NHS Ayrshire and Arran

Patients with peri-acetabular bone metastases are currently treated by trauma services ad hoc, or by tertiary referral services such as sarcoma teams. These patients are high risk, with a significant complication rate, and benefit from a tertiary MDT approach. We aimed to assess the cost benefit of instituting a tertiary MBD service in a medium size DGH. This was a prospective modelling study estimating the cost of managing the MBD workload at a medium-sized orthopaedic centre (population 423,000) over a ten-year period (2026–2035). The cost-analysis projected cost differences in the following areas: implant cost, outpatient/inpatient care cost, intraoperative fracture rate and metalwork failure. In the study Health board (2026–2035), cancer prevalence will increase from 4528 to 8004 and the number of complex hip metastases will rise from 19 to 34/year. Instituting a tertiary MBD service will see implant costs rise from a mean of £94,536/year (baseline model) to £153,839 (total £593,026 over ten years). With more patients managed electively, patient care cost will fall from £2 million (baseline model) to £1.7 million in the MBD service (average saving of £29,748/year). Three metalwork failure scenarios were modelled versus the baseline projected 5% failure rate (13 with metalwork failure over ten years). A failure rate of 3% in the MBD service (8 patients) would save £222,634, 2% (5 patients) would save £333,951 and 1% (3 patients) would save £445,268. Overall, failure rates of 2% and 1% would favour an MBD service over the status quo (less expensive by £215/year 2% failure rate and £10,917/year 1% failure rate). This is the first cost-analysis to be performed on setting up a tertiary referral MBD service in a UK orthopaedic trauma unit. With a metalwork failure rate of 1% at five years, a tertiary MBD service would save £109,168 over ten years.

Cancer during pregnancy is uncommon. Symptoms caused by new cancers in pregnancy can be difficult to recognise leading to a delay in diagnosis and treatment. Ovarian cancer during pregnancy poses a further diagnostic challenge due to the vague symptoms that it can present, along with difficulty in the interpretation of tumour markers. Presentation with acute abdominal pain, in the presence of an ovarian cyst, can be misdiagnosed as benign conditions such as ovarian torsion or haemorrhage. We present a case of a highly aggressive small-cell ovarian carcinoma diagnosed in the third trimester of pregnancy. Ultrasound and MRI scans provided some information on the complex nature of the ovarian cyst. She underwent laparotomy with salpingo-oophorectomy, which was followed by Caesarean birth 2 weeks later at 34+ weeks’ gestation. There was a rapid progression of disease between the two surgeries. Despite starting chemotherapy soon after, she became unwell after two cycles due to disease progression and suspected sepsis. She was unable to continue further treatment. She spent her last few days at home with her family. The final histology with specific stains confirmed the diagnosis of ovarian small cell carcinoma hypercalcaemic type.

Objectives This study aimed to generate new qualitative insights to understand the rehabilitation needs of people living with a confirmed or presumed diagnosis of ischaemia with no obstructive coronary arteries (INOCA), explore which aspects of current cardiovascular prevention and rehabilitation programmes could meet the needs of people with INOCA and where adjustments (if any) may be appropriate. Design Semistructured qualitative interview study. Participants Interviews were undertaken (n=17; 88% female, age range 31–69 years) with people with a confirmed or presumed diagnosis of INOCA. Results Findings highlighted concerns around a lack of evidence-based guidance for cardiovascular prevention and rehabilitation programmes for patients with INOCA. Participants expressed a desire for modular cardiovascular prevention and rehabilitation programmes that could be accessed flexibly to accommodate episodic fluctuations in symptoms. Participants suggested that existing cardiovascular prevention and rehabilitation programme content needed adjustment including enhanced psychosocial support, supervised low-impact physical activity and specialist dietary advice and medication reviews. Additional elements specific to INOCA should be made available as appropriate including acute care planning and a module to provide information and support for female-specific issues. The importance of involving INOCA patients in the codesign of future programmes and associated training was emphasised. Conclusions People with INOCA are willing to engage with cardiovascular prevention and rehabilitation programmes and express a desire for more support. This patient group shares some barriers to rehabilitation programme attendance with other cardiac patient groups, but they also have specific concerns about the need for improved professional knowledge and evidence-based guidance regarding the management of INOCA. Cardiovascular rehabilitation programmes need to be delivered flexibly and individually tailored to ensure the relapsing and remitting nature of INOCA and associated support needs are addressed.

