 4 false positives. In the remaining 13, 8 underwent same day PCI and 1 was referred for CABG, Revascularisation Rate (RR) 69%. The RR was 66% in the 6/10 patients for whom CTFFR analysis was not possible referred for angiography, 1 same day PCI and 3 CABG. 12 other patients in the post CTFFR cohort were referred for angiography with a revascularisation rate of 42%, 2/4 PCI patients had same day procedures 1 had CABG. In the CTCA only cohort 54% of PCI procedures were same day compared to 84% in the CTFFR group. A rough estimate of costs using CTCA, DSE, CTFFR, Angiography and PCI per patient across the 2 cohorts showed £310 per patient pre and £471 per patient post CTFFR (AHSN cost model). There was no appreciable difference in cath lab admissions in the CTCA first groups before and after the introduction of routine CTFFR, 35/363 (9.6%) vs 36/276 (13%). <h3>Conclusion</h3> This single centre observational study showed in our practice that CTFFR identified patients with significant coronary disease suitable for coronary intervention and streamlined care. The reductions in costs and angiography in the NICE model were not seen. <h3>Conflict of Interest</h3> NIL

Current methods of stabilizing a patient's neck after a suspected spinal injury do not provide adequate safety and comfort for the patient.Standard practice is to immobilize all trauma patients with suspected cervical spinal column injury at the scene of accident, during transport and in the hospital until a spinal injury can be excluded [1]. This practice has been adopted worldwide, and in the UK applies to around 440,000 trauma patients annually, the equivalent figure for the US is around 5 million patients [2]. Immobilization procedures usually involve fitting a disposable semi-rigid cervical collar, known as a neck brace.There are many well-documented complications and problems associated with collars. These include increased intracranial pressure as a result of restriction to the jugular vein [3], skin ulceration [4] and compromise of the airway [5]. Furthermore, studies into how effective collars are at immobilising the cervical spine [6] leads to a questioning of whether their widespread use is justified.Collars and current methods of immobilising a patient's spine have been widely recommended and adopted as best practice, based on a trial carried out in 1983 [7], and there is no real evidence to suggest that the benefits of immobilising patients in conventional collars outweigh the risks and complications mentioned above.The Necksafe project was set up in February 2011 and has brought together designers, engineers and clinicians to investigate problems with existing collars and redesign this critical medical product to improve its safety and functionality.The typical journey of a trauma patient, the situations where collars are worn, problems the collars pose to clinical care and the best way of immobilizing the cervical spine were investigated.An extensive program of user research was carried out involving design ethnography, co-design workshops and interviews with stakeholders. Over a period of several months the team accompanied ambulance ride-outs, shadowed staff in relevant areas of hospitals, in particular the emergency and imaging departments, and spent time mapping typical patient journeys. The aim was to identify the broadest possible range of stakeholder, problem and unmet user needs, leading to the formulation of a design brief.The next stage of the project concerned the definition of the ideal method of immobilizing the cervical spine taking into account the user needs. It was noted that the “gold standard” of cervical immobilization is considered to be the “halo brace”. This device, used for treating patients with unstable cervical fractures, is surgically fixed to the skull and has firm supports linking the “halo” to the torso. Recognizing that this structure owes its effectiveness to extended bracing points, above and below the cervical spine, the team faced the challenge of how to deliver the same level of immobilization in a product that is applied in the field by a paramedic as a temporary means of protecting the neck.A process of experimentation involved hand-making 15 structures for volunteers mainly by using polymer splinting materials. Lessons were learned from each prototype, gradually optimizing the structure, shape and contact surfaces.The next challenge was to accommodate a large range of patients and make the device practical to use. By using a 3D laser scanner to collect geometric data from the rough prototype structures, further design and concept development could take place using CAD (Computer Aided Design) and rapid prototyping. Five iterations of resolved prototypes were reviewed with doctors and paramedics, greatly informing the design direction by confirming functional aspect, identifying potential problems with the design and prioritizing user needs.Once the majority of the user requirements had been fulfilled, a small batch of prototypes was manufactured for clinical evaluations.The test schedule was designed to compare the new brace to the conventional collar most frequently used by UK NHS ambulance services.20 healthy volunteers were measured for range of motion (ROM) in a laboratory setting. Each subject was asked to move as far as possible in each direction without causing injury in both a seated and supine position. ROM was measured during extension, flexion, lateral flexion (right and left) and lateral rotation (right and left). The measurements were done using Xsens® 3D motion tracking sensors.Skin Interface Pressures were also measured for each subject by placing sensor pads between the skin and the primary contact surfaces. These measurements were carried out