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Introduction and hypothesis In 2019, the UK National Institute for Health and Care Excellence (NICE) recommended discussion of all primary prolapse cases at a multidisciplinary team (MDT) meeting prior to surgery. However, following the COVID-19 pandemic, face-to-face meetings were suspended. The aim of this study was to evaluate the role of MDT meetings in an observational retrospective review of primary prolapse cases and determine whether alternatives to face-to-face MDT meetings such as virtual and remote paper result in different outcomes. Methods A total of 100 consecutive patients with primary prolapse, who had already been through face-to-face MDT meetings in 2019, were subjected to remote paper (independent review by team members, who then submit a paper outcome to the MDT meeting chair) and a virtual MDT meeting by the same team (blinded). Outcomes included agree, minor amendment (changing the order of priority of the compartment, changing procedure from + to +/−), major amendment (adding/removing a compartment) and insufficient information. MDT outcomes were compared for remote paper, virtual, and face-to-face MDT options. Results In 88% of cases, face-to-face MDT meetings agreed to proceed unchanged (4% minor amendment, 7% major amendment, 1% insufficient information). This compared with 80% at virtual MDT (5% minor amendment, 11% major amendment, 4% insufficient information) and 74% when conducted by remote paper (5% minor amendment, 15% major amendment, 6% insufficient information). There was no significant difference in outcomes among the MDT meeting formats (Chi-squared 7.73, p =0.26). Conclusions Multidisciplinary team discussion changes management in a minority of primary prolapse cases. Similar MDT decisions are produced by virtual and remote paper formats, although the latter had the lowest concordance of opinions.

Ulcerative colitis and Crohn’s disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn’s and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn’s disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn’s disease, including patients, their families and friends.

BackgroundPatient-centred trial design and delivery; improves recruitment and retention, with a direct impact on increased cost and time efficiency of research; increases participant satisfaction; encourages participation by a more representative patient group; allows research teams to better meet participants’ psychosocial needs; and ensures outcomes that matter to patients are prioritised. Research in this area is increasing, however most explorations focus on narrow facets of trial participation. The aim of this project was to systematically identify the breadth and diversity of patient-centred factors influencing participation and engagement in clinical trials and collate these into an organising framework.MethodsRobust qualitative and mixed methods systematic reviews are becoming increasingly common in health research. The protocol for this review was prospectively registered on PROSPERO, CRD42020184886. We used the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework as a standardised systematic search strategy tool. 3 databases were searched as well as references checking, and thematic synthesis was conducted. Screening agreement was performed (Cohen’s kappa coefficient 0.97, excellent agreement) and code and theme checking were conducted by 2 independent researchers.ResultsData were drawn from 285 peer-reviewed articles. Approximately half were in oncology, with the others in 22 different specialities. 7 (2.5%) were in respiratory medicine. 300 discrete factors were identified, which were sorted into 13 major themes and subthemes. Themes and level-one subthemes are shown in the table 1. Many of the identified factors are straightforward, generalisable and transferable across most specialities and disease models. Others are complex, at times contradictory, and may be context or disease specific.Abstract P116 Table 1 Theme Level 1 Subtheme Prior to clinical trial participation Patient population perceptions of researchHow patients learn about trialsRecruitment methods Motivation to take part in trials Altruistic and societal motivationsIndividualistic motivationsIndividualistic and altruistic interaction Barriers to participation Practical barriersAttitudinal barriersProtocol design barriersInvestigational product factorsConflict of interest concernsBarriers created by study timelines Facilitators to participation Increasing trial flexibilityFinancial compensationOvercoming cultural and language barriersAssisting patients to understand the trialImproving trial design factors Demographic factors influencing the decision to enrol in trials General considerations and interaction potentialKnowledge and trustAgeGenderSexualityRace and ethnicitySocioeconomic statusEducation levelLanguage, religious and cultural considerationsFunctional statusFamily structureEmployment status Impact of care structure and experience on trial enrolment Location and structure of clinical carePrevious trials experiencesPrevious healthcare experience Two-way interaction between health status and trials Interaction between health status and trial enrolmentInteraction between trial participation with health and other HCPs Psychological impact Factors modifying impact on psychological wellbeingPositive psychological consequencesNegative psychological consequences Validity of consent General ConsiderationsPaediatric specific consent/assentConsent in difficult circumstances (e.g. intrapartum trials)Consent of incapacitated adults Impacts of participation on day-to-day life Aspects of trial participation with significant negative impact on lifeFactors improving trial participant experience Special considerations Reproductive healthEnd of life trials Leaving a trial before protocol completion Choosing to withdraw from a trialIntervention related reasons leading to withdrawalTrial design or implementation related reasons leading to withdrawalMajor life events resulting in withdrawalEarly closure or patient ineligibility Experiences of trials ending Anxiety about the end of trialsPost-trial follow up arrangementsConclusionsWe have used a robust systematic review methodology to develop a framework to guide other researchers towards the important patient-centred themes to consider when designing and delivering trials. Some of the identified factors are disease specific. Respiratory medicine currently lags behind other specialities such as oncology in identifying factors influencing patient perceptions and experiences of trials. Given the benefits of understanding and incorporating patient views into research, and the volume of active respiratory research, we suggest more exploration is needed in respiratory medicine and its subspecialities.