Background Older people in care homes are some of the frailest in society. Managing their care can be complex and recognition of residents who are dying can be challenging for care home staff (Macgregor,Rutherford, McCormack, et al. BMJ Open. 2021;11(2):e049486). Reasons for this are multifactorial, including multi-comorbidities, lack of training in the recognition of the signs of end of life. SPICTTM and SPICT-4AllTM are tools designed to help staff recognise declining health allowing for timely planning ensuring future care is aligned with residents’ preferences and wishes (Piers, DeBrauwer, Baeyens, et al. BMJ Support Palliat Care. 2021 May 31:bmjspcare-2021–003042). Aims By the end of 2023 three care homes will have engaged with a tailored palliative care education programme and implemented the SPICTTM tool with at least two residents. Method • Working group set up – hospice and care home professional support team. • Training needs analysis identified education requirements. • Care homes offered a tailored palliative education programme. • Participants asked to use SPICTTM over the 4–month period of the course. • ‘Would I be surprised if the resident died in the next year?’ (Van Lummel, Letswaard, Zuithoff, et al. Palliat Med. 2022;36(7):1023–1046) question helped identify residents where SPICTTM maybe appropriate. • Regular check–in with participants. • Pre and post education session evaluation. Results • 100% of attendees recognised that end of life care planning would be required during the last 6–12 months of a resident’s life. • 100% of attendees believed the SPICTTM tool would be useful in their care home. • 86% of attendees had used the SPICTTM tool with at least two residents within their home. Conclusion This very small pilot identified that with support and education, SPICTTM can significantly increase staff awareness of what to look for when a resident is in the last year of life allowing for timely future care planning. This pilot is now being rolled out across Ayrshire.

Large bowel obstruction is most commonly due to colorectal carcinoma, diverticular disease or volvulus. Rare causes of large bowel obstruction like endometriosis may occur in premenopausal women and diagnosis of large bowel endometriosis can be challenging to confirm preoperatively. Hence, clinicians should maintain a high index of suspicion for rare causes of large bowel obstruction like endometriosis. This may require complete surgical resection of the involved bowel to eliminate the risk of local recurrence.

Background Prior to the COVID‐19 pandemic a flexible approach to visiting was adopted by many Intensive Care Units in the United Kingdom. Due to the rapid spread globally of COVID‐19, significant policy changes were put in place, including the restriction on visitors to patients in hospital. Evidence has emerged demonstrating the negative impact of these restrictions on patients with COVID‐19, their families and the staff caring for them. However, there is limited data about the impact of these restrictions in the non‐COVID ICU environment. Aim This study aimed to explore the experiences of staff caring for non‐COVID‐19 patients in a cardiothoracic critical care unit during the COVID‐19 pandemic. Study Design This qualitative research study adopted a grounded theory methodological approach. This methodology was used due to the unique situation, with no prior research available. We recruited healthcare staff that worked in a cardiothoracic critical care unit during the COVID‐19 pandemic. Semi structured interviews were carried out, transcribed, and analysed. Using the data collected, a theory was constructed. Results Interviews were carried out with 20 healthcare staff from a range of professions including nurses, doctors, and allied health professionals. Following data analysis four main categories emerged from the data: impact and implementation of visiting restrictions; the dehumanisation of patients; end‐of‐life care and witnessing distress. From these four categories, a theory has emerged suggesting that healthcare staff in a non‐covid ICU were regularly exposed to potentially moral injurious events, despite being shielded from caring for patients with COVID‐19. Conclusions This study provides a theory that healthcare staff caring for non‐COVID‐19 critical care patients during the period of visiting restrictions were exposed to potentially morally injurious events. Relevance to clinical practice Repeated exposure to potentially morally injurious events can lead to the development of moral injury and its adverse consequences. This study highlights the need to support all staff in the post COVID era, including those who worked in a non‐COVID environment.

