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Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.

ObjectivesA retrospective analysis of relationship between pulse oximetry, lactate and fluid balance during first five post operative days and patient outcomes after Norwood stage 1MethodsA retrospective, single centre analysis of etiometric data during a 5 year period (Jan 2016- Dec 2020) was performed on children undergoing Norwood stage 1 procedure. SpO2 (minute by minute data), arterial lactate (229 total readings at various timepoints) and daily fluid balance was collected for the first five post operative days . The studied outcomes are listed in table 1.Results32 patients were identified. Four were excluded due to lack of access to etiometric data. Patient demography and surgical characteristics are demonstrated in table 1. Outcome parameters studied are demonstrated in table 2The ICU and hospital stays were higher in the children who died (23.5 and 62.5 days) as compared to the survivors (10.75 and 34 days) although not statistically significantly different [p=0.19 (los_icu), p=0.37 (los_hosp)]Median percentage of time pulse saturations (SpO2) remained < 75% was 22.4 + 12.3; >85% was 11.7 + 8.8 and within targeted range of 75%-85% was 62.8+ 9.4.No statistically significant correlation was found between the percentage of time saturations were l<75% or >85% or daily fluid balance with any of the studied outcomes. They were also not able to significantly predict any of the listed outcomes. However, lactate at 42 hr and beyond demonstrated moderate to strong association with los_icu (r=.55,p=.01). Lactate at 42 hr was also able to significantly predicted los_icu, F(1, 19) = 8.1, p =.01 accounting for 29.9% (R2) of the variation in los_icu (adjusted R2 = 26.3%) (figure 1). Multiple regression model(s) including lactate , fluid balance, cardiopulmonary bypass times and pulse oximetry times were not good.ConclusionOnly persistent hyperlactatemia at 42 hours showed an association and predicted increased length of ICU stay. Limitations of a single centre, retrospective nature and small sample size prevent generalization of these results. A larger prospective study alongside analysis of data from a larger single ventricular registry could provide more information about the utility of bedside etiometry data in studying patient journey and outcomes.Abstract 7970 Figure 1Linear regression model for lactate at 42 hours post operatively and ICU length of stay[Image Omitted. See PDF.]Abstract 7970 Table 1Patient demography and surgical characteristics[Image Omitted. See PDF.]Abstract 7970 Table 2Outcome parameters[Image Omitted. See PDF.]ReferencesPrimeaux J, Salavitabar A, Lu JC, Grifka RG, Figueroa CA. Characterization of post-operative hemodynamics following the norwood procedure using population data and multi-scale modeling. Front Physiol. 2021;12:603040. Published 2021 May 13. doi:10.3389/fphys.2021.603040Wasaki T, Takeuchi M, Taga N, Oe K, Shimizu K, Morita K. Masui. 2004;53(9):1008–1013.

Clozapine remains the only evidence-based antipsychotic for treatment-resistant schizophrenia (TRS). The ability to predict which patients with their first onset of schizophrenia would subsequently meet criteria for treatment resistance (TR) could help to diminish the severe functional disability which may ensue if TR is not recognized and correctly treated. This is a 5-year longitudinal assessment of clinical outcomes in a cohort of 246 first-episode schizophrenia spectrum patients recruited as part of the NIHR Genetics and Psychosis (GAP) study conducted in South London from 2005 to 2010. We examined the relationship between baseline demographic and clinical measures and the emergence of TR. TR status was determined from a review of electronic case records. We assessed for associations with early-, and late-onset TR, and non-TR, and differences between those TR patients treated with clozapine and those who were not. Seventy per cent (n = 56) of TR patients, and 23% of the total study population (n = 246) were treatment resistant from illness onset. Those who met criteria for TR during the first 5 years of illness were more likely to have an early age of first contact for psychosis (<20 years) [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.25-4.94] compared to those with non-TR. The relationship between an early age of first contact (<20 years) and TR was significant in patients of Black ethnicity (OR 3.71, 95% CI 1.44-9.56); and patients of male gender (OR 3.13 95% CI 1.35-7.23). For the majority of the TR group, antipsychotic TR is present from illness onset, necessitating increased consideration for the earlier use of clozapine.

