St Richard's Hospital

Multidisciplinary simulation training is crucial in paediatric education, providing a safe environment to enhance technical and non-technical skills, especially for high-risk, low-frequency events. Despite evidence of improved patient outcomes and reduced errors, widespread implementation faces significant barriers. This review explores current obstacles and strategies to overcome them, aiming to advance paediatric care. Multidisciplinary simulation training demonstrably improves teamwork, communication, and clinical performance in paediatric acute care, leading to reduced medical errors and improved patient outcomes. However, pervasive barriers hinder its integration, including logistical issues (e.g., staff reallocation, coordination), financial constraints, and cultural resistance (e.g., fear of judgment, lack of psychological safety). Organisational challenges like insufficient leadership support and protected time, alongside educational complexities in curriculum design and debriefing, also limit effective implementation. Case studies highlight successful strategies, such as brief in-situ sessions, strong leadership advocacy, and fostering psychologically safe environments. Overcoming these multifaceted barriers requires a concerted effort. Key priorities include securing sustainable funding, integrating simulation into routine workflows, promoting psychological safety, and gaining strong leadership buy-in. Future research should focus on evaluating long-term patient outcomes and developing standardised assessment tools to ensure multidisciplinary simulation training effectively prepares healthcare professionals and improves paediatric patient safety.

Eligible donation after brain death (DBD) donors may rarely proceed via the donation after circulatory death (DCD) pathway. The incidence, reasons for pathway divergence, and graft and recipient outcomes in the United Kingdom of this cohort are unknown. We aimed to establish the incidence of eligible DBD to DCD donors in the United Kingdom, the reasons for pathway divergence, organ donation and utilization rates, and the renal graft and recipient outcomes for this cohort. UK electronic and article records were reviewed for all eligible DBD donors proceeding via the DCD pathway from 2012 to 2022. Incidence and stated reasons for pathway divergence, including direct family quotations and time to mechanical asystole, were recorded. These data, in addition to organ donation and utilization rates and those pertaining to renal graft and recipient survival rates, were compared with "standard DCD" and "standard DBD" control groups. One hundred twenty-three eligible DBD donors proceeded via the DCD pathway, overwhelmingly due to a familial desire to be present at mechanical asystole. Median time to asystole was comparable between the cohort and DCD control groups, but the range of times was considerably shorter in the cohort group. Donation and utilization rates were similar between all groups except for the notably lower rates in liver donation for DCD control. Graft and recipient survival rates were similar for all groups, but there was a nonsignificant reduction in delayed graft function (DGF) for the cohort versus DCD control and a significant reduction in DGF for the DBD versus DCD control groups. Eligible DBD donors proceeding via the DCD pathway is a rare event in the United Kingdom and overwhelmingly occurs due to a familial desire to witness asystole. This cohort proceeded to asystole more reliably within acceptable time periods for donation, have higher donation and utilization rates for liver grafts, and may show reduced rates of DGF for renal grafts versus "standard DCD" groups.

Abstract Background There is emerging evidence for the potential utility of left bundle branch area pacing (LBBAP), as an alternative to conventional cardiac resynchronization therapy (CRT). The utility of right ventriculography by way of power injector to facilitate lead placement has not yet been reported in the literature. Case summary A 79-year-old female, with a background of poorly rate-controlled atrial fibrillation, presented with worsening dyspnoea. She had recently undergone single-chamber pacemaker insertion prior to an atrioventricular nodal (AVN) ablation, owing to failure in achieving successful CRT coronary sinus lead placement. She had clinical evidence of volume overload, and her electrocardiogram demonstrated right ventricular pacing. Echocardiography demonstrated left ventricular (LV) impairment, with an ejection fraction (EF) of 35%, and severe functional mitral regurgitation (MR). Her diagnosis was overall consistent with pacing-induced cardiomyopathy (PIC). In this patient, the use of right ventriculography, using power-injector-delivered contrast, successfully facilitated placement of an LBBAP lead, with confirmation of good threshold and sensing parameters. Following an upgrade to conduction system pacing, the patient recovered well. On recent follow-up, repeat echocardiography (24 months post initial presentation) demonstrated improved LV function (EF 45% from 35%) and only mild-to-moderate MR. Discussion In conclusion, we demonstrate the utility of right ventriculography to facilitate placement of an LBBAP lead, successfully treating a patient who developed PIC from chronic right ventricular pacing following AVN ablation.

IntroductionHepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and a major global health concern. Due to its high incidence and mortality, early detection and intervention are crucial for improving patient outcomes and reducing disease burden.Cirrhosis is a significant risk factor for the development of HCC and a correlation between the risk of HCC and the duration and severity of cirrhosis exists. Given this increased risk, patients with cirrhosis require regular surveillance for HCC to facilitate early detection and thus improve outcomes.MethodsWe conducted a case review of all new diagnoses of HCC that were recorded within our hepatobiliary MDTs between February 2018 – November 2022 (57 months). Data was evaluated for demographics, disease status, tumour staging, mode of presentation (surveillance vs non-surveillance), prognosis and treatments offered in cirrhotic patients.Results128 new cases of HCC were identified from our database. 89 (70%) had underlying cirrhosis and are described here. Their median age was 72 and they were predominantly male (72%).NAFLD accounted for most new diagnoses (38%), followed by alcohol (26%), HCV (15%), cryptogenic cirrhosis (9%) and haemochromatosis (6%).Patients were graded according to their Child Pugh (CP) Score: A (42%), B (47%), C (11%).Diagnoses were staged according to the Barcelona Criteria: 0 (1%), A (18%), B (10%), C (27%), D (44%).56% of HCC diagnoses were in newly presenting index cases of cirrhosis, made outside of the local surveillance programme. These patients were older (median age 74 vs 70) and of more advanced disease staging (CP B/C 74% vs 58% & BCLC C/D 84% vs 54%). As a result, fewer curative treatments were offered outside of the surveillance group (74% vs 41% offered palliative care only) and their prognosis was worse (75 vs 292 days median survival from diagnosis date).ConclusionsOur data illustrates HCC demographics and staging in a real-world secondary care setting. It highlights the growing tide of older metabolic disease that presents significant challenges when considering treatment options and prognosis given the inherent co-morbid profile of this patient group.It also demonstrates the clear need for more rigorous and structured approaches to cirrhosis detection and HCC surveillance; given that most cirrhotic patients are being diagnosed outside of a surveillance programme, with more advanced disease and thus poorer prognoses. Data from this review supports the ambition of local cancer alliance programmes to invest resources into improving UK HCC surveillance.

Visual methods are becoming more evident in health research. Timeline drawings have been used as a participatory tool alongside interviews in life course research. In this article, we describe how a method involving timeline generation can explore patient experiences along a treatment continuum. Grounded in previously published evidence and using specific examples from two studies exploring the experiences of young people treated for chronic pain, we outline the key components of this method. Moreover, we highlight the flexibility of its application and the importance of using a person-centered approach in tailoring the application pragmatically to study population-specific needs and characteristics, while answering the research question. We also reflect on how the dynamic visual display of the timeline and participants’ explanations add perspective and understanding to complex and multidimensional human experiences associated with healthcare treatment. Furthermore, we outline how this method can help capture changes in the meaning and sense-making of these experiences over time, all the while fostering empowerment in study participants. Finally, the key considerations of using the method are outlined. It is our aim that this article provides the details required to inspire others to consider this novel method as a means of capturing the healthcare experiences of young people with other chronic conditions, an important first step in fostering the changes required to improve the quality of healthcare services and research.

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations.Cite this article: Bone Joint J2023;105-B(1):21-28.