bluuebunny/crossref_metadata_2025 huggingface dataset:
On the impossibility of extreme event thresholds in the absence of global warming
Authors: Diffenbaugh Noah S , Davenport Frances V
Published: October 2021

The exceptional severity of recent climate extremes has raised the question of whether some events would have been impossible in the absence of global warming. This question is critical for climate adaptation, but is challenging to answer given the length and non-stationarity of the observational record. The large single-model ensemble climate simulations archived in the Coupled Model Intercomparison Project (CMIP6) offer a unique opportunity to explore whether the hottest temperatures of the current climate are more extreme than any that could have occurred in the absence of human forcings. We first analyze the one CMIP6 model that has daily data archived for large ensembles in both the historical all-forcings and historical natural forcings experiments. We find that, for large areas of the world, the maximum daily-, seasonal- and annual-scale thresholds of the large single-model ensemble with natural and human forcings (‘all-forcings’) are never reached in the large single-model ensemble with only natural forcings. However, we also identify widespread areas—notably in the northern hemisphere mid-latitudes—where the hottest thresholds of the all-forcings ensemble are frequently exceeded in the absence of human forcings. Further analysis suggests that human forcings other than greenhouse gases (GHGs) are a primary cause of this discrepancy. For example, when comparing the late and early periods of the CMIP6 historical all-forcings experiment, other large single-model ensembles exhibit similar muting of extremely warm years over northern-hemisphere mid-latitude regions. However, under GHG-only forcing, all years in the recent period are hotter than the hottest early-period year over most of the globe. These results suggest that, although the hottest possible events in the current climate may have been virtually impossible in the absence of historical GHG emissions, other non-GHG anthropogenic forcings have muted the emergence of previously impossible events.
One extreme fire weather event determines the extent and frequency of wildland fires
Authors: Wang Xianli , Swystun Tom , Oliver Jacqueline , Flannigan Mike D
Published: October 2021

Understanding climate change impacts on wildland fire activity has been constrained by the high uncertainty embedded in the prediction of fire size (FS), annual number of fires (ANF), and annual area burned (AAB). While there has been a sustained effort to make connections between fire weather and fire activity, most studies have focused on individual parameters instead of treating them as a connected group. This study explores the intrinsic relationships among the major parameters of fire activity and how they relate to fire-conducive weather conditions to determine optimal prediction models. We found maximum number of fire spread days and maximum FS best predict ANF and AAB, respectively. Assessing the robustness of these relationships across Canada’s ecozones showed they are stronger in the Cordillera than in the Shields and Plains and more universal for AAB than for ANF. We also found skewness of FS distributions may play an important role in relationship strength. These relationships provide a unique way to model future fire activities under changing climate conditions.
A single-step strategy for general construction of metal sub-nanoclusters on graphdiyne
Authors: Xiong Huatian , Zou Haiyuan , Rong Weifeng , Wang Yongsong , Dai Hao , Ji Yongfei , Duan Lele
Published: October 2021

Metal sub-nanoclusters (SNCs) inherit the metrics of unsaturated active sites and ultrahigh metal utilization from single-atom catalysts (SACs), and they can drive the reactions involving multiple adsorbates by their enriched metal cofactors that beyond SACs. However, the current synthetic strategy offers limited versatility to prepare SNCs due to their subnanometric feature and high active surface. Herein, we demonstrate a universal and facile one-pot reaction to construct wide assortments of metal SNCs with the size of 2 to 3 nm on graphdiyne (GDY), denoted as M-SNCs/GDY (M = Co, Ni, Cu, Ag, Pd, Rh, Au, Ir, and Pt). Systematic investigations reveal that the correlated metal SNCs formation undergone the nucleation and growth process, during which the metal single-atoms were first anchored and then served as nuclei to grow SNCs confined on GDY. The electrochemical CO2 reduction reaction (eCO2RR) catalyzed by Cu-SNC/GDY and a Cu single-atom catalyst on GDY (Cu-SAC/GDY) was investigated to demonstrate the advantages of SNCs over SACs in manipulating the multicomponent reaction. Cu-SNC/GDY exhibited promoted Faradic efficiency (FE) of carbon products and suppressed competing hydrogen evolution reaction compared to the Cu-SAC/GDY. Benefiting from the function of multiple active centers, a C2+ FE of 31.6% was achieved over the Cu-SNC/GDY at −0.7 V versus reversible hydrogen electrode, which is 11-fold higher than that of Cu-SAC/GDY. In situ infrared spectroelectrochemistry confirmed that Cu-SNC/GDY could adsorb more eCO2RR intermediates over Cu-SAC/GDY. This study delivers a single-step strategy for preparing metal SNCs on GDY and expands the scope of SNCs.
New TiTaNbZrMo high-entropy alloys for metallic biomaterials
Authors: Li Chenwei , Ma Ying , Yang Xu , Hou Minghao
Published: October 2021

