ItemSuccessful treatment of ureteral-stent-related fungal ball using fluconazole instillation through a nephrostomy tube(Elsevier, 2023-09-01) Chacko, A. Z.; Misra, S.The kidneys are the most common solid organ to be infected by Candida sp. And may occur due to hematogenous spread, ascending infection, or with the presence of stent and nephrostomy tubes. Evidence for treatment is limited to case reports. We successfully cleared a candida infection of a ureteric stent in a 35-year-old diabetic gentleman by instilling 300 mg of fluconazole in 500 mL of normal saline over 8 hours once daily for 7 days via the nephrostomy tube. ItemOpenSAFELY NHS Service Restoration Observatory 2: changes in primary care clinical activity in England during the COVID-19 pandemic(Royal College of General Practitioners, 2023-05-01) Curtis, H. J.; MacKenna, B.; Wiedemann, M.; Fisher, L.; Croker, R.; Morton, C. E.; Inglesby, P.; Walker, A. J.; Morley, J.; Mehrkar, A.; Bacon, S. C.; Hickman, G.; Evans, D.; Ward, T.; Davy, S.; Hulme, W. J.; Macdonald, O.; Conibere, R.; Lewis, T.; Myers, M.; Wanninayake, S.; Collison, K.; Drury, C.; Samuel, M.; Sood, H.; Cipriani, A.; Fazel, S.; Sharma, M.; Baqir, W.; Bates, C.; Parry, J.; Goldacre, B.BACKGROUND: The COVID-19 pandemic has disrupted healthcare activity across a broad range of clinical services. The NHS stopped non-urgent work in March 2020, later recommending services be restored to near-normal levels before winter where possible. AIM: To describe changes in the volume and variation of coded clinical activity in general practice across six clinical areas: cardiovascular disease, diabetes, mental health, female and reproductive health, screening and related procedures, and processes related to medication. DESIGN AND SETTING: With the approval of NHS England, a cohort study was conducted of 23.8 million patient records in general practice, in situ using OpenSAFELY. METHOD: Common primary care activities were analysed using Clinical Terms Version 3 codes and keyword searches from January 2019 to December 2020, presenting median and deciles of code usage across practices per month. RESULTS: Substantial and widespread changes in clinical activity in primary care were identified since the onset of the COVID-19 pandemic, with generally good recovery by December 2020. A few exceptions showed poor recovery and warrant further investigation, such as mental health (for example, for 'Depression interim review' the median occurrences across practices in December 2020 was down by 41.6% compared with December 2019). CONCLUSION: Granular NHS general practice data at population-scale can be used to monitor disruptions to healthcare services and guide the development of mitigation strategies. The authors are now developing real-time monitoring dashboards for the key measures identified in this study, as well as further studies using primary care data to monitor and mitigate the indirect health impacts of COVID-19 on the NHS. ItemDrugless and radiographer led: the start of a new era for CT coronary angiography(BMJ, 2023-06-01) Morgan-Hughes, G.; McNally, R.; Gibbs, C. G.; Iacovides, S.; Kirat-Rai, P.; Thiriphoo, N.; Powell, A.; Stuckey, C.; Thorpe, R.; Mayo, L.; Roobottom, C.OBJECTIVE: Since inception CT coronary angiography (CTCA) has required facilitating beta blockers (BB). However, CT technology has improved rapidly as has radiographer and reporter expertise. Using these factors, we instituted a radiographer led cardiac CT service (RLCCTS), without routine BB, which we studied for quality control (QC). METHODS: RLCCTS started October 2021 using a wide detector array CT system, with 20 min slots. QC study was registered with the clinical audit team, University Hospitals Plymouth, CA_2020-21-118. Uniform reporting was agreed including indication, BB administration, demographics, dose length product (DLP) and the coronary artery disease-reporting and data system (CAD-RADS) score. Uncertain CAD-RADS meant a non-diagnostic scan (NDS). Six months of data were collected; stable chest pain (SCP) patients, who have national CTCA QC comparators, were analysed using descriptive statistics. RESULTS: Of 1475 patients, 447 were not SCP patients-known CAD (157); valves (286); removed (4, data incomplete) leaving 1028 SCP patients CTCA for analysis. Demographics-mean age 63 years, body mass index 29, 50.4% women. BB therapy-four patients (two recalls). Overall, 36/1024 or 3.5% were NDS; median DLP 173mGy×cm; mean heart rate (HR) 70 bpm, 99/1024 or 9.7% HR >90 bpm (45% not sinus rhythm). CONCLUSIONS: Quality for RLCCTS was judged by NDS rate and DLP. National QC comparators suggest 4% NDS rate; median DLP for SCPP CTCA 209 mGy×cm. RLCCTS compares favourably. With modern cardiac CT, experienced radiographers and reporters, 'drugless' RLCCTS can deliver 20 min slot CTCA with satisfactory QC indicators. ItemEleven key measures for monitoring general practice clinical activity during COVID-19: A retrospective cohort study using 48 million adults' primary care records in England through OpenSAFELY(eLife Sciences Publications