Stroke Simulation Improves Medical Student Confidence in Recognition and Management of Acute Stroke and TIA

Introduction: By the time of graduation medical students need to be equipped to recognise and manage acute stroke and TIA (Transient Ischemic Attack). Despite inclusion of acute stroke and TIA in our local curriculum less than 10% of students (2/30) reported directly observing stroke thrombolysis. Due to COVID restrictions no student was able to attend TIA clinic. To improve students practical understanding of assessment and management of acute stroke and TIA a simulation-based teaching session was designed. Method(s): The simulation session consisted of a hyperacute stroke assessment (2 scenarios) and management simulation and a simulated TIA clinic (3 scenarios). Students were asked to complete a pre-course and postcourse questionnaire regarding their confidence in 8 domains, on a continuous scale 0 to 5. Result(s): There were 23 participants over 2 sessions. 18/23 completed the pre-course questionnaire and 16/23 the post-course questionnaire. The mean confidence reported by students increased in all domains: recognition of acute stroke from 3.3 to 4.8;identifying candidates for thrombolysis, 3.1 to 4.6;discussing thrombolysis with a patient or carer, 2.3 to 4.1;knowing when to call for senior support, 3.1 to 4.3;asking for a patient to be transferred to facilitate acute stroke care, 2.2 to 4.2;recognising a TIA, 2.8 to 4.9;requesting investigations for TIA, 2.5 to 4.6;and discussing anticoagulation with a patient from 2.9 to 4.4. Conclusion(s): Improvements in confidence of medical students in assessing and managing acute stroke (including thrombolysis) and TIA can be achieved through a stroke medicine themed simulation session.

Unpacking the 'Black Box of Horrendousness': A Qualitative Study Exploring the Barriers and Facilitators to Conducting Trials Involving Adults Lacking Capacity to Consent

Background: Trials involving adults who lack capacity to consent encounter a range of ethical and methodological challenges, resulting in these populations frequently being excluded from research. Excluding participants who lack capacity leads to unrepresentative trial populations which risks producing biased estimates of treatment effects, as well as denying these groups an equitable opportunity to participate in and benefit from research and limiting the ability to provide them with evidence-based care. The importance of improving the design and conduct of clinical trials to ensure the inclusion of under-served groups has received attention right across the global research community. However, currently, there is little evidence regarding the nature and extent of the challenges to including adults with impaired capacity in trials, nor strategies to improve the design and conduct of such trials. This qualitative study explored researchers' and healthcare professionals' experiences of the barriers and facilitators to conducting trials involving adults lacking capacity to consent. Method(s): Semi-structured interviews were conducted remotely with 26 researchers and healthcare professionals with experience in a range of roles, trial populations, and settings across the United Kingdom. This included trials in emergency conditions such as cardiac arrest, surgical, and trauma-related trials, as well as people with dementia and those living in care homes. Participants included trial managers, chief investigators, and research nurses. Interviews were audiorecorded and transcribed verbatim. Data were analyzed using thematic analysis. Result(s): A number of inter-related barriers and facilitators were identified and mapped against key trial processes including when making trial design decisions, navigating ethical approval, assessing capacity, identifying and involving alternative decision-makers, and when revisiting consent. Three themes were identified: (1) the perceived and actual complexity of trials involving adults lacking capacity, (2) importance of having access to appropriate support and resources, and (3) need for building greater knowledge and expertise to support future trials. Conducting trials involving adults who lack capacity was facilitated by having prior experience with these populations, effective communication between research teams, contributions from public involvement, and the availability of additional data to inform the trial. Barriers included the complexity of the legal frameworks and ethical approval processes, the role of gatekeepers, a lack of access to expertise and training, and the resource-intensive nature of these trials. Participants also identified a range of context-specific recruitment issues and highlighted the importance of ''designing in'' flexibility and use of adaptive strategies which were especially important for trials during the COVID-19 pandemic. Participants identified the need for further training and support. A number of recommendations are made for research funders and those designing and conducting trials, as well as at a policy and research governance level. Conclusion(s): Researchers encountered a number of barriers, including both generic and context or population-specific challenges, which may be reinforced by wider factors such as resource limitations and knowledge deficits. Greater access to expertise and training, and the development of supportive interventions and tailored guidance, is urgently needed in order to build research capacity in this area and facilitate the successful delivery of trials involving this under-served population.