The advantages of high entropy alloy with good comprehensive properties provide a potential opportunity to explore and develop new alloys suitable for human implantation. In this experiment, TiTaNbZrMo high entropy alloy was designed and prepared by alloy design and first principle. The calculation results predict that the phase composition of each high entropy alloy is BCC structure, and the designed high entropy alloy has structural stability; the non-equal atomic ratio TiNbTaZrMo high-entropy alloy has higher ductility than the equal atomic ratio TiNbTaZrMo high-entropy alloy; the B/G, Poisson’s ratio υ and (C
12-C
44) values of Ti30(NbTaZr)60Mo10 alloy are the largest, indicating that the toughness of this alloy is the best, and the Young’s modulus value is the smallest. The experimental results show that the yield strength of Ti30(NbTaZr)60Mo10 alloy is 1132 MPa, the plastic strain is 33%, and the wear resistance and corrosion resistance are good. The potential of Ti30(NbTaZr)60Mo10 in biological field is proved by calculation and experimental test, which provides an important basis for its industrial application in biomedical alloy.
Characterization and beneficiation of Ethiopian kaolin for use in fabrication of ceramic membrane
Authors: Zewdie Tsegahun Mekonnen , Prihatiningtyas Indah , Dutta Abhishek , Habtu Nigus Gabbiye , Van der Bruggen Bart
Published: October 2021

Kaolin (china clay) is a rock material that is very rich in kaolinite. A kaolin ore from Debre Tabor, Ethiopia containing 59.2 wt% SiO2, 24.9 wt% Al2O3, 2.4 wt% Fe2O3, and 8.22 wt% loss on ignition (LOI) was physically beneficiated, chemically leached, and thermally treated for possible industrial use, especially for ceramic membrane fabrication. The leaching experiments were carried out using oxalic acid solutions as leaching reagents for the iron extraction process. The effect of acid concentration, reaction temperature, and contact time on iron leaching was investigated. It was determined that the rate of iron extraction increased with the oxalic acid concentration, leaching temperature, and contact time. A substantial reduction of iron oxide (2.4 to 0.36 wt%) from the raw kaolin was observed at operating conditions of 2.0 M oxalic acid, the temperature of 120 °C, and contact time of 120 min. A maximum kaolin whiteness index of 81.4% was achieved through this leaching process. Finally, the physically beneficiated, chemically leached, and thermally treated kaolin raw material was used to fabricate a low-cost kaolin-based ceramic membrane. After firing at 1100 °C the ceramic membrane was found to have a mass loss of 11.04 ± 0.05%, water absorption of 8.9 ± 0.4%, linear shrinkage of 14.5 ± 0.05%. It was demonstrated to be chemically stable, having less than 3% mass loss in acid solution, and less than 1% mass loss in alkali solution. The newly developed membranes have thus properties comparable to commercial ceramic membranes.
An inside/outside Ramsey theorem and recursion theory
Authors: Fiori-Carones Marta , Shafer Paul , Soldà Giovanni
Published: October 2021

Inspired by Ramsey’s theorem for pairs, Rival and Sands proved what we refer to as an inside/outside Ramsey theorem: every infinite graph

G
G

contains an infinite subset

H
H

such that every vertex of

G
G

is adjacent to precisely none, one, or infinitely many vertices of

H
H

. We analyze the Rival–Sands theorem from the perspective of reverse mathematics and the Weihrauch degrees. In reverse mathematics, we find that the Rival–Sands theorem is equivalent to arithmetical comprehension and hence is stronger than Ramsey’s theorem for pairs. We also identify a weak form of the Rival–Sands theorem that is equivalent to Ramsey’s theorem for pairs. We turn to the Weihrauch degrees to give a finer analysis of the Rival–Sands theorem’s computational strength. We find that the Rival–Sands theorem is Weihrauch equivalent to the double jump of weak König’s lemma. We believe that the Rival–Sands theorem is the first natural theorem shown to exhibit exactly this strength. Furthermore, by combining our result with a result of Brattka and Rakotoniaina, we obtain that solving one instance of the Rival–Sands theorem exactly corresponds to simultaneously solving countably many instances of Ramsey’s theorem for pairs. Finally, we show that the uniform computational strength of the weak Rival–Sands theorem is weaker than that of Ramsey’s theorem for pairs by showing that a number of well-known consequences of Ramsey’s theorem for pairs do not Weihrauch reduce to the weak Rival–Sands theorem. We also address an apparent gap in the literature concerning the relationship between Weihrauch degrees corresponding to the ascending/descending sequence principle and the infinite pigeonhole principle.
Interpreting Africa: Imperialism and independence in African Affairs
Authors: Westcott Nicholas
Published: October 2021

The continuous publication over 120 years of African Affairs, originally the Journal of the African Society, provides an invaluable source for charting Britain’s shifting perceptions of and interaction with Africa. Though limited, its readership included many of those most closely involved in Britain with studying and engaging with Africa during the 20th century. The journal charts a significant change: from an initial curiosity about Africa that included Africans’ own perception of and writing about their world; through a period when imperial perspectives on how to rule and how to develop African colonies dominated; to a more academic analysis of the dynamics of independence and how independent African countries subsequently evolved; and finally to a growing engagement with African scholars themselves and African perceptions of the changes taking place on the continent. At each stage a number of themes emerge that illuminate our understanding of how Africa was seen and interpreted by the British and, latterly, by Africans.
Pro-neurotensin/Neuromedin N and Hypertension Risk: A Prospective Study
Authors: Nicoli Charles D , Long D Leann , Plante Timothy B , Howard George , Judd Suzanne E , Schulte Janin , Cushman Mary
Published: October 2021

Background

Neurotensin, a neuropeptide with direct cardiac effects, has been associated with prospective risk of hypertension-related conditions through measurement of its precursor, pro-neurotensin/neuromedin N (pro-NT/NMN). Its association with incident hypertension has not been evaluated.