Ltd., 2023-07-01) Fisher, L.; Curtis, H. J.; Croker, R.; Wiedemann, M.; Speed, V.; Wood, C.; Brown, A.; Hopcroft, L. E. M.; Higgins, R.; Massey, J.; Inglesby, P.; Morton, C. E.; Walker, A. J.; Morley, J.; Mehrkar, A.; Bacon, S.; Hickman, G.; Macdonald, O.; Lewis, T.; Wood, M.; Myers, M.; Samuel, M.; Conibere, R.; Baqir, W.; Sood, H.; Drury, C.; Collison, K.; Bates, C.; Evans, D.; Dillingham, I.; Ward, T.; Davy, S.; Smith, R. M.; Hulme, W.; Green, A.; Parry, J.; Hester, F.; Harper, S.; Cockburn, J.; O'Hanlon, S.; Eavis, A.; Jarvis, R.; Avramov, D.; Griffiths, P.; Fowles, A.; Parkes, N.; MacKenna, B.; Goldacre, B.BACKGROUND: The COVID-19 pandemic has had a significant impact on delivery of NHS care. We have developed the OpenSAFELY Service Restoration Observatory (SRO) to develop key measures of primary care activity and describe the trends in these measures throughout the COVID-19 pandemic. METHODS: With the approval of NHS England, we developed an open source software framework for data management and analysis to describe trends and variation in clinical activity across primary care electronic health record (EHR) data on 48 million adults.We developed SNOMED-CT codelists for key measures of primary care clinical activity such as blood pressure monitoring and asthma reviews, selected by an expert clinical advisory group and conducted a population cohort-based study to describe trends and variation in these measures January 2019-December 2021, and pragmatically classified their level of recovery one year into the pandemic using the percentage change in the median practice level rate. RESULTS: We produced 11 measures reflective of clinical activity in general practice. A substantial drop in activity was observed in all measures at the outset of the COVID-19 pandemic. By April 2021, the median rate had recovered to within 15% of the median rate in April 2019 in six measures. The remaining measures showed a sustained drop, ranging from a 18.5% reduction in medication reviews to a 42.0% reduction in blood pressure monitoring. Three measures continued to show a sustained drop by December 2021. CONCLUSIONS: The COVID-19 pandemic was associated with a substantial change in primary care activity across the measures we developed, with recovery in most measures. We delivered an open source software framework to describe trends and variation in clinical activity across an unprecedented scale of primary care data. We will continue to expand the set of key measures to be routinely monitored using our publicly available NHS OpenSAFELY SRO dashboards with near real-time data. FUNDING: This research used data assets made available as part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation (grant ref MC_PC_20058).The OpenSAFELY Platform is supported by grants from the Wellcome Trust (222097/Z/20/Z); MRC (MR/V015757/1, MC_PC-20059, MR/W016729/1); NIHR (NIHR135559, COV-LT2-0073), and Health Data Research UK (HDRUK2021.000, 2021.0157). ItemImproving the quality of rehabilitation following anterior cruciate ligament reconstruction surgery, in an outpatient physiotherapy department(BMJ, 2023-07-01) Henning, M.; Henning, R.; Dummett, J.Anterior cruciate ligament reconstruction (ACLR) is a type of orthopaedic knee surgery and physiotherapy rehabilitation is undertaken for several months postoperatively, often with the aim of returning the patient to sport. Variations in postoperative protocols to guide rehabilitation exist between National Health Service (NHS) Trusts. Although there is no single guideline to guide clinicians, strong evidence does support several clinical measures to be included post-ACLR, to improve outcomes and reduce the need for revision surgery. This project aimed to align our NHS Trust's ACLR physiotherapy care with best-evidence.A literature review was completed to establish key quality standards for ACLR rehabilitation. A retrospective notes audit was then undertaken to quantify the baseline quality of care, measured against these standards. Quality improvement methods were used to improve the quality of care and postoperative rehabilitation processes for ACLR patients. A new evidence-based, postoperative rehabilitation protocol was created, a core group of clinicians was formed to see ACLR patients and a rehabilitation class, solely for ACLR patients was also implemented.The key process measure for the project was patients engaging in 'criteria-driven progressions of rehabilitation'. This 'criteria-driven progressions' rate increased from 0% at baseline to 100% during the project period. Overall, non-attendance rates maintained at a similar level from 5.4% at baseline to a final rate of 4.8%. There was also an increase in mean 'return to sport' times, from 6 to 9.9 months, which is in line with best-evidence recommendations.The previous rehabilitation provided in our trust was not aligned with current evidence. This quality improvement project has led to improvements in patient care and lessons from the project will allow other trusts to learn from the changes made, to improve their own care pathways.