PrEP Use, Sexual Behaviour, and PrEP Adherence Among Men who have Sex with Men Living in Wales Prior to and During the COVID-19 Pandemic.

We examined PrEP use, condomless anal sex (CAS), and PrEP adherence among men who have sex with men (MSM) attending sexual health clinics in Wales, UK. In addition, we explored the association between the introduction of measures to control transmission of SARS-CoV-2 on these outcomes. We conducted an ecological momentary assessment study of individuals in receipt of PrEP in Wales. Participants used an electronic medication cap to record PrEP use and completed weekly sexual behaviour surveys. We defined adherence to daily PrEP as the percentage of CAS episodes covered by daily PrEP (preceded by ≥ 3 days of PrEP and followed by ≥ 2 days). Sixty participants were recruited between September 2019 and January 2020. PrEP use data prior to the introduction of control measures were available over 5785 person-days (88%) and following their introduction 7537 person-days (80%). Data on CAS episodes were available for 5559 (85%) and 7354 (78%) person-days prior to and following control measures respectively. Prior to the introduction of control measures, PrEP was taken on 3791/5785 (66%) days, there were CAS episodes on 506/5559 (9%) days, and 207/406 (51%) of CAS episodes were covered by an adequate amount of daily PrEP. The introduction of pandemic-related control measures was associated with a reduction in PrEP use (OR 0.44, 95%CI 0.20-0.95), CAS (OR 0.35, 95%CI 0.17-0.69), and PrEP adherence (RR = 0.55, 95%CI 0.34-0.89) and this may have implications for the health and wellbeing of PrEP users and, in addition to disruption across sexual health services, may contribute to wider threats across the HIV prevention cascade.

Eosinophilic granulomatosis with polyangiitis: Diagnostic and therapeutic challenges during COVID-19 pandemic