Methods

From 2003 to 2007, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled 30,239 Black or White adults age ≥45. Pro-NT/NMN was measured in 1,692 participants without baseline hypertension (self-reported antihypertensive use or blood pressure ≥140/90 mm Hg) who underwent follow-up assessment in 2013–2016. A sensitivity analysis was conducted using a lower threshold (≥130/80 mm Hg) to define hypertension. Three robust Poisson regression models were fitted to risk of incident hypertension, adding demographics, cardiometabolic risk factors, and dietary covariates.

Results

Six hundred and fourteen participants developed hypertension over 9.4 years of follow-up. Pro-NT/NMN ranged from 14 to 1,246 pmol/l, with median [interquartile range] 154 [112, 206] pmol/l. Pro-NT/NMN was not associated with hypertension overall (fully adjusted incidence rate ratio per SD increment log pro-NT/NMN 1.03, 95% confidence interval 0.95–1.11). Results of sensitivity analysis did not differ substantially.

Conclusions

Baseline pro-NT/NMN was not associated with incident hypertension. This may be a result of neurotensin’s long-term interactions with other molecular regulators of blood pressure, such as the renin–angiotensin–aldosterone system.
Multimodal medical image fusion using adaptive co-occurrence filter-based decomposition optimization model
Authors: Zhu Rui , Li Xiongfei , Huang Sa , Zhang Xiaoli
Published: October 2021

Motivation

Medical image fusion has developed into an important technology, which can effectively merge the significant information of multiple source images into one image. Fused images with abundant and complementary information are desirable, which contributes to clinical diagnosis and surgical planning.

Results

In this article, the concept of the skewness of pixel intensity (SPI) and a novel adaptive co-occurrence filter (ACOF)-based image decomposition optimization model are proposed to improve the quality of fused images. Experimental results demonstrate that the proposed method outperforms 22 state-of-the-art medical image fusion methods in terms of five objective indices and subjective evaluation, and it has higher computational efficiency.

Availability and implementation

First, the concept of SPI is applied to the co-occurrence filter to design ACOF. The initial base layers of source images are obtained using ACOF, which relies on the contents of images rather than fixed scale. Then, the widely used iterative filter framework is replaced with an optimization model to ensure that the base layer and detail layer are sufficiently separated and the image decomposition has higher computational efficiency. The optimization function is constructed based on the characteristics of the ideal base layer. Finally, the fused images are generated by designed fusion rules and linear addition. The code and data can be downloaded at https://github.com/zhunui/acof.

Supplementary information

Supplementary data are available at Bioinformatics online.
56 ‘A Closed-Loop Audit on The Appropriateness of Urine Testing Carried Out on Surgical Patients in The Acute Surgical Unit in University Hospital Limerick as Compared with Hospital Guidelines’
Authors: Murphy B , Amin K , Ali N
Published: October 2021

Aim

The acute surgical unit (ASU) in University Hospital Limerick (UHL) has a high turnover of patients of all surgical specialties, many of whom are sent home without the need for admission or follow-up. Urinalysis is very accessible, and is carried out on many patients, prior to them being seen by a doctor. Inappropriate urinalysis sets off a cascade of inappropriate urine culture, antimicrobial treatment and a waste of resources and time of nursing, medical and laboratory staff. We aim to identify and reduce inappropriate testing.

Method

The notes of all ASU patients during a one-week period were analysed using the ‘Therefore Navigator’ application, where all patient notes are scanned on leaving the ASU. Data relating to presenting complaint, presence or absence of urinary symptoms and abdominal pain, and urine dipstick and culture results (if performed) was collected for each patient. The results were compared with UHL guidelines on testing, an information sheet was designed and placed in ASU, and an education session for nursing staff was carried out. The second cycle was performed one month later.

Results

In the first cycle, 68% of the 99 ASU patients had urinalysis, and 48% had urine culture performed. Of cultures performed, only 23 of 47 (49%) were deemed indicated according to the guidelines. In the second cycle, 39% had urinalysis. 28% had urine cultured, 79% of these were deemed to have been indicated.

Conclusions

Inappropriate urine testing in the ASU decreased following teaching for nursing staff, together with an information leaflet being placed in the ASU.
99 Perfecting the Proforma – A Full-Cycle Audit on The Quality of Documentation of The Hand Trauma Proforma At the Regional Plastic Surgery Department
Authors: Noshirwani A , Phillips B , Hosain M , Drewniak K , Parekh V , Bell D
Published: October 2021

Aim

We aimed to assess the quality of record-keeping of the departments hand trauma proforma, identify areas of improvement, and to implement and assess the quality of an updated proforma.

Method

Data from 101 parameters was collected for 20 patients undergoing surgery for an upper limb injury in November 2019. An updated proforma was implemented and a further 20 patients were analysed in February 2020. All fields were compared between two audit cycles and comments were collected.