ObjectivesThis project aimed to describe nutritional deficiencies seen in patients referred to the local specialty feeding clinic with an ARFID feeding pattern. The feeding clinic offers an MDT approach for children with complex feeding issues, who may be at risk of medical complications.MethodsA retrospective electronic case record analysis was completed for new referrals to the service in 2022. 3 records were rejected due to insufficient information, with further analysis completed on 46 records. Data included: reason for referral, nutritional deficiencies identified on laboratory testing and dietary history.ResultsThree main reasons for referral were identified: avoidant/restrictive feeding behaviour (ARFID) n=26 (56.5%), weaning from enteral tube feeding n=12 (26%) and weight faltering n=9 (19.5%).Further analysis was carried out for the 26 patients with an ARFID feeding pattern. In these patients the most common coexistent diagnosis was autism or suspected autism (73% n=19).21 patients (81%) were referred for bloods. Fourteen of these patients had at least one nutritional deficiency identified. The commonest deficiencies were iron (n=8), vitamin D (n=4), and vitamin C (n=4). Vitamin A, vit B12, folate, phosphate, calcium and zinc deficiencies were also found.Analysis of dietary history indicated that vit C deficiency was commonly found in those with dairy based diets, whereas those with vit A or B12 deficiency had predominantly potato based diets. Similar to findings in other studies.1 Those with iron deficiency alone were often on a multivitamin.None of those with nutritional deficiencies were documented as having nutritional deficiency disease e.g. scurvy or xerophthalmia.ConclusionIn these patients with an ARFID feeding pattern referred to a specialist clinic, there was a high pick up rate of nutritional deficiencies for those who had blood tests checked. No nutritional deficiency disease was reported in this group. However the challenge of performing investigations in this group, such as visual fields/acuity to identify nutritional optic neuropathy, are evident. Also, patient reporting of symptoms may be impaired.2 There was variation in the nutritional bloods ordered by clinicians, which will have impacted pick-up rates.Dietary history is key to identify those at risk of deficiency and the most likely deficiencies. Not all nutritional deficiency will be identified on laboratory testing as plasma levels may not reflect whole body stores.3 Following a detailed dietary history, there should be a low threshold to consider nutritional screening in those with significantly restricted eating, particularly if they do not tolerate multivitamin supplementation.ReferencesYule S, et al. Nutritional deficiency disease secondary to ARFID symptoms associated with autism and the broad autism phenotype: a qualitative systematic review of case reports and case series. J Acad Nutr Diet, 2021.Schimansky S. et al. Nutritional blindness from avoidant-restrictive food intake disorder – recommendations for the early diagnosis and multidisciplinary management of children at risk from restrictive eating. Archives of Disease in Childhood, 2023.Assessment and Treatment of Children and Young people with Avoidant Restrictive Food Intake Disorder (ARFID): BDA ARFID Special Interest Group, June 2022.

Studies of the long-term course and outcome of psychoses tend to focus on cohorts of prevalent cases. Such studies bias samples towards those with poor outcomes, which may distort our understanding of prognosis. Long-term follow-up studies of epidemiologically robust first-episode samples are rare. AESOP-10 is a 10-year follow-up study of 557 individuals with a first episode of psychosis initially identified in two areas in the UK (South East London and Nottingham). Detailed information was collated on course and outcome in three domains (clinical, social and service use) from case records, informants and follow-up interviews. At follow-up, of 532 incident cases identified, at baseline 37 (7%) had died, 29 (6%) had emigrated and eight (2%) were excluded. Of the remaining 458, 412 (90%) were traced and some information on follow-up was collated for 387 (85%). Most cases (265, 77%) experienced at least one period of sustained remission; at follow-up, 141 (46%) had been symptom free for at least 2 years. A majority (208, 72%) of cases had been employed for less than 25% of the follow-up period. The median number of hospital admissions, including at first presentation, was 2 [interquartile range (IQR) 1-4]; a majority (299, 88%) were admitted a least once and a minority (21, 6%) had 10 or more admissions. Overall, outcomes were worse for those with a non-affective diagnosis, for men and for those from South East London. Sustained periods of symptom remission are usual following first presentation to mental health services for psychosis, including for those with a non-affective disorder; almost half recover.