Case report-IntroductionCOVID-19 pandemic affected medical practise significantly and caused difficulties in accessing necessary investigations at the appropriate time. As of March 2020, NHS England issued measures to redirect staffs and resources in preparation for the rising cases of coronavirus. As a result of this, non-urgent tests/treatments were put on hold. We present a new case of EGPA admitted to our district general hospital during the COVID-19 pandemic to highlight the challenges faced. The diagnosis was reached based on clinical judgment in the absence of some confirmatory tests as well as the decision of starting immunosuppressant treatment during the pandemic.Case report-Case descriptionA 41-years-old lady with a background of well-controlled asthma, presented with five days history of paraesthesia and swelling in both legs. She also reported mild pleuritic chest pain, which radiated to her left arm. Physical examination revealed left foot drop. She had reduced sensation on the L5-S1 dermatomal distribution with absent ankle reflex and reduced knee reflex of her left leg. Her left calf was swollen and tender. The rest of her examination was unremarkable.Baseline blood revealed raised WCC of 19.3 with significant eosinophilia (10). CRP and ESR were 135 mg/L and 48mm/hr, respectively. Electrocardiogram showed new T-wave inversion in the anterolateral leads with significantly raised troponin levels. There was ground glass appearance in both lungs, keeping with suspected COVID-19 and no evidence of pulmonary embolus was found on CTPA. MRI spine confirmed no evidence of cauda equina compression. Deep vein thrombosis was also excluded with US doppler.She was treated as myocarditis and pneumonia secondary to probable COVID-19 infection. Echocardiogram revealed severe LVSD (EF < 35%) with no LV hypertrophy. Three days later, she became acutely breathless and required high flow oxygen. New bilateral basal crackles were found on auscultation. Her antibiotic regimes were escalated to intravenous infusion.A revised CT report suggested the findings may correlate with eosinophilic pneumonia or EGPA. MRI of lower legs proved muscular oedema in bilaterally, which was suggestive of myositis with fasciitis. There was no significant change on the thigh musculature. CK level was slightly elevated (403 IU/L). Urinalysis was positive for blood (3+). Given the strong clinical suspicion of EPGA, a decision to start high dose steroid therapy was made, despite the pending immunology results. After the third dose of the methylprednisolone, pulsed cyclophosphamide was started along with high dose oral prednisolone. The patient was discharged home following significant clinical improvement.Case report-DiscussionThis patient has fulfilled 4 out of 6 criteria of ACR 1990 classification for EGPA, which are eosinophilia, bronchial asthma, mononeuritis multiplex and pulmonary infiltrates on radiological images. However, in the context of current pandemic, these changes on chest CT findings could also be suggestive of COVID-19 pneumonitis.At present, there is no reliable test for COVID-19. Even though RT-PCR testing has been the gold standard for diagnosing suspected cases, the clinical sensitivity and specificity of these tests are variable. A negative test may not rule out infection. In our case, the patient was tested twice at separate times to rule out the possibility of COVID-19 infection.During the pandemic, there is extremely limited access to some confirmatory tests. We were not able to perform nerve conduction studies on our patient as the service was suspended, instead, we sought neurologist's review to confirm the mononeuritis multiplex. We also sought advice from haematologist to rule out the possibility of hyper-eosinophilic syndrome as bone marrow biopsy was unavailable. The screen for atypical pneumonia, aspergillosis, viruses, and tuberculosis were negative. By excluding the alternative diagnoses related to eosinophilia, we concluded that this was likely to be a case of first presentation EGPA.Our next obstacle was intr ducing remission-induction regimens during COVID-19 pandemic. BSR does not recommend starting new treatment due to the increased risk of infection. We had to weigh out the benefits and risks of initiating immunosuppression. Our patient was made aware of the potential risks involved which include severe infection with COVID-19. She was also shifted to a side room with strict infection control precautions and PCP prophylaxis prescribed before starting pulsed methylprednisolone and cyclophosphamide. Fortunately, her neurological symptoms resolved after three days of steroid therapy. Eosinophils count dropped within 1 day to zero, after the first dose of IV methylprednisolone.Case report-Key learning pointsDespite the rising cases of COVID-19 infection, it is essential to keep an open mind and consider alternative diagnosis if a patient did not respond to conventional treatment. As EGPA and COVID-19 pneumonia share similar clinical and radiological presentation, clinical judgement is essential when making the diagnosis as the treatments for both conditions are vastly different. When EGPA is suspected, a multidisciplinary team should be involved in the evaluation of different organ involvements as well as ruling out other causes of eosinophilia. The role of specialists' inputs is extremely important in reaching the diagnosis, especially with limited access to the usual confirmatory tests due to reduced services during the pandemic.In addition, when there is an increased risk of infection such as during the COVID-19 pandemic, it is essential to weigh up the benefits and risks of commencing immunosuppressant treatment carefully. Patients need to be involved in the decision-making process as well as take precautions to minimise the risk of infection. The decision to start remission induction regimes should not be delayed if there is a presence of life or organ threatening disease manifestations in EGPA patients. Our patient has had a life-threatening disease because of multi-organ involvements (cardiac, pulmonary, and neurological systems).

Use of visual basic in microsoft word to Facilitate data collection for covid-19 studies

Introduction There is a national target to recruit 100,000 patients with COVID-19 to the PRIEST study. Use of a research proforma to collect the required data risked Emergency Department (ED) physicians collecting this dataset at the expense of their more usual clinical history. Use of paper admission forms which could not be taken from COVID-19 'dirty' to 'clean' areas either resulted in work duplication to transcribe information written in the 'dirty' zone or potential recall error/omission when staff completed paperwork later in the 'clean' zone. Methods The solution (in a hospital which still uses paper notes) was an electronic admissions document, completed in the dirty zone and printed out in the clean zone. The use of Visual Basic (VB) allowed insertion of scripts to automate data extraction for research and quality improvement use. Microsoft Word was preferred because of staff familiarity, combined with better data governance than cloud solutions such as Google Forms and better legibility/formatting than research data collection tools such as REDCap. Results VB enhanced Word documents offer similar benefits for management of patients in COVID-19 treatment areas and for subsequent follow up. The electronic forms were received well by staff, as they allowed for clerking and PRIEST to happen simultaneously. Clinical staff remarked that the form also acted as a prompt when clerking, which reduced the time taken to carry out subsequent patient encounters. Research teams found the form much easier to process, as it negated the need to quarantine notes prior to assessment and allowed for data to be extracted immediately into an Excel spreadsheet. Conclusion The use of VB not only increased staff safety, but it also allowed researchers to contemporaneously process data. Whilst a mixed paper and electronic notes system is less than perfect, the adjunct of the virtual form was well received during the COVID-19 pandemic. Future expansion of VB use as an adjunct to medical clerking will be considered and has already been piloted in the collection of data for COVID-19 patients admitted to our hospital.