AimTo conduct a feasibility trial investigating a structured diagnostic pathway versus usual care for adults presenting with chronic breathlessness in primary care.MethodsTen GP practices were cluster randomised to a structured diagnostic pathway including a panel of early investigations (Intervention group) or Usual care. Eligible patients were recruited opportunistically: ≥40 years old, first presentation of chronic breathlessness, with no prior diagnosis for breathlessness. Feasibility outcomes included recruitment and retention rate. The number of investigations and coded diagnoses were recorded from the healthcare record. Patient reported outcome measures (PROMs) for breathlessness, mental health and health-related quality of life were collected at baseline, six and 12 months.Results48/220 (22%) patients were recruited between November 2019 and February 2021: 65% female, mean (SD) age 66(11) years, BMI 31.2(6.5), median (IQR) MRC dyspnoea scale 2(2–3). 41/48 (85%) participants returned PROMs. The Intervention group had a median (IQR) of 8(7–9) tests compared with 5(3–6) tests in UC within three months. At 12 months, 11/25 (44%) patients in the Intervention group had a coded diagnoses for their breathlessness versus 6/23 (26%) patients in Usual care. A comparison of the PROMs between groups are shown in table 1.Abstract P115 Table 1PROMs at baseline, six and 12 months Usual care (n=19) Intervention (n=22) Baseline 6 months 12 Months Baseline 6 months 12 Months Mean group difference (IG-UC) change from baseline at 12 months MDP† Immediate perceptionEmotional response 14.0(12.9)9.8 (12.2) 13.7 (14.0)8.4 (12.0) 16.6 (15.2)10.9 (12.5) 24.8 (12.1)18.6(12.0) 13.6 (10.6)11.9(11.9) 12.0 (10.1)11.7 (13.1) -15.4 (3.5)*-8.5 (3.8)* Dyspnoea-12† 7.4 (5.8) 9.4 (7.9) 9.1 (9.0) 12.7 (8.2) 8.7 (8.4) 8.1 (7.0) -6.3 (2.6)* CHQDyspnoea 3.3 (1.2) 3.6 (1.4) 3.7 (1.4) 3.0 (1.3) 4.5 (1.4) 4.3 (1.7) 1.0 (0.5)* HADSAnxietyDepression 5.7 (4.1)5.6 (3.7) 5.6 (4.6)5.3 (4.0) 5.3 (4.3)6.1 (4.2) 7.5 (4.5)5.3 (3.2) 5.7 (3.1)4.7 (4.4) 7.3 (4.5)6.0 (4.9) 0.3 (1.0)0.3 (1.0) EQ5D-5LIndex ScoreVAS 0.76 (0.16)68 (15) 0.70 (0.33)66.3 (18.2) 0.72 (0.25)67 (20) 0.63 (0.31)74 (17) 0.76 (0.20)74.30 (14.8) 0.71(0.26)67 (19) 0.12 (0.07)*-6 (5) *mean difference between groups in change from baseline at 12 months is greater than minimal clinical important difference (MCID).Data presented as Mean (SD) or Mean (SE) for between group difference. MDP = Multidimensional Dyspnoea Profile, CHQ = Chronic Heart Questionnaire (self-report), HADS = Hospital Anxiety and Depression Score, EQ5D-5 L = EuroQol- 5 Dimension 5 level questionnaire, VAS = Visual Analogue Scale. †a reduction in score indicates reduced symptom burden.ConclusionThe recruitment and retention rate indicate a cRCT to investigate a structured diagnostic pathway in primary care is feasible. The Intervention group underwent more investigations and more patients had a recorded coded diagnosis at 12 months compared with Usual care. PROMs indicate potential patient level benefit, but the intervention group were more symptomatic at baseline. An adequately powered clinical trial is needed to investigate these initial results.Please refer to page A214 for declarations of interest related to this abstract.