Results

The overall completion rate increased. Documentation of the responsible consultant increased to 100%, along with an increase in documenting of hobbies and injury mechanism. X-ray findings (55% to 85%) and antibiotic plan (35% to 80%) increased. Implementation of a free text box resulted in written descriptions of injury to compliment sketches. In the operation note, documentation of anaesthetic type used increased, along with tourniquet use and time. There was clearer documentation of the injury, findings, and procedure, with greater use of diagrams to illustrate the repair. There was a drop in the recording of post-op plans (100% to 85%), post-op antibiotics (90% to 75%), and follow-up plan (95% to 60%). Clinicians commented to increase the size of the free-text box and hand diagram on the operative page to facilitate easier drawings.

Conclusions

The Hand Trauma Proforma has made good progress from its original version but requires further adjustments to ensure complete data input. It sets a high standard for data collection and presents itself as a useful tool for units across the United Kingdom.
185 Comparing the Contents of The On-Call ENT SHO Bag at A Busy District General Hospital to ENT UK Guidelines – A Quality Improvement Project
Authors: Sooriyamoorthy T
Published: October 2021

Aim

To compare the contents of the ENT SHO bag with the recommendations by ENT UK.

To address any deficiencies in the bag and prevent it from recurring in the future.

Method

Over 5 consecutive days, the night SHO would compare the contents of the ENT bag with a checklist based on ENT UK guidelines. This was repeated post-intervention.

Results

The initial data collection showed that the bag was missing numerous items, ranging from tongue depressors to nasal catheters. It also contained bulky, unnecessary items such as Lahey forceps. The bag was replenished, unnecessary items removed, and a new checklist was introduced which the SHO had to complete every night shift. Any missing equipment was to be replaced at that time. PPE was added to the bag. The next round of data collection showed that the bag remained well stocked, with only minor equipment missing such as merocele packs and Sofradex drops. However, the bag contained alternatives such as Rapid Rhinos and Gentisone drops.

Conclusions

The introduction of a checklist has ensured that the SHO bag remains well stocked. This improves the efficiency of on-calls as the SHO no longer has to repeatedly travel between A&E and ENT stores. This is also beneficial when dealing with emergencies as all the equipment is readily accessible. The addition of PPE was prudent as ENT is a high-risk speciality in the COVID pandemic. Currently the checklist is completed weekly, in order to reduce the workload for the SHO – something to re-audit in the future.
194 Referral of Paediatric Fractures from The Emergency Department to Virtual Fracture Clinic
Authors: Effiom D
Published: October 2021

Introduction

Virtual Fracture clinics (VFCs) are an alternative to the traditional fracture clinic. Recent evidence reports them to be safe, cost-effective, and efficient model without significant compromise to patient care.

Aim

This audit aims to assess VFC referrals from the paediatric emergency department (ED) and ensure the appropriateness of these referrals.

Method

This was a retrospective audit done at a large district general hospital in the United Kingdom (UK). We included patients under 18 years old presented to the emergency department with suspected or confirmed fractures and referred to virtual fracture clinics within a period of one month. The performance was measured against both local and national guidance (NICE & BOAST 7).

Results

Thirty patients were eligible. Thirty-three per cent of patients were appropriately referred to the VFC and ’seen’ within 72 hours. Comparing those referred 63.3% were appropriate, with inappropriate referrals mainly due to false-positive fracture diagnosis or fractures safe to be discharged home. Only 67.8% per cent of patients were managed correctly as per suspected or confirmed diagnosis with regards to fixation (i.e., splint).

Conclusions

The target of 100% compliance has failed. Fractures deemed safe to be discharged home from the ED are being repeated referred, radiographic interpretations often over-diagnose, and management within the department in sub-optimal. Recommendations include improving junior radiographic interpretation skills and awareness of the local and national guidelines, with another audit cycle to assess for improvement.
206 Audit of Time to Surgical Fixation of Distal Radial Fractures Compared to British Orthopaedic Association Standard for Trauma (BOAST) Guidelines at Busy District General Hospital
Authors: Sooriyamoorthy T
Published: October 2021

Aim

BOAST guidelines state that intra-articular distal radial fractures should be operated on within 72 hours of injury and extra-articular distal radial fractures which require surgical management should be operated on within 7 days. The aim of this audit was to see how the orthopaedic department at a busy district general hospital compared to these guidelines.

Method

Retrospectively looked at operations carried out over a 10-month period. All Manipulation Under Anaesthesia, K wire and Open Reduction Internal Fixations of distal radial fractures were included.

Results

Over the 10-month period, 49 intra-articular and 60 extra-articular fractures were operated on. 65% of intra-articular fractures were fixed within 72 hours and 82% of extra-articular fractures were fixed within one week. Mean time from date of injury to operation was 3.88 days for intra-articular and 2.98 days for extra-articular fractures. Mean time from decision of surgery to operation was 2.32 days for intra-articular and 2.18 days for extra-articular fractures.