P257 Use of visual basic in microsoft word to facilitate data collection for COVID-19 studies

IntroductionThere is a national target to recruit 100,000 patients with COVID-19 to the PRIEST study. Use of a research proforma to collect the required data risked Emergency Department (ED) physicians collecting this dataset at the expense of their more usual clinical history. Use of paper admission forms which could not be taken from COVID-19 ‘dirty’ to ‘clean’ areas either resulted in work duplication to transcribe information written in the ‘dirty’ zone or potential recall error/omission when staff completed paperwork later in the ‘clean’ zone.MethodsThe solution (in a hospital which still uses paper notes) was an electronic admissions document, completed in the dirty zone and printed out in the clean zone. The use of Visual Basic (VB) allowed insertion of scripts to automate data extraction for research and quality improvement use. Microsoft Word was preferred because of staff familiarity, combined with better data governance than cloud solutions such as Google Forms and better legibility/formatting than research data collection tools such as REDCap.ResultsVB enhanced Word documents offer similar benefits for management of patients in COVID-19 treatment areas and for subsequent follow up. The electronic forms were received well by staff, as they allowed for clerking and PRIEST to happen simultaneously. Clinical staff remarked that the form also acted as a prompt when clerking, which reduced the time taken to carry out subsequent patient encounters. Research teams found the form much easier to process, as it negated the need to quarantine notes prior to assessment and allowed for data to be extracted immediately into an Excel spreadsheet.ConclusionThe use of VB not only increased staff safety, but it also allowed researchers to contemporaneously process data. Whilst a mixed paper and electronic notes system is less than perfect, the adjunct of the virtual form was well received during the COVID-19 pandemic. Future expansion of VB use as an adjunct to medical clerking will be considered and has already been piloted in the collection of data for COVID-19 patients admitted to our hospital.

Decarbonising the critical sectors of aviation, shipping, road freight and industry to limit warming to 1.5-2 degrees C

Limiting warming to well below 2 degrees C requires rapid and complete decarbonisation of energy systems. We compare economy-wide modelling of 1.5 degrees C and 2 degrees C scenarios with sector-focused analyses of four critical sectors that are difficult to decarbonise: aviation, shipping, road freight transport, and industry. We develop and apply a novel framework to analyse and track mitigation progress in these sectors. We find that emission reductions in the 1.5 degrees C and 2 degrees C scenarios of the IMAGE model come from deep cuts in CO2 intensities and lower energy intensities, with minimal demand reductions in these sectors' activity. We identify a range of additional measures and policy levers that are not explicitly captured in modelled scenarios but could contribute significant emission reductions. These are demand reduction options, and include less air travel (aviation), reduced transportation of fossil fuels (shipping), more locally produced goods combined with high load factors (road freight), and a shift to a circular economy (industry). We discuss the challenges of reducing demand both for economy-wide modelling and for policy. Based on our sectoral analysis framework, we suggest modelling improvements and policy recommendations, calling on the relevant UN agencies to start tracking mitigation progress through monitoring key elements of the framework (CO2 intensity, energy efficiency, and demand for sectoral activity, as well as the underlying drivers), as a matter of urgency. Key policy insights Four critical sectors (aviation, shipping, road freight, and industry) cannot cut their CO2 emissions to zero rapidly with technological supply-side options alone. Without large-scale negative emissions, significant demand reductions for those sectors' activities are needed to meet the 1.5-2 degrees C goal. Policy priorities include affordable alternatives to frequent air travel;smooth connectivity between low-carbon travel modes;speed reductions in shipping and reduced demand for transporting fossil fuels;distributed manufacturing and local storage;and tightening standards for material use and product longevity. The COVID-19 crisis presents a unique opportunity to enact lasting CO2 emissions reductions, through switching from frequent air travel to other transport modes and online interactions. Policies driving significant demand reductions for the critical sectors' activities would reduce reliance on carbon removal technologies that are unavailable at scale.