IntroductionInducible laryngeal obstruction (ILO) is an upper airway condition which describes a reversible narrowing of the larynx, leading to breathlessness symptoms. Due to poor recognition and similar presentation to asthma, the diagnosis of ILO can be delayed up to 4.8 years. The current gold standard assessment tool is currently laryngoscopy. However, there are inherent challenges with this invasive method.AimsTo determine the prevalence of ILO in a UK respiratory population.To evaluate the use of spirometry and impulse oscillometry as diagnostic tools for ILO, and their predictive ability to determine laryngoscopically- confirmed ILO.Method98 patients were included in the service evaluation: 68 females (mean ± SD: age 54 ± 15.9) and 30 males (mean ± SD: age 55 ± 14.2), all of whom had been referred to a Tertiary referral service.Prevalence calculations were used to determine the prevalence of ILO as well as to establish characteristics displayed in those who had been diagnosed with ILO. Binary logistic regression was also used to examine whether spirometry values (FEV1, FEV1/FVC and ERV) and IOS values (Z5 Hz, R5 Hz, Rin5) were associated with the likelihood of having an ILO diagnosisResultsThe model incorporating spirometry parameters was statistically significant (p=0.00), with FEV1/FVC and ERV significantly contributing towards the model. This is suggestive that spirometry values FEV1/FVC and ERV can be potential predictors of diagnosing ILO. However, the model incorporating Z5 Hz, R5 Hz and Rin5 parameters was not statistically significant (p=0.129, p=0.119, p=0.061), and did not therefore significantly contribute towards the model. This is suggestive that the IOS values Z5 Hz, R5 Hz, Rin5 were not found to be potential predictors of diagnosing ILO.ConclusionThis study found spirometry values FEV1/FVC and ERV were significant predictors of a subsequent diagnosis of ILO. However, IOS values Z5 Hz, R5 Hz, Rin5 were not found to be predictors of diagnosing ILO in the model.Further prospective studies with larger patient groups may be useful to investigate any further value of the use of IOS as a clinical indicator in the assessment of ILO.

IntroductionInducible laryngeal obstruction (ILO) is defined as an inappropriate laryngeal closure causing difficulty breathing. Speech and language therapy (SLT) is the cornerstone of treatment. This survey aimed to gain insight into ILO services within the UK and its treatment and management.MethodThe 24-question online survey was completed by 43 speech and language therapists across the UK.ResultsAll participants had heard of the term ‘ILO’ and were practicing in a range of adult services; ENT (n=40), respiratory (n=25), head and neck cancer (n=14), acute (n=9), neurology (n=5), gastroenterology (n=7), allergy (n=5), critical care (n=4), rehabilitation (n=7), community (n=12) and other (n=4).31 participants (74%) were involved in ILO diagnosis, 36 (83%) in treatment, 34 (79%) worked within a multi-disciplinary team (MDT) which included respiratory physicians (n=26), ENT consultants (n=34), SLT (n=36), physiotherapists (n=21), psychologists (n=10), clinical nurse specialists (n=16), dieticians (n=12), gastroenterologist (n=10), nurse (n=2).15 (36%) have access to local MDT meetings, 5 (12%) regional MDT meetings, 39 (90%) to laryngoscopy and 14 (33%) to provocation laryngoscopy. Laryngoscopy (± provocation) was completed by ENT (n=19), SLT (n=11), respiratory physician (n=3) or other (n=6).Participants reported patients having a range of co-morbidities including asthma (n=40), breathing pattern disorder (n=35), reflux (n=39), nasal disease (n=25), bronchiectasis (n=22), chronic cough (n=37) and other (n=15) and had access to a range of diagnostic testing.Therapy was provided either face to face (n=17), virtually (n=2), both (n=17) or neither (n=5). Most therapy was provided one-to-one (94%) with one SLT providing group therapy.The wait time for diagnosis ranged from less than 3 months (n=9), 3–6 months (n=16), 7–12 months (n=7) and greater than 12 months (n=2). The wait time for therapy ranged from less than 3 months (n=19), 3–6 months (n=14), 7–12 months (n=2). Barriers to treatment and diagnosis are shown in figure 1.Abstract P107 Figure 1Bar chart showing barriers to service developmentConclusionsParticipants felt the greatest barriers to service development were lack of funding, training, and expertise. We hope this survey will identify the need for further service provision and aim for more streamlined services, reducing inequalities depending on geographical location.