using a Tekscan® sensor system.Five healthy volunteers were measured for ROM during a mock extrication from a vehicle. Two systems were used to collect data: Xsens® (as before) and CODA, a technology that uses infra-red markers to track position.Venous return was measured on 15 volunteers by a sonographer to determine restriction of blood flow in the neck.Formal design feedback was gathered from 20 paramedics as well as five volunteers with no medical experience.The new design of neck brace comprises two basic sub assemblies: a front portion (the anterior brace) and a rear portion (the posterior brace).The front portion creates a frame around the outside of the patient's face, making contact with the forehead and the upper chest. The height of the front frame adjusts vertically using a simple grip and self-locking mechanism to allow for different size of patients. It also flexes laterally to accommodate different head widths.The rear portion locks onto the front portion and makes contact with the back of the head (occipital bone) and between the shoulder blades.A patent has been filed for unique aspects of the design.Preliminary analysis of data collected from the clinical testing indicates that the new brace offers significant benefits in reducing extension, lateral flexion and lateral rotation.The mean reductions in movement have been measured as 23%, 25% and 42% respectively. The new brace is also 10% more effective at preventing flexion.The new design also offers the following improvements over existing collars:Feedback from volunteers and paramedics has confirmed the above advantages of the new design. Volunteers also highlighted that the new design provides better comfort.After a process of extensive user research and intensive concept development a new cervical immobilization device has been subjected to initial clinical evaluations indicating significant improvements in performance compared with conventional collars.The brace provides a better degree of immobilization, better fit for a broader range of patient sizes, better access for clinical interventions, improved blood flow through the brain and enhanced comfort to patient.Implementation of this design will reduce complications associated with conventional collars.This project highlights the effectiveness of user research and collaboration during the design and development phases as a catalyst for innovation in medical device design.

The 9 th London Trauma Conference (#LTC2015) and London Cardiac Arrest Symposium (#LCAS2015) built on the previous meetings with an emphasis on innovation, research, and enthusiasm for the medical care of major trauma, cardiac and critically ill patients. From the 8-11 th December 2015 delegates from over 20 countries attended The Royal Geographical Society for the four days of the conference. The opening two days of the conference focussed on current issues in major trauma, with air ambulance and pre-hospital critical care on day three, and the London cardiac arrest symposium returning as the fourth and final day. Concurrent breakaway sessions ran alongside the main conference including; trauma haemorrhage research, paediatric trauma, and masterclasses on cardiac ultrasound and resuscitation, thoracotomy, REBOA, and an introduction to ECLS and ECMO. The major trauma programme consisted of two days of lectures, keynote lectures and short 'quickfire' sessions. Professor Tim Coats opened the conference by talking about the role of the highly performing trauma unit in trauma networksoutlining the problems of maintaining high levels of care in systems which increasingly bypass to major trauma centres but bring severely injured irregularly to trauma units. Professor Kjetil Sreide then addressed the topic of iatrogenesis in trauma, giving examples from different points in the patient pathway. The prevention of iatrogenesis is based on acceptance of it's presence and then promoting prevention with a culture of safety, training and focus on the team approach. Dr Matt Thomas finished up by summarising the landscape of research in trauma over the previous year, as well as outlining what can be expected in the year ahead. The following sessions approached key issues in neurotrauma, opened by a seasoned London Trauma Conference speaker Mr Mark Wilson. He spoke on current early neurological imaging, with mobile CT scanning already a reality in mainland Europe and the trialling of near infrared spectroscopy (NIRS) as a potential pre-hospital imaging modality. Professor Geoffrey Raisman followed with a fascinating talk on spinal cord regeneration, outlining how nerve regeneration to replace damaged portions has already been trialled with some success. He related a moving case where olfactory nerve fibres were used to repair spinal cord injury with one of the ultimate medical triumphsmaking a paraplegic patient walk again. Professor Andrew Maas then lectured expertly on why he sees head injury as a silent epidemic with potentially life-changing consequences. Dr Markus Skrifvars closed the session with a sobering presentation on the link between alcohol consumption and the vast number of traumatic brain-injured patients that are intoxicated when they present. Lunch was followed by Professor Karim Brohi, who delivered a talk on the early immune response to trauma and novel potential approaches to ameliorate this genomic storm. Other speakers in the afternoon included Professor Marc Turner delivering his vision for the trauma transfusion pack of 2025, and discussed whether stem cells may in the future become our source of blood for emergency transfusion. Professor Susan Brundage challenged the trauma myths of today, dismissing the Golden Hour as ancient history, with the platinum five minutes more relevant to 21 st century trauma. She concluded that our cultural understanding of context is crucial in understanding why myths occur and therefore how they can be dispelled. Two overseas speakers addressed key issues in major incidents. Professor Jeff Upperman from Los Angeles spoke with passion, knowledge and experience on the challenging topic of paediatric penetrating trauma and the staggering gun violence statistics he faces in the US, with 355 mass shootings in less a year. The complexities of the gun lobby in the US are one of the many difficulties faced, and he emphasized the urgent need for action to reduce the current 3000 deaths in children from firearms injuries. Dr Ishay Ostfeld presented the Israeli approach to mass casualty events. 