Conclusions

Clearly, the management of extra-articular fractures is closer to the standards set by BOAST guidelines. It can be difficult to establish from an x-ray whether a fracture is extending into a joint surface - this can delay the fracture clinic appointment and the operation. The difference between the mean time of injury to operation and mean time of decision of surgery to operation for intra-articular fractures show that once the decision to operate has been made, it is carried out quickly. Educating A+E and orthopaedic staff on recognising intra-articular fractures could expedite the time to surgery.
242 Is Iliosacral Screw Fixation Safe to Perform in a Day Surgery Unit?
Authors: Crawford P , Brown C , Jones B
Published: October 2021

Introduction

Iliosacral screw (ISS) fixation is a percutaneous, fluoroscopy-guided technique which can be used to treat sacroiliac joint pain. During the covid-19 pandemic much of our elective practice has moved from the tertiary referral hospital to the local day surgery unit. We aimed to determine if this procedure is safe to perform as a day case procedure.

Method

Twelve patients underwent ISS between 2011-2017: 6 single ISS fixation, 4 two ISS fixation and 2 bilateral ISS fixation. All patients undergoing concurrent procedures were excluded. Mean age 44 years old (range 19-79); 58% male. Surgical time, length of stay, blood transfusion requirement, haemoglobin drop, and significant analgesic events were assessed.

Results

Average surgical time was 55 mins (single ISS; range 30-75 mins), 71 mins (two ipsilateral ISS; range 45-100 mins) and 105 mins (bilateral ISS; range 90-120 mins). All patients were discharged within 72 hours; 67% within 24 hours (4 single ISS, 2 two ISS, 2 bilateral ISS). There were no post-operative haemoglobin drops warranting blood transfusion and no delay to discharge due to significant analgesic events.

Conclusions

ISS fixation may be safe to perform in a day surgery unit due to acceptable surgical time, length of stay and complication rate. A larger sample size may be required to draw definitive conclusions.
254 An Audit to Assess the Completion of Consent Forms in the Department of Trauma and Orthopaedics
Authors: Sultana E
Published: October 2021

Aim

The objective was to audit how well the consent forms were being completed by junior doctors and registrars in the orthopaedic ward. This helped to assess whether the consent forms before orthopaedic procedures were being filled out according to the standards stated in the RCS and NICE guidelines.

Method

The initial audit was carried out in January 2020 in the three orthopaedic surgery wards at the Queen’s Medical Centre in Nottingham. Cross sectional data was collected by checking the consent forms to assess whether the important headings and sub-headings were filled out legibly with adequate information.

Results

All consent forms filled up in the study sample had the patient details and the name of the surgery written completely and accurately. 75.6% of the forms had the name of the Responsible Health Professional written, while the remaining had left the space blank or wrote an incorrect name. More than 90% of the forms had the intended benefit, and the possible risks of the orthopaedic operation written in the most suitable format. The likelihood of a blood transfusion being required was filled out in 78.6% of the forms. All consent forms were signed by a doctor, however, only 53% of the doctors provided both their name in print and contact number in the consent form.

Conclusions

Consent is an essential prerequisite for any operative procedure. By detecting the parts of the consent form that were frequently filled out inadequately, awareness was raised about the possible legal consequences of it.
261 The Use of MRCP to Investigate Bile Duct Stones
Authors: Ma J , Jethwa P
Published: October 2021

Aim

Association of Upper Gastrointestinal Surgeons (AUGIS) latest guideline advocates stratification of patients with gallstone disease to determine their risks of common bile duct (CBD) stone and to perform Magnetic resonance cholangiopancreatography (MRCP) for those at intermediate risk. The study assessed the appropriateness of our local hospital’s MRCP requests in accordance to the AUGIS standard.

Method

Inpatient MRCP requests for suspected ductal gallstones between June and December 2019 were identified retrospectively. Admission history, ultrasound, MRCP findings and liver function tests were collected from hospital electronic records. Patients with previous cholecystectomy were excluded. Patients were categorized into ‘low risk’, ‘intermediate risk’ and ‘high risk’.

Results

67 patients were included in the study and 24 patients were discovered to have CBD stones on MRCP. The majority of patients (54%) were considered ‘intermediate risk’, whilst the ‘low risk’ group consisted of 13% of the MRCP requests and ‘high risk’ group comprised of 33 %. Amongst those in the ‘low risk’ group, only 1 of 9 patients (11%) had cbd stone identified on MRCP. 19% patients in the intermediate group were found to have CBD stone, whilst 73% patients in the high-risk group were identified to have CBD stone. On average, patients underwent MRCP within a day of request.

Conclusions

A high proportion of patients at high risk for CBD stone were referred for MRCP, contrary to AUGIS guideline. Inpatient MRCP referrals should be considered carefully in this category as it potentially increases length of stay without change in clinical management.
277 Smoking and Alcohol Use Assessments in Head and Neck Surgical Inpatients: An Audit to Improve Health Promotion
Authors: Crossley E , Findlay C , Sipaul F
Published: October 2021

Aim

Head and neck cancer incidence is expected to rise, with smoking and alcohol consumption the greatest risk factors. The related CQUIN target encourages identification of patients who smoke and drink harmful amounts of alcohol. Locally these questions are integrated into discharge summaries. We aimed to review questionnaire completion and encourage staff to give advice to minimise patients’ future head and neck cancer risk.

Method

We conducted a retrospective audit of adult patients admitted locally under head and neck surgeons in a three-month period. Local audit standard was completion of the questionnaires in 95% of patients. Intervention was education of ENT juniors (foundation and core trainees) alongside ward-based prompts. Re-audit was conducted for two-months following intervention.