IntroductionThe merger of two similar hospitals but with very different sleep pathways allowed a comparison, particularly of the use of Clinical Nurse Specialists (CNS) on one of the sites.MethodsA retrospective study was conducted on patients set up on CPAP on the two sites, sampled from August to December 2018; allowing a reasonable follow up period before the covid pandemic started. Data were collected on time from referral to CPAP set up, severity, patient outcomes, and approximate costs of the variable parts of the pathways. A total of 132 episodes were investigated.ResultsAll patients on the consultant led site saw a consultant at least once and were all given an autoset device. None of the patients on the CNS led site required a consultant appointment, and only one was given an autoset device, the rest receiving a fixed pressure machine. This resulted in significant differences in set up costs between the two sites. The use of CNS significantly reduced waiting times by expanding the number of new appointments available. Compliance hours and change in Epworth score were comparable between the two sites. The number of patient visits on the consultant led site was higher than the CNS led site.Interestingly severity was significantly higher on the CNS site, however a number of patients on the consultant site were given CPAP on the basis of an essentially normal oximetry, but with compelling symptoms which may explain at least part of this difference. Mean CPAP pressure used was significantly lower on the CNS site, which predominantly relied on fixed pressure machines, however as the compliance hours and change in Epworth sleepiness scale were not significantly different, this does not suggest undertreatment in this group. BMI was not different in the two patient groups, and thus does not explain the differences seen in severity or CPAP pressure.Abstract P111 Table 1Mean (unless otherwise stated) figures comparing the patients, their outcomes, and the costs of the two pathways Consultant led CNS led Referral to set up no. days 213.5 56.0 (p<0.01) Desaturation index 20.5 39.1 (P<0.01) Body mass index 36.4 35.6 (NS) Improvement in Epworth 7.19 5.6 (NS) Compliance Hours 5.36 5.73 (NS) Proportion of patients compliant 61.9% 67.6% CPAP Pressure 12.21 10.49 (p<0.01) Number of patient visits 5.83 4.84 Estimated variable staff costs £39.73 £27.42 Machine costs £350.00 £181.89 Total variable costs £389.73 £209.31 ConclusionsCNS led sleep clinics increase capacity and reduce costs compared to consultant led ones, without negatively impacting patient outcomes. The use of autoset devices did not significantly influence compliance and sleepiness compared to fixed pressure machines in this study.

IntroductionPatients with Bronchiectasis generally have a cough, for which suppression is normally not recommended (BTS, 2018)1. In clinical practice we noticed an increased referral from our physiotherapy team to Speech & Language Therapy (SLT), for management of chronic cough and upper airway symptoms.MethodWe conducted a retrospective review of the referral databases looking at a period of 20 months (April 2020 to January 2022). A cohort of 274 patients were reviewed, who had been referred with a diagnosis of Bronchiectasis. 28 (10%) were identified who had either been referred to SLT or Physiotherapy by the other specialty, or to both from the Consultant team. All patients had bronchiectasis diagnosed by High Resolution CT scan. Further analysis of this group was carried out.ResultsThe main reasons for referral were isolated. From Physiotherapy this was predominantly an ongoing symptom of globus pharyngeus and dry non-productive cough despite adequate clearance. The referrals from SLT were to ensure adequate secretion management (figure 1).All the 28 patients had developed a dry and less productive cough which originated at the level of the throat, with or without a separate productive cough. All these patients were suspected to have Inducible Laryngeal Obstruction (ILO) or Cough Hypersensitivity, 19 (68%) have had this confirmed on diagnostic laryngoscopy. The remaining patients have not had this investigation due to a combination of factors.In general, those referred from Physiotherapy to SLT had a higher BSI (bronchiectasis severity index) median of 5 compared to 2. Infection rates were on average less than 2 per year and all were undertaking effective clearance.On review of all referral cohorts for those who had attended at least two treatment appointments with SLT (N=16), 31% (N=5) have been discharged with resolved symptoms and a further 44% (N= 7) reported improved control of symptoms.Abstract P109 Figure 1Reason for referralConclusionWhat this cohort shows is that within the management of Bronchiectasis, it is appropriate to consider upper airway cough in those that continue to be symptomatic despite good chest clearance and minimal infections.ReferenceBritish Thoracic Society (2018). British Thoracic Society Guideline for Bronchiectasis in adults.