Objectives Head and neck cancer has a 5 per cent incidence of synchronous primary cancer. Synchronous primary cancers are commonly detected with imaging and flexible nasoendoscopy. Routine panendoscopy is still being used to screen for synchronous primary cancers. The aim was to establish the method of detection of synchronous primary cancer. Methods A retrospective cohort study of newly diagnosed head and neck cancer patients with a synchronous primary cancer, presented at the West of Scotland Head and Neck Multidisciplinary Team from December 2020 to August 2022. This study is Level 3 evidence. Results A total of 2325 patients were presented to the Multi-Disciplinary Team with head and neck cancer and 54 (2.3 per cent) had SPC; 63.8 per cent (30) of patients had a panendoscopy. All patients with comprehensive out-patient assessment had their synchronous primary cancer detected on examination or imaging, without the need for panendoscopy. Conclusion Panendoscopy did not detect any new synchronous primary cancer in patients assessed with flexible nasoendoscopy and imaging. With modern high-resolution imaging and fibreoptics, panendoscopy does not play a role in the detection of synchronous primary cancers.

Background/Objectives: The importance of family carer dementia education is highlighted in research, practice guidance, and policy. Less attention is paid to how facilitators learn and prepare for their role. This research aimed to explore and describe facilitator learning experiences within a bespoke Scottish Carers’ Academy designed around a theory-guided approach called Care Empathia. A healthcare and university partnership ensured integration with services and the fusion of dementia higher education know-how with clinical practice expertise. Methods: Nineteen facilitator questionnaires were completed from two Carer Academy hubs; thirteen participated in online focus groups. Results: The questionnaire findings highlighted the learning gained from being a facilitator, observing expert facilitators in action, and listening to the testimonies of family carers. The framework analysis of the focus group data identified six themes, including safe learning approaches, the art of facilitation, emotional work, team learning, and leadership. These findings highlight the importance of facilitator preparation and the advantages of co-delivery models that combine clinical and practice education expertise. Conclusion: Facilitators need to understand how to walk the talk of theory-guided educational models, be open to reciprocity in learning, and be prepared for the emotional work of delivering trauma-informed practical dementia care education to family carers.

Introduction: A minimum unit price (MUP) for alcohol of £0.50 per unit (1 UK unit = 10 mL/8 g alcohol) was introduced in Scotland in May 2018. Few previous studies have examined the impact of alcohol pricing policies on people who are alcohol dependent. This study aimed to evaluate the effect of MUP on people who are alcohol dependent including changes in alcohol consumption and health status, as well as potential unintended consequences. Methods: Three waves of cross-sectional data were collected in Scotland (intervention) and Northern England (control) at 0–6 months pre-implementation then 3–9 months and 18–22 months post-implementation. The sample was N = 706 people receiving treatment related to their alcohol use. We collected structured interview data including recent drinking information via a 7-daytimeline-follow-back drinking diary. Difference-in-difference analyses estimated change in indicators in Scotland compared to England at both post-implementation timepoints. Results: The proportion of participants consuming alcohol costing on average <£0.50 per unit in Scotland decreased from 60.6% at 0–6 months prior to MUP implementation to 6.3% at 3–9 months post-implementation (p < 0.0004). There was no significant change in the indicators for alcohol consumption, severity of dependence, health status, other substance use, deprivation level or parenting. Discussion and Conclusions: The introduction of MUP in Scotland was associated with increases in the prices paid for alcohol by people with dependence and presenting to treatment services. There was no evidence of changes in their alcohol consumption or health status. There was also no evidence of harmful unintended consequences for this population.