Results

Initial audit reviewed 99 discharge summaries, and re-audit reviewed 115. Following intervention there was improved documentation of smoking status from 27.3% to 48.7% (n = 27/99 vs n = 56/115) and alcohol use from 36.3% to 51.3% (n = 36/99 vs n = 59/115) respectively. However, even in re-audit a significant proportion were documented as ‘unable' to answer (smoking 41.7%, alcohol 42.6%); of these the majority were day case procedures (smoking n = 35/48, alcohol n = 42/49).

Conclusions

Staff education can encourage doctors to discuss smoking and alcohol and represents health promotion and a reduction in risk of malignancy. Many day case patients were documented as ‘unable’ to answer; this may reflect that discharge paperwork is frequently completed in the immediate post-operative period. Further improvement could be achieved with educational interventions for registrars and consultants, and consideration of the practical challenges negatively impacting questionnaire completion for day case patients.
295 Secondary Prevention of Cardiovascular Risk Factors in Patients Admitted Under the Vascular Service - Full Cycle Audit
Authors: Abadi P H , Forsyth J , Drury D
Published: October 2021

Aim

Peripheral arterial disease (PAD) is strongly associated with general cardiovascular morbidity and mortality. This audit aimed to monitor and improve compliance with NICE guidelines CG147 & TA607 for PAD patients that presented to our vascular service.

Method

Patients were audited from September to October 2020. The audit reviewed prescription of anticoagulant/antiplatelet agents, lipid modification, optimisation of diabetes control and smoking cessation advice. Our intervention was to conduct a single teaching session for junior doctors that emphasised medication checks, checking HBA1c/ensuring appropriate diabetic referrals, and implementation/documentation of any smoking cessation advice. We also introduced a dedicated computer for conducting the vascular surgery morning ward round. Re-audit was undertaken between November to December 2020.

Results

The first audit included 32 patients. It revealed 100% compliance with anticoagulant/antiplatelet prescribing. 82% were prescribed appropriate lipid modification. There was 75% compliance with diabetic referrals for patients with high HBA1c results. There was only 19% compliance with smoking cessation advice/documentation. The re-audit process included 27 patients. There was 100% compliance with antiplatelet/anticoagulant prescriptions. 26 (96%) patients were prescribed appropriate lipid modification. There was now 100% compliance with appropriate referral to the diabetic team. There was also 100% compliance with smoking cessation advice/assistance/documentation.

Conclusions

A single teaching session for junior doctors familiarising them with the current national guidelines, and introduction of a dedicated computer for ward rounds significantly helped improve our compliance with national guidelines for secondary prevention of vascular disease.
303 Adherence to Nil by Mouth Guidelines in A Tertiary Centre
Authors: Muscat E , Fabre I , Mohiuddin K
Published: October 2021

Aim

Fasting before general anaesthetic aims to decrease the volume and acidity of stomach contents during surgery, which therefore reduces the risk of aspiration. This is a second cycle closed loop reaudit which had implemented Nil by mouth (NBM) guidelines during the first cycle as an intervention to improve knowledge. Preoperatively, adult patients should remain fasted for a minimum duration as below:

During the second cycle interventions were included such as: teaching to junior doctors and nurses including specific teaching during induction of new surgical doctors and posters displaying the NBM guidelines were placed in surgical wards. These were carried out despite restrictions during the COVID-19 pandemic.

Method

The same questionnaire was redistributed amongst staff members (nurses and HCA) throughout various surgical wards and junior doctors. Results were compared with the initial audit during this second cycle to assess whether any improvements had been made after implementation of interventions.

Results

Total number of staff:

Conclusions

A significant improvement in knowledge and understanding of the NBM guidelines was demonstrated with all members of staff and practice was in accordance with NICE guidelines.
307 Awareness and Reporting of Needle Stick Injury Amongst Junior Doctors in a General Surgery Department
Authors: Mistry R , Mahamud I
Published: October 2021

Introduction

This audit was performed to see if a new cohort of junior doctors in a general surgery department had received legally required sharps injury training, assess knowledge on what to do if a needle stick/splash injury were to occur; and to provide necessary training.

Method

Questionnaires about trust needle stick policy training including current job grade, awareness of general principles, reporting of previous needle stick injuries and barriers to reporting of needle stick injuries were filled in. Training was provided on needle free devices and trust needle stick/splash injury protocol. After training, a second questionnaire was filled in to see if there was better understanding of the trust protocol and the necessary steps after injury. The same group of junior doctors were re-audited at a later date to see if the knowledge gained from training had been retained.

Results

All junior doctors (total of 11) in general surgery reported receiving no formal needle stick/splash training since starting at the trust on the trust policy and no formal induction on needle-free devices and what to do in the event of a needle stick injury since starting at the trust. All doctors felt aware of what to do after training provided with time pressures being identified as a barrier for not reporting all needle stick injuries. Re-audit one month later demonstrated all doctors had awareness of the trusts needle stick/splash injury protocol.

