Scottish Society of Physicians 64 th Annual Meeting

Thursday 29 & Friday 30 September 2022

ABSTRACT BOOK

Venue:

Hybrid Event: The Townhouse Hotel, Melrose & Microsoft Teams

Scottish Society of Physicians is a charity registered in Scotland. No. SC029462

CONTENTS

Oral presentations:

Session 1 – page NP3

Index of Poster Presentations – page NP10

Thursday 29 September 2022

ORAL PRESENTATIONS

SESSION 1

Chair: Dr Rob Laing, Consultant Physician, Aberdeen Royal Infirmary

Recognising and Responding to the Vulnerable Patient

Dr Niall Campbell

Consultant Liaison Psychiatrist, NHS Borders

Objective: To enable the Physician to recognise and respond appropriately to the vulnerable patient within the clinical setting and gain a deeper understanding of what it means to be vulnerable.

Physicians are often aware of patient's vulnerability, whether it be coming to terms with a new cancer diagnosis or managing chronic illness. The challenge comes in knowing what to do with those patients who seek answers we don't have. This is further complicated by the patient who presents with a vulnerability in the context of abuse at the hands of a loved one, friend, acquaintance, carer, or institution. It is in these circumstances that Physicians can feel out of their depth in being able to offer solutions or guidance to reduce the risk of harm to the patient. The physician may struggle to identify patient cues suggesting increased vulnerability, avoid the emotional quagmire that may ensure if one does identify a problem. There is often the dilemma of who and where to seek help or advice. It is essential for physicians to have a framework in mind when dealing with these challenging situations, an understanding of the need to share our concerns and recognise that this is not something you should be dealing with alone.

Update on Type 2 Diabetes

Dr Alison Heggie

Consultant in Diabetes and Endocrinology, NHS Highland

Type 2 Diabetes is common in medical inpatients, and the prevalence is increasing in the UK. There has been significant growth and development in newer drugs for Type 2 Diabetes in the past 20 years. Many of the newer medications have significant benefits both for glycaemic control and other areas, in particular cardiovascular and renal health. Yet as with any medication there are potential adverse effects which could present on the acute take. This presentation will cover the range of medications for type 2 diabetes, their benefits and potential problems, along with case studies for illustration.

SESSION 2

Chair: Dr Ruth Richmond, President, Scottish Society of Physicians

Investigation and management of gastrointestinal bleeding

Dr John Wilson

Consultant Gastroenterologist, NHS Fife

The technical and logistic provision of services for GI bleeding has improved, but mortality remains significant at 6–10%. Nearly all of those who do not survive have serious co-morbidity. The more rigorous adoption of principles already well-established would save lives, but gaps within service provision also need to be addressed. Current models of service would benefit from review.

Chest pain, troponin and why, when you ask five cardiologists, you get seven answers

Dr Anne Scott

Consultant Cardiologist, NHS Forth Valley

Chest pain is the second most common reason to present to the emergency department. Potential causes are innumerable. Dr Scott will explore the utility of clinical judgement, ECG's and biomarkers in such presentations and review real cases which provide important learning points. Dr Scott will also attempt to shed light on the vagaries of cardiologists and why when you ask two cardiologists you might be faced with three opinions!

FITZGERALD PEEL LECTURE

What makes medical work so demanding? Insights from occupational psychology

Dr Caroline Elton

Occupational Psychologist & Author “Also Human”

The 2022 GMC Trainee survey found that 40% of trainees felt burnt out to a high or very high degree because of their work. But what exactly is burn out? And what is it about contemporary medical practice that the reported levels of burnout are so high? In this talk, the origins of the concept of burnout will be traced, and evidence presented that although wellbeing at work has deteriorated following the Covid-19 pandemic, burnout was a significant issue in the medical workforce both in the UK, and across the world, long before 2020. Drawing on the work of Viktor Frankl, the argument will be made that burnout happens when highly motivated professionals, who identify with their work, find themselves unable to accomplish their work goals and thus feel unable to make a significant personal contribution through their work. This model locates the origins of burnout in aspects of the work environment, rather than as being due to a lack of personal resilience on the part of the doctor. With reference to research carried out by occupational psychologist Michael West, the specific aspects of the work environment that increase the risk of burnout will be explored. Finally, with reference to insights from Martin Seligman's positive psychology approach, practical steps that individual clinicians can take to enhance the quality of their working environments will be outlined.