The aim of this article is to illustrate the experienced and optimal patient journeys of people with multiple sclerosis. A review of research published in the British Journal of Neuroscience Nursing in 2024 was conducted to build on the insights and provide guidance around each part of the patient journey, from diagnosis to care. A composite patient journey was created based on the experiences of the MS patients interviewed as part of the ALERT study. Many people with multiple sclerosis experience delayed diagnosis and management of bladder and bowel dysfunction, leading to significant physical and psychosocial consequences. The composite patient journey showed common clinical touchpoints where care was sub-optimal. There was a lack of early discussions about bladder and bowel issues, insufficient patient education and missed opportunities for intervention. Early diagnosis, patient education and integrated care pathways are essential for managing neurogenic bladder and bowel dysfunction in people with multiple sclerosis. By addressing these issues proactively, healthcare providers can improve patient outcomes and quality of life. Policy initiatives should focus on increasing awareness, education and developing clinical guidelines to support effective bladder and bowel management. Integration of care services reduces inequities and improves wellbeing.

Background Patients with heart failure and iron deficiency have diverse causes for hospitalization and death that might be affected by iron repletion. Objectives The purpose of this study was to explore causes of hospitalizations and deaths in a randomized trial (IRONMAN) of heart failure comparing intravenous ferric derisomaltose (FDI) (n = 568) and usual care (n = 569). Methods Patients with heart failure, left ventricular ejection fraction ≤45%, and either transferrin saturation <20% or serum ferritin <100 μg/L were enrolled. Median follow-up was 2.7 years (Q1-Q3: 1.8-3.6 years). A committee adjudicated the main and contributory causes of unplanned hospitalizations and deaths. RRs (rate ratios) for selected recurrent events with 95% CIs are also reported. Results Compared with usual care, patients randomized to FDI had fewer unplanned hospitalizations (RR: 0.83; 95% CI: 0.71-0.97; P = 0.02), with similar reductions in cardiovascular (RR: 0.83; 95% CI: 0.69-1.01) and noncardiovascular (RR: 0.83; 95% CI: 0.67-1.03) hospitalizations, as well as hospitalizations for heart failure (RR: 0.78; 95% CI: 0.60-1.00), respiratory disease (RR: 0.70; 95% CI: 0.53-0.97), or infection (RR: 0.82; 95% CI: 0.66-1.03). Heart failure was the main cause for 26% of hospitalizations and contributed to or complicated a further 12%. Infection caused or contributed to 38% of all hospitalizations, including 27% of heart failure hospitalizations. Patterns of cardiovascular and all-cause mortality were similar for patients assigned to FDI or usual care. Conclusions In IRONMAN, FDI exerted similar reductions in cardiovascular and noncardiovascular hospitalizations, suggesting that correcting iron deficiency might increase resistance or resilience to a broad range of problems that cause hospitalizations in patients with heart failure. (Intravenous Iron Treatment in Patients With Heart Failure and Iron Deficiency; NCT02642562)

Despite significant progress in cardiovascular pharmacotherapy and interventional strategies, cardiovascular disease (CVD), in particular ischaemic heart disease, remains the leading cause of morbidity and mortality among women in the UK and worldwide. Women are underdiagnosed, undertreated and under-represented in clinical trials directed at management strategies for CVD, making their results less applicable to this subset. Women have additional sex-specific risk factors that put them at higher risk of future cardiovascular events. Psychosocial risk factors, socioeconomic deprivation and environmental factors have an augmented impact on women’s cardiovascular health, highlighting the need for a holistic approach to care that considers risk factors specifically related to female biology alongside the traditional risk factors. Importantly, in the UK, even in the context of a National Health Service, there exist significant regional variations in age-standardised mortality rates among patients with CVD. Given most CVDs are preventable, concerted efforts are necessary to address the unmet needs and ensure parity of care for women with CVD. The present consensus document, put together by the British Cardiovascular Society (BCS)’s affiliated societies, specifically portrays the current status on the sex-related differences in the diagnosis and treatment of each of the major CVD areas and proposes strategies to overcome the barriers in accessing diagnoses and treatments among women. This document aims at raising awareness of the scale of the current problem and hopes to stimulate a multifaceted approach to address sex disparities and enable future comprehensive sex- and gender-based research through collaboration across different affiliated societies within the BCS.