Conclusions

The training provided was effective in providing legally required training and improving staff and patient safety.
343 Knowledge and Confidence of Nursing Staff in Burns Management
Authors: Bakhiet A
Published: October 2021

Background

Nursing staff play a pivotal role in the management of burns patients. It is essential that nurses are confident in following the various protocols for these patients. Due to Covid-19, many nursing staff have been redeployed to other specialties, with reduced availability of Burns teaching days also impacting on Burns care. The aim of this audit was to determine the level of education and confidence of burns management amongst nursing staff.

Method

Data collection proformas were handed out to all nursing staff working on a ward that receives burns patients. The data was subsequently collated, analysed and presented at a local meeting.

Results

A total of 44 proformas were distributed. The average confidence ratings of nursing staff (on a scale of 1-10) when managing 5%, 10% and 15% burns patients were 6.4, 5.2 and 3.8 respectively. 89% had received no formal burns education within the past 2 years.

Conclusions

Optimal burns care is dependent on a multidisciplinary approach, with burns nurses playing a central role. The complex requirements of these patients require nursing staff to have a broad range of knowledge and skills so as to coordinate the patient’s management. This study shows that confidence increases with experience and decreases with an increasing severity of burn. Through this study we were able to identify the main areas of knowledge discrepancy amongst the nurses, as well as determine their preferred means of learning. We are currently organising a Burns education programme for the nursing staff tailored to the feedback received in this audit.
376 Management of Breast Cancer in elderly patients
Authors: Moutsos I , Noronha J
Published: October 2021

Aim

To evaluate the care and outcomes for women with breast cancer over the age of 70 and to compare our performance at AUH against the national outcomes.

Method

Using the online database at AUH we gathered the following data: age, TNM status, surgical management, histology, adjuvant treatment (radiotherapy, chemotherapy, hormone therapy, targeted therapy) and reasons for alterations in planned therapy.

Results

We audited 176 patients between 2018 and 2019. Age varied between 70 and 95 years old. 10 patients suffered from DCIS, 152 from invasive breast cancer and 14 from de novo metastatic breast cancer. 40% of patients with DCIS with underwent WLE, 40% underwent mastectomy and 20% were not offered an operation as they were unfit. Invasive breast cancer accounted for the majority of cases. 86% were ER/PR positive and 12.2% were Her-2 positive. 35.7% underwent mastectomy, 64.4% underwent WLE and 0.8% VAB excision. 51.7% had Sentinel node biopsy, 15.3% underwent axillary clearance and 1.7 % had axillary sampling. 7.9% of patients presented with metastatic disease. 2.6% of those patients had palliative radiotherapy. Primary endocrine therapy was commenced on 21.1% of patients. Factors that lead to PET were that 47% of patients were unfit for an operation, 20.6% refused surgical intervention, 11.7% had concurrent aggressive malignancy and 8.8% were inoperable.

Conclusions

Overall, successful results were achieved for this group of patients compared to the national outcomes. 99.4% of patients in our centre had triple assessment prior to MDT. Further review of functional status and service outcomes will be required to be audited.
379 Improving Flow: A Quality Improvement Project on The Processing of Vascular Surgical Microbiology Samples
Authors: Wang L , Gilbert J , Ireland D , Samarasinghe D , Sritharan G
Published: October 2021

Aim

Tissue samples taken during vascular surgical operations are commonly sent for microbiological analysis, owing to the relatively high incidence and serious consequences of infection in these cases. Delays in obtaining results from these samples can hinder clinical management, leading to prolonged inpatient stay and adverse clinical outcomes. The aim of this audit was to identify causes for delay in obtaining microbiology results and to improve the service.

Method

A closed loop quality improvement project performed at a tertiary vascular centre in London. We initially identified all tissue microbiology samples sent from vascular surgical operations performed during April 2019 and record the time when samples reach microbiology laboratory and the time when results were made available. Re-audit data was collected in November 2019.

Results

Initial audit showed that on average, results were available for clinicians 9.1 days after the sample was taken and 7.3 days after the sample had reached the laboratory. Samples required an average of 44 hours to transit to the laboratory and notably there is delay if surgery is performed on Friday (71 hours). Additionally, one sample was missing. Following utilization of the urgent sample pathway and raising awareness amongst staff, re-audit data showed significant reduction in average time of transit (33 hours) with much reduced transit time on Friday (36 hours). Results were available 7.7 days following sample date, compared to 9.1 days before.

Conclusions

Utilization of existing pathway and staff training can reduce delays in microbiology sample processing. However, further analysis is necessary to ensure sustained improvement.
396 A 6-Month Audit of Initial Diabetic Foot Assessment and Documentation for Patients Undergoing Major Lower Limb Amputations in An Orthopaedics Ward
Authors: Lai L , Wong L Y , bin Hassan Z
Published: October 2021

Aim

To determine if adequate diabetic foot assessment and documentation were done at the Orthopaedics ward for patients undergoing a below-knee amputation (BKA) or above-knee amputation (AKA).

Method

Retrospective data from August 2019 to January 2020 were taken from paper documentation and e-records from the Orthopaedics ward and operation theatre. Diabetic foot assessments were based on the ASEANPlus guidelines for diabetic foot wounds which included foot inspection (for dermatological or musculoskeletal abnormalities), vascular (palpation of dorsalis pedis and posterior tibial pulses, ABSI measurement) and neurological assessments (testing of sensation and ankle reflexes). The assessments were deemed “adequate” or “inadequate” based on the information found on documentation.