Why did you do this work?Frequent attenders to Emergency Departments (EDs) contribute to overcrowding, long wait times, increased workload, and financial pressures on an already stretched health care service.1 In this Paediatric Emergency Department (PED) we see a number of children who are ‘frequent attenders’.Understanding the characteristics of these frequent attenders is crucial for developing targeted interventions. Previous studies have shown themes include children <5 years, chronic health conditions, and psychosocial factors including mental health and parental anxiety.2 What did you do?In December 2023 a multidisciplinary group was set up in the Paediatric Emergency Department (PED) to identify patients frequently attending the PED and to gain insight into factors influencing attendances. Patients included were <16 years old who attended the PED ≥7 times within a 3-month period (pulled from electronic case records) as well as patients identified by PED clinicians. Case notes are reviewed and discussed at a monthly meeting. 70 retrospective patient records were analysed from December 2023- July 2024.Cases are reviewed to see how targeted interventions can ensure that children/families receive the right care, in the right place at the right time.1 What did you find?Factors contributing to increased number of ED attendances are complex. Themes identified were: expectations of the health service; parental worry/overestimation of the severity of their child’s illness; heightened anxiety due to previous hospital admissions/chronic underlying health conditions. Also difficulty in accessing their GP in terms of location or ease of getting appointments.Frequent attenders identified constituted approximately 0.14% of all ED attendances in the time period. 30 (43%) of children were highlighted for health visitor/school nurse support including safeguarding supervision. 21 (30%) were referred to another service/speciality, including the respiratory rapid access clinic. 10 (14%) were known to the hospital with a chronic condition. 5 (7%) of families were educated on other services available. 4 (6%) parents were felt to have significant health anxiety. There were 4 (6%) presentations with childhood mental health concerns and in 4 (6%) there was a safeguarding concern.What does it mean?Reducing frequent attendances requires a multifaceted approach.3 We have identified common themes and will continue to build patient and public partnerships.4 Multi-agency working should continue, and we aim to submit a business case for a health visitor based in the PED.The frequent attender’s group has raised awareness amongst ED clinicians and enabled staff to discuss openly with families who attend the department frequently. Parental/caregiver education is vital, with signposting to alternative services, empowering self-care for limited ailments/illness, and encouraging the use of primary care. A frequent attender’s leaflet with links to resources has been developed to be used in the ED to aid discussion with families. We hope that this model can be used elsewhere to improve patient care.ReferencesGreenfield, et al. BMJ Open 2021.Malcolm, et al. PLoS ONE 2022.Blair, et al. Archives of Disease in Childhood 2017.Jacob, et al. Clinical Medicine 2016.

Maltreatment increases risk for psychopathology in childhood and adulthood, thus identifying mechanisms that influence these associations is necessary for future prevention and intervention. Emotion dysregulation resulting from maltreatment is one potentially powerful mechanism explaining risk for psychopathology. This study tests a conceptual model that distinguishes deprivation and threat as distinct forms of exposure with different pathways to psychopathology. Here we operationalize threat as exposure to physical and/or sexual abuse and deprivation as exposure to neglect. We test the hypothesis that threat and deprivation differentially predict use of avoidant strategies and total regulation. Data were drawn from the Longitudinal Studies on Child Abuse and Neglect (LONGSCAN study; N = 866), which followed high-risk children from age 4 to 18. At age 6, children and their parents reported on adversity exposure. Case records documented exposure to abuse and neglect. At 18, adolescents reported on regulation strategies and psychopathology. Regression analyses indicated that greater exposure to threat, but not deprivation, predicted greater use of avoidant strategies in adolescence. Moreover, avoidance partially mediated the longitudinal association between exposure to threat in early childhood and symptoms of internalizing psychopathology in adolescence. Results suggest that abuse and neglect differentially predict regulation strategy use and that regulation strategy use predicts psychopathology.