IntroductionA number of series have reported on the use of minimally invasive diaphragmatic plication (MI-DP), but very little is reported on patients with diaphragmatic paralysis who do not undergo surgery. We reviewed all patients referred to us for consideration of MI-DP to gain insight into the epidemiology and natural history of the disease, and how this may influence surgical decision-making.MethodsWe retrospectively reviewed all patients referred for consideration of MIS-DP from April 2017 to May 2022 to analyse demographic, clinical and radiographic data. In all cases, before surgery was performed, there was a minimum 18-month observation policy from first documented evidence of paralysis.Results58 patients were referred and screened. Demographics, aetiology, symptoms, physiological and radiological aspects are summarised in table 1. Radiological and/or symptomatic evidence of diaphragmatic paralysis was present for a median of 20 months (3–134) from onset to first surgical assessment. 15 patients (26%) underwent MIS-DP (M:F 8:7, median age 56, 22–77); symptomatic improvement was achieved in 14 (98%). 15 patients (26%) remained under review. 28 patients (48%) were rejected for surgery (reasons also reported in table 1). Of these, 8 were rejected due to symptomatic improvement, while 5 showed spontaneous recovery at a later stage after being turned down. In this subgroup (n=13, 22%), median time from onset to recovery was 32 months (21–68). Patients were more predominantly male (84%), younger (median 52), had slightly higher FEV1 (median 74%) and FVC (median 78%). Despite VC drop >15% being more frequent (46%), presence of paradoxical movement was less likely (23% only). The proportion of patients with severe symptoms was however similar, as it was radiological severity on CXR, laterality and distribution of aetiology.Abstract P110 Table 1ConclusionDiaphragmatic paralysis is a complex condition for which spontaneous recovery is not uncommon and surgery is indicated in select cases. A multidimensional assessment is required as no single aspect alone seems able to predict evolution. Our results support the continuation of a judicious 18-month minimum observation policy, which could merit extension for certain patients.

IntroductionILO is an important co-morbidity and mimic of asthma. Patients with ILO have a high symptom burden and are often inappropriately prescribed asthma treatments (including high dose oral corticosteroids) which are ineffective in treating ILO. ILO is diagnosed using Continuous Laryngoscopy with Provocation/Exercise (CLP/E) and can be effectively treated with speech and language therapy (SALT) based interventions.MethodWe provide a multidisciplinary, holistic assessment for patients referred to the severe asthma clinic. For patients with upper airway symptoms further assessment, including CLP/E, is arranged. On the day of CLP/E, patients complete objective questionnaires and have a focused clinical history. In addition, we use the Breathing Pattern Assessment Tool, and in those with a high score indicating breathing pattern disorder (BPD), we measure end-tidal CO2. CLP/E is performed in Respiratory Physiology which is equipped with a treadmill, exercise bike, and a range of inhaled triggers e.g. perfumes/cleaning products. The CLP/E is undertaken by a respiratory doctor and observed by SALT, and physiologist. We use disposable laryngoscopes to avoid infection control issues. Spirometry is performed before and after CLP/E.ResultsWe have performed 40 CLE/Ps with no significant adverse events. We found 7 cases of ILO (17.5%), 9 cases of BPD (22.5%), 10 of laryngeal hypersensitivity (25%), 3 of dynamic airway collapse (7.5%), 3 of psychological overlay (7.5%), and 1 patient had a tracheal web. Some patients had more than one of these diagnoses. Treatment with SALT is initiated at the time of testing utilising biofeedback.ConclusionCLP/E plays an essential role in the investigation and management of patients presenting to the severe asthma clinic. It enables diagnosis of co-morbidities that require MDT treatment. CLP/E is a safe procedure that can easily be performed in an appropriate hospital setting by SALT or doctors trained in bronchoscopy.