Results

Only 67/81 data pieces were available for analysis (AKA=26, BKA=41), with an average age of 60 years. Inspection of the foot was most adequately assessed and documented (100%), followed by vascular and neurological assessment. For vascular assessment, palpation of pulses was done in 94% cases, and ABSI was performed in 76%. For neurological assessment, assessment of sensation was performed in 55%, while ankle reflexes were only assessed and documented in 25% cases.

Conclusions

Overall, the local practice had poor documentation of diabetic foot assessment, especially in vascular and neurological assessments. Possible reasons for poor practice include lack of guidance for incoming junior doctors starting their Orthopaedics rotation, and subsequently, the lack of skills and confidence in performing said assessments. Measures that could be done to improve the quality of practice include teaching key examinations to junior staff and having closer monitoring of notes documentation during ward rounds.
421 Closed loop analgesia audit, a Single Centre Experience in Raigmore Hospital, Inverness, Scotland
Authors: Chan J H
Published: October 2021

Aim

Assess are we following the analgesic step ladder accurately and if not are the reasons clear and documented?

Method

A closed-loop audit performed on the use of the WHO Analgesic ladder in surgical patients. We looked at the compliance of the analgesic ladder and are the reasons documented or explained when the ladder is not followed. The data was collated, analysed, and presented at an audit meeting. We then implemented changes in the form of educational sessions and information leaflets sharing, as well as email reminders among staff. Post-implementation showed an improvement in the documentation when the analgesic ladder was not followed.

Results

A total of 103 surgical patients were included. Prior to the implementation of interventions, 83.3% of patients had analgesia prescribed following the analgesic ladder. Of those remaining patients who had analgesia prescribed not according to the analgesic ladder, only 50% documented the indications and reasons. Post-implementation, the analgesic ladder compliance dropped to 50.9% with documentation improvement to 56%.

Conclusions

All surgical patients have prescribed analgesia when needed. Though WHO ladder compliance has shown reduction compared to the first data sample, the reasons are clinically justified, and improvements have been shown in documentation after intervention though there is still room for improvement for documentation. This is perhaps surgical teams are more aware of the choice of analgesia used post-intervention while taking the analgesic ladder into consideration. Stepwise multimodal analgesia prescribing will improve analgesic effect hence improves post-operative recovery hence reduce the length of hospital stay as part of the ERAS protocol.
572 Closed-Loop Clinical Audit on Blood Results in Urology Department During Ward Rounds
Authors: Sahni D S , Kosk P
Published: October 2021

Aim

Clinical governance states that blood results should be flagged during ward rounds to enable better assessment of inpatients. As per our institutional Protocol, each patient is assigned a blood sheet which should be updated every day with outstanding bloods flagged with a circle. The aim of the audit was to evaluate the quality of blood result sheets and to discuss results in order to enhance patient care.

Method

Data was collected from the Urology ward at Glasgow Royal Infirmary continuously during November 2020. We reviewed the flagging of abnormal bloods and whether clear documentation of baseline eGFR was included. Intervention was carried out by series of discussion with the nursing and the medical staff along with display posters throughout the ward and staff rooms.

Results

Overall, first cycle assessed 65 folders and second assessed 79. We noticed that the flagging of outstanding blood results increased from 70% to 74%. Documentation of baseline eGFR raised from 32% to 44%. Initially, only 73% of results were appropriately placed in the correct patient nursing folder which improved and reached 100% on review.

Conclusions

The first cycle of the audit demonstrated serious breach of protocols which could delay and affect patient care. The re-audit cycle post intervention illustrated that active efforts on the part of medical and nursing staff can significantly improve the outcomes. However, sustained intervention in the form of audits and induction program is needed to bring a sustainable change in the departmental practice.
580 Vascular Distal Bypass Early Surveillance Audit
Authors: Soliman H , Halawa M , Awad R , Tan J
Published: October 2021

Introduction

Due to inconsistency in Duplex surveillance following distal bypass for peripheral arterial disease at our district general hospital. We planned an audit aiming to assess our current early surveillance of distal vascular bypass.

Method

The latest twenty patients who underwent distal bypass were collected retrospectively from the theatre’s records. Their clinical and imaging records were analysed to ascertain the timing of 1st duplex after the procedure. We also examined the discharge medications. We chose the standard advised by Society for Vascular Surgery that every patient following the procedure ideally should have (Clinical examination + ABPI + Duplex) at 1, 3, 6 and 12 months then annually.

Results

8 patients (40%) had a Duplex within 1 month, while 10% did not have a scan at all. Time range between the procedure and first Duplex was 1-11 months with a mean of 4 months. All patients were discharged on at least a single antiplatelet agent while only 70% were prescribed statins. Six patients needed an intervention for blocked graft but eventually failed, only one patient had a Duplex in a timely fashion, the stenosed graft was salvaged by angioplasty.

Conclusions

There was no clear standardized surveillance protocol for vascular team juniors to follow. In addition, discharge of distal bypass patients sometimes is carried by general surgery team during weekends and unlikely that a Duplex is booked. We suggested booking the Duplex in theaters soon after performing the procedure to ensure inclusion in the surveillance protocol, education of junior doctors and re-auditing in 1 year.