'Scoop and run' has replaced the concept of 'stay and play' , with triage occurring in hospital rather than in a pre-hospital setting. They aim to have all severely injured patients evacuated within 30 minutes and most receive operative intervention within 90 minutes. The day two morning session heard Dr Conor Deasy speak about trauma team performance, highlighting the advantages that can be gained from 'in situ' simulation and the use of video. Professors Wolfgang Voelckel and Simon Carley spoke about the fascinating complexities of decision-making and clinical judgement in the resus room. The latter encouraged delegates to analyse and utilise their feedback, reflect on case notes and be disciplined in learning about ones thinking processes. Mr Ross Fisher began a paediatric themed series of talks by arguing the case for specialised paediatric trauma units. This was supported by Dr Natalie May who reiterated the challenges faced when treating these patients. An informative summary of how to approach paediatric imaging was provided by Radiologist Dr Caren Landes, who referred to the revised NICE guidelines for the indications for CT head and c-spine imaging. A personal and reflective account by Kirsti Soanes addressed how best to manage the parents of a child during paediatric resuscitation. Dr Jeff Upperman provided a dynamic introduction to the afternoon session on major incidents. He spoke about preparedness, the importance of recovery and resilience, and argued that planning for children tends to be inadequate. The Peter Baskett memorial lecture was given by Professor Pierre Carli who gave an insightful and impressive account of France's response to the recent terrorist attacks in Paris. This was followed by an international panel discussion with representatives from the US, Norway, Israel and France. They highlighted the importance of lessons that can be learnt from the experiences of others, and discussed topics that included triage systems, the proximity of EM personnel to the 'hot zone' and how best to recognise when a system is overwhelmed. Professor Anders Oldner then spoke about the post resuscitation phase of care in trauma patients and the significant challenge posed by post injury sepsis. Mr Jan Jansen provided a surgeon's insight into penetrating and blunt cerebrovascular neck injuries. He advocated the strength of CT angiogram in detecting injuries and the use of selective non-operative management when indicated. The final session

<h3>Aim</h3> To improve NSTEMI care; with a particular focus on the timing of angiography in NSTEMI and same day discharge after angiography and follow on percutaneous coronary intervention (PCI).Setting: Single site non-surgical centre in the NHS, with a national target for 75% of NSTEMI patients to have angiography within 72 hours of admission. <h3>Methods</h3> In August 2020 we invited a change expert to facilitate a session. Stakeholders included: Nurses- ACS/ACU/Cardiology Ward/Cath Lab/Rehab/MINAP audit/Matron; Head of Service; Site managers; Radiographers; Cardiac physiologists; Emergency Physicians; Paramedics; Cardiologists and our local pathway manager. The session focussed on heart attack care and set realistic goals. The patient pathway, current model of care and future directions were discussed, and an improvement plan was made. The goals included Improving patient experience ≥ 75% of angiography within 72 hours of admission for NSTEMI Increased same day discharge (golden patient) Direct admission to a free bed on the Acute Cardiac Unit (ACU) for high risk NSTEMI from the community via the ambulance serviceThe key steps to achieving change were Smart listing –cases were labelled NSTEMI or NSTEMI GP (golden patient) on the ordering system – started in April 2021 Buy in from operators for a NSTEMI patient on the list each morning ahead of elective work Recovering PCI cases in the general cardiology ward NSTEMI patient information, a new leaflet given to patients by the rehab team A half an hour biweekly meeting was held on Teams facilitated by our pathway manager. Progress was tracked, these meetings also generated ideas. <h3>Results</h3> The project started in September 2020. The percentage of NSTEMI patients undergoing angiography increased steadily from a baseline of 60% to the most recent figure of 93%. In the six months following the introduction of smart listing, the same day discharge rate, or ‘Golden Index’ was 41% up from 27% in the preceding 6 months. On a base of 400 MINAP verified NSTEMI patients that is a saving of 56 hospital bed days.A patient satisfaction survey following discharge of 15 randomly selected recent patients showed an 87% understanding rate of their diagnosis and treatment. <h3>Conclusion</h3> A local approach to pathway management for NSTEMI, involving stakeholders was successful in improving care, preserving income, freeing up hospital beds and will hopefully continue to deliver further benefits. <h3>Conflict of Interest</h3> None To Declare