ObjectivesRespiratory illness is the leading cause of mortality in children with cerebral palsy (CP). A consensus statement published by Gibson et al identified 9 risk factors for respiratory disease in CP predisposing to increased 5 year risk of hospital admission with associated morbidity and healthcare burden.1 The aim of this project was to evaluate the number and demographics of children in Southern Trust with CP and identify their respiratory risk factors.MethodsCase records were identified from the Cerebral Palsy Register and Child Development Clinic. The specified inclusion criteria were as follows: age <18 years, resident in Southern Trust, diagnosis of CP.The Cerebral Palsy Register provided data regarding GMFCS classification, previous seizures, swallow difficulties and drooling. The patients’ electronic healthcare records were reviewed to determine respiratory hospital admissions over the previous 12 months, antibiotic use for respiratory infections, current seizures, diagnosis and treatment of reflux, frequent snoring and paediatric review within preceding 18 months.ResultsA total of 114 patients were identified. The GMFCS classification of the patients were as follows: Level 1 (23%), Level 2 (30%), Level 3 (14%), Level 4 (14%), Level 5 (19%). 70% of patients received a paediatric review over the preceding 18 months; all GMFCS Level 5 children were reviewed. 7% had a respiratory hospital admission over past 12 months; all were, or predicted to be, GMFCS Level 5 and comparatively younger (18% <6year, 5% 6–12year, 5% 12–18year).25% of patients had swallow difficulties; of whom 94% were GMFCS Level 4 or 5. 28% drooling issues; of which 78% were GMFCS were Level 4/5. 17% of patients had seizures in preceding 12 months. 9% had frequent respiratory symptoms; all were GMFCS Level 4/5. 9% had received at least 2 antibiotics for chest infections over the preceding 12 months; 90% were GMFCS Level 4/5. 23% of children had reflux; 84% were GMFCS Level 4/5. 5% of children snored frequently; 90% were GMFCS Level 4/5.ConclusionThere are many predisposing risk factors for respiratory hospital admission that can be challenging to recall in the outpatient setting. Children with GMFCS 4/5 have concomitant respiratory risk factors. Children <6 years appear to have greater risk of respiratory hospital admission. The findings suggest the introduction of a respiratory checklist for children with GMFCS 4/5 could ensure the modifiable risk factors are identified, optimised and prompt timely referral to a respiratory specialist.ReferenceGibson N, Blackmore AM, Chang AB, Cooper MS, Jaffe A, Kong WR, Langdon K, Moshovis L, Pavleski K, Wilson AC. Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement. Dev Med Child Neurol. 2021 Feb;63(2):172–182. doi: 10.1111/dmcn.14640. Epub 2020 Aug 9. PMID: 32803795; PMCID: PMC7818421.

Elucidating the heterogeneous etiologies of autism will require investment in comprehensive longitudinal data acquisition from large community based cohorts. With this in mind, we have established a hospital-university-based (HUB) database of autism which incorporates prospective and retrospective data from a large and ethnically diverse population. The collected data includes social-demographic characteristics, standardized behavioral testing, detailed clinical history from electronic patient records, genetic samples, and various neurological measures. We describe the initial cohort characteristics following the first 18 months of data collection (188 children with autism). We believe that the Negev HUB autism database offers a unique and valuable resource for studying the heterogeneity of autism etiologies across different ethnic populations.

Objectives To obtain timely and detailed data on COVID-19 cases in the United States, the Centers for Disease Control and Prevention (CDC) uses 2 data sources: (1) aggregate counts for daily situational awareness and (2) person-level data for each case (case surveillance). The objective of this study was to describe the sensitivity of case ascertainment and the completeness of person-level data received by CDC through national COVID-19 case surveillance. Methods We compared case and death counts from case surveillance data with aggregate counts received by CDC during April 5–September 30, 2020. We analyzed case surveillance data to describe geographic and temporal trends in data completeness for selected variables, including demographic characteristics, underlying medical conditions, and outcomes. Results As of November 18, 2020, national COVID-19 case surveillance data received by CDC during April 5–September 30, 2020, included 4 990 629 cases and 141 935 deaths, representing 72.7% of the volume of cases (n = 6 863 251) and 71.8% of the volume of deaths (n = 197 756) in aggregate counts. Nationally, completeness in case surveillance records was highest for age (99.9%) and sex (98.8%). Data on race/ethnicity were complete for 56.9% of cases; completeness varied by region. Data completeness for each underlying medical condition assessed was <25% and generally declined during the study period. About half of case records had complete data on hospitalization and death status. Conclusions Incompleteness in national COVID-19 case surveillance data might limit their usefulness. Streamlining and automating surveillance processes would decrease reporting burdens on jurisdictions and likely improve completeness of national COVID-19 case surveillance data.