Background Borderline personality disorder (BPD) is a severe mental disorder that is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and mood as well as marked impulsivity. BPD has its peak incidence and prevalence from puberty through to emerging adulthood. BPD is a controversial diagnosis in young people. Commonly, young people with BPD are under-diagnosed, untreated, are not in employment or training and are estranged from their families. Yet, they have complex needs and are at high suicide risk. Aim To assess the feasibility of conducting a randomised controlled trial (f-RCT) of a BRIDGE, a brief intervention programme for young people (age 14-24) with BPD symptoms (sub-threshold or threshold) in a community sample from Scotland, UK. Method Forty young people (age 14-24) meeting criteria for BPD symptoms, will be randomised in a 1:1 ratio to receive either a) the BRIDGE intervention plus service-as-usual or b) service-as-usual alone. Follow up will be 12 weeks and 24 weeks post-intervention. The study is carried out between 2021 to 2024. Outcome The two primary outcomes of the MQ funded, BRIDGE project (f-RCT) are i. recruitment rates and ii. retention rates. The study will present the acceptability and appropriateness of our putative outcome measures for a future definitive randomised controlled trial (d-RCT). Impact Young people with BPD benefit from good clinical care and targeted intervention, however are regularly missed or mislabelled. The community based feasibility trial would provide initial evidence of variable needs of young people with complex needs, who maybe missed or excluded from services as they don’t “fit” a model/diagnosis. Workable multi-agency service model proposed in the trial would be a major advance in understanding care pathways regardless of trial outcome. Clinical Trial Registration ClinicalTrial.gov, identifier NCT05023447

The use of remote technology, via telephone and video, was rapidly introduced across health services at the outset of the COVID‐19 pandemic and is likely to future. This study investigated the experience and opinions of staff working in Specialist Intellectual Disability Community Teams, with the aim of clarifying the advantages and disadvantages of remote technology in this setting and helping to guide service development. Fourteen members of staff from seven different health disciplines across seven NHS Greater Glasgow and Clyde Community Intellectual Disability Teams were interviewed using a semi‐structured format. Thematic analysis identified three overarching themes: use of remote technology; efficiency and limitations. Participants reported clear efficiency advantages using remote technology but some challenges with communication and completing comprehensive patient assessments. There was support for the ongoing use of remote technology in the assessment and treatment of people with intellectual disability, particularly for multidisciplinary meetings. However, participants also described a need for face to face assessments, particularly for people with more severe intellectual disability, with complex care needs or when particular assessments are required (such as a new patient appointment or physical assessment).

Background Outcome measurement in child and adolescent forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aimed to identify studies which validate structured instruments available for use as outcome measures in the child and adolescent forensic mental health service cohort and assess the quality of these studies. Methods A systematic review was conducted following PRISMA guidelines. Studies were identified by searching six online databases in November 2023. The quality and risk of bias of each study meeting inclusion criteria was independently assessed by two authors using the Crowe Critical Appraisal Tool. Results were synthesised narratively. Results A total of eight studies were identified which met inclusion criteria. These looked at six instruments which primarily focused on outcome measures in the areas of treatment motivation, level of functioning, psychiatric symptoms, care needs and response to social situations. Papers scored between 17/40 and 30/40 on the Crowe Critical Appraisal Tool. Studies were rated as low (n = 1), moderate (n = 6), high (n = 1) or very high quality (n = 0). Conclusions Despite the large number of structured instruments potentially available, evidence for their use as outcome measures in child and adolescent forensic mental health services is limited. Future research should aim to validate current structured instruments for use in the forensic child and adolescent setting, with consideration of whether new instruments should be developed specifically for this group. Such instruments should be developed with both young people as service users and professionals who will be utilising the instrument in mind.