Friday 30 September 2022

SESSION 3

Chair: Dr Effie Dearden, Consultant Geriatrician, Borders General Hospital, Melrose

Biologic drugs – what the general physician needs to know

Dr Anne McEntegart

Consultant Rheumatologist, Glasgow Royal Infirmary

The focus of this talk will be on the use of biologic drugs in rheumatology.

Areas covered will be

current biologic drugs used in rheumatological practice

HIV infection in medical clinics

Dr Dan Clutterbuck

Consultant in Genitourinary and HIV medicine & Clinical Lead for Sexual and Reproductive Health, Chalmers Centre, Edinburgh

In 2020, Scotland achieved the UNAIDS 90:90:90 targets of 90% of people living with HIV being diagnosed, 90% of those diagnosed being on therapy and 90% of those on therapy having an undetectable viral load. Scotland's ambition to achieve zero new HIV transmissions by 2030 will be announced on World AIDS Day 2022 and is now realistic. The major obstacle remains identifying undiagnosed infections in a low prevalence population. I will discuss the potential barriers to routine testing and the indications for HIV testing in general medical settings, along with a quick overview of the elements involved in making HIV transmission elimination a reality.

Ocular presentations to acute medicine

Dr Justin McKee

Consultant in Medical Ophthalmology, NHS Lothian

This presentation will cover the main interfaces between ophthalmology and acute medicine. The main topics covered will be the swollen optic disc, ophthalmic manifestations of giant cell arteritis, double vision, ocular infections and the emerging topic of ophthalmic complications of immunotherapy.

SESSION 4 – SCIENTIFIC ABSTRACT PRESENTATIONS

Chair: Professor Jesse Dawson, Professor of Stroke Medicine, University of Glasgow

(presenting author underlined)