Aims This pilot program aimed to enhance the psychiatry experience for foundation doctors (FYs) working at Ayr Hospital by identifying perceived areas where psychiatric support would benefit training, development or education. Subsequently strategies were aimed to be implemented by the psychiatry liaison service to enrich FYs' experience during their medical and surgical rotations. Feedback was aimed to be obtained to determine if the program would have value to other district hospitals and grades of junior doctors. Methods Unstructured interviews with 4 FYs were conducted in October 2023 to explore the current experience of psychiatry in medical or surgical placements at Ayr Hospital. Identified themes included barriers to completing supervised learning events (SLEs) for mental health cases (a requirement of the 2021 Foundation Curriculum), limited exposure to psychiatry teaching opportunities, and obstacles to pursuing development of interest in psychiatry (such as time to shadow psychiatry, or discuss career prospects in psychiatry). A pilot program was initiated in November 2023 to improve the experience and education of psychiatry for FYs. This involved: • Providing dedicated time on wards for FYs to complete SLEs with a member of the liaison service. • Providing time for FYs to shadow the role of liaison psychiatry. • Providing additional teaching tutorials, focused on topics chosen by FYs. • Providing the opportunity to discuss and develop interest in psychiatry. A survey to obtain both quantitative and qualitative feedback was sent to each FY that engaged in the program. Results 17 FYs engaged in the pilot program, with 13 providing feedback. All respondents felt the program increased their knowledge and confidence in approaching cases with a psychiatry element. They also all found the experience positive and a productive use of time. All deemed the program would be useful for other foundation trainees in medical hospitals. Free text feedback highlighted the program's value in facilitating case discussions, removing obstacles in completing mental health SLEs, providing useful relevant tutorials and providing opportunity to discuss further interest of psychiatry. Conclusion The pilot program successfully achieved its aim to improve FYs' experience of psychiatry. Although not measured in the survey, the program also appeared to foster positive relationships between the liaison service and junior medical staff. It also helped identify new appropriate referrals for the liaison service. An expansion of the program is planned to other district hospitals in Ayrshire and Arran, including consideration of expanding the participation to wider members of the junior doctor cohort.

Aims This project's purpose was to improve the identification and management of patients at risk of or suffering from alcohol withdrawal at the point of admission. Ultimately aiming to prevent avoidable harm to patients and reduce the burden on local services within NHS Ayrshire & Arran. Methods The project began in August 2023 with Alcohol & Drug Liaison Nurses (ADLN) carrying out twice daily walkthroughs of the Emergency Department and Combined Assessment Unit. ADLNs were instructed to engage with these clinical teams, helping to identify those at risk, provide management advice and accept relevant referrals. A retrospective audit was completed covering patients referred to the alcohol and drug liaison team (ADLT) in July 2023 and a prospective audit covering October 2023. Quantitative data gathered included prescription of benzodiazepines & Pabrinex, time from admission to prescription and administration of treatments, any changes to treatment advised, and whether treatments administered correctly. Additional qualitative data was gathered through a short staff survey carried out in November 2023 asking if the project had been helpful in identifying patients, improving management, and making staff feel supported. Results There was a 33% increase in referrals from July (n = 15) to October (n = 20), with a slightly greater proportion coming from ED (80% vs 85%). The average time from admission to benzodiazepine prescription fell by 2hrs and to administration by 8hrs. However, changes were advised to benzodiazepines prescriptions more frequently (12% increase). Pabrinex prescriptions were being completed overall for patients both before (92%) and after (100%) the project. Average time from admission to pabrinex prescription fell by 2hrs but to administration increased by 0.5hrs. Additionally, cases of incorrect pabrinex administration increased from 31% to 47% between the two periods. Staff feedback was very positive; project was very (45%) or somewhat (35%) helpful in identifying patients at risk, very (30%) or somewhat (50%) helpful in managing alcohol withdrawal, and very (55%) or somewhat (20%) helpful in making staff feel more supported with this patient group. Conclusion This project demonstrated that additional support can improve identification of patients, speed of initial management decisions, and staff confidence. However, it also showed a significant knowledge/skills gap across both departments leading to continued problems with patients receiving timely and appropriate treatment. ADLN ward input cannot be continuous, as such practical changes are required to help maximize Liaison input. Following this project's recommendation, work has begun to develop an Alcohol Withdrawal Bundle and associated staff training.