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Title	Use of AI and access to banked bio samples for the detection and diagnosis of patients with heart failure from electronic health records: a population cohort study
AUTHORS	Mon Myat Oo,1 Chuang Gao,2 Christian Cole,3 Yoran Hummel,4 Magalie Guignard-Duff,5 Emily Jefferson,6 James Hare,7 Adriaan Voors,8 Rudolf de Boer,9 Carolyn Lam,10 Jasper Tromp,11 Chim C. Lang12
CURRENT POST (e.g., medical student, ST3, consultant) / DEPT/HOSPITAL (all authors)	1. Research fellow, Division of Molecular and Clinical Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland 2. Health data scientist, Health informatic centre, School of Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland 3. Senior Lecturer, Health informatic centre, School of Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland 4. Co-founder, Us2.ai 5. Senior Data Engineer, Health informatic centre, School of Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland 6. Director, Health informatic centre, School of Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland 7. Co-founder and CEO, Us2.AI, Singapore 8. Professor of Cardiology, University Medical Centre Groningen, Groningen. 9. Professor in Cardiology, University of Groningen, the Netherlands 10. Senior Consultant, Department of Cardiology and Director of Women's Heart Health, National Heart Centre Singapore 11. Assistant Professor, National University of Singapore 12. Consultant cardiologist, Division of Molecular and Clinical Medicine, University of Dundee, United Kingdom of Great Britain & Northern Ireland
INTRODUCTION	Heart failure (HF) is a clinical syndrome which is caused by either structural and/or functional cardiac abnormality.[1] There are 3 types of heart failure classified according to left ventricular ejection fraction (LVEF): HF with reduced ejection fraction (HFrEF); HF with mid-range EF (HFmREF) and HF with preserved EF (HFpEF).[2] HFpEF is widely regarded to be of the greatest challenge due to increasing prevalence and limited disease modifying medication therapy. With an expanding diversity of electronic health record (EHR) resources that include clinical data, imaging, banked bioresources and plasma samples, application of artificial intelligence-based machine learning algorithms to electronic health records offers opportunities to generate timely real-world evidence to enhance patient care and facilitate research.
PATIENTS AND METHODS	Retrospective data analysis using clinical data set, routinely stored in health informatic centre (HIC) Tayside from 1994 to 2021. This data was linked to the community-dispensed prescriptions, echocardiography data, hospital admissions (Scottish Morbidity Record), and mortality data (General Registry Office). These filtered data was linked with plasma sample stored in the NHS Tayside SHARE register and Digital Imaging and Communications in Medicine (DICOM) images.
RESULTS	Among 3680 patient records with linkage to echocardiographic DICOMs and blood samples, we identified 236 patients with HFpEF, 156 with HFrEF, and 185 controls. Compared to HFrEF, patients with HFpEF were older, more often women and had less coronary artery disease. Compared to controls, patients with HFpEF and HFrEF had greater LV mass, higher mitral E/e’ ratio, higher pulmonary artery systolic pressure, more impaired LV strain and more RV dysfunction. While most patients with HFrEF were on guideline-directed medical therapy, relatively few mineralocorticoid receptor antagonists were described. NT-proBNP levels were elevated in HFpEF, and more in HFrEF, compared to controls. During a median follow up time of 1089 days, 39% of HFpEF and 63% of HFrEF experienced hospitalization or death, compared to only 5% of controls.
CONCLUSIONS	We demonstrate the feasibility of AI-automated detection and classification of HF from routine surveillance of electronic health data, yielding cohorts with clinical and echocardiographic characteristics similar to epidemiologic studies, with raised natriuretic peptides and poor outcomes expected in these patient populations. Such AI-assisted electronic surveillance may be useful for automated monitoring of clinical records for early disease detection, treatment quality improvement initiatives, and case finding for clinical trials.
REFERENCES	[1] McDonagh, T.A., et al., Corrigendum to 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J, 2021. 42(48): p. 4901. [2] Heidenreich, P.A., et al., 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022: p. 101161cir0000000000001063.

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Fitzgerald Peel Prize Winner
TITLE	Evaluation of a clinically supervised patient self-management programme in a COVID virtual ward
AUTHORS	Melville M, Mackay TW, Kelly CA.
CURRENT POST (e.g. medical student, ST3, consultant) / DEPT/HOSPITAL (all authors)	IMT3 Borders General Hospital/NHS England
INTRODUCTION	NHS Borders rapidly established a COVID virtual ward [1, 2] with the objective of evaluating the impact on acute bed utilisation, patient outcomes, interaction with healthcare services and patient and staff experience.
PATIENTS AND METHODS	The service was operational from 14th February to 20th March 2022 supporting three COVID patient groups: admission avoidance, early supported discharge and monitoring of high risk patients eligible for community treatment. Following initial assessment and documentation of baseline clinical observations patients were issued with a pulse oximeter, disposable thermometers, paper diary and escalation plan and were asked to record their symptoms, heart rate, temperature and oxygen saturation three times a day. Patients were contacted regularly by telephone by a healthcare professional to offer ongoing clinical advice and support. Retrospective evaluation was undertaken using a mixed methods approach, including analysis of data collected at the point of care in the electronic patient record, patient feedback questionnaires, staff and patient interviews.
RESULTS	41 patients (age range of 27–84 years) were managed in the virtual ward. 95% of patients were discharged within 14 days of COVID symptom onset, with a mean of 8 calls per patient and mean follow up of 8 days. 23 patients recorded abnormal clinical observations which met escalation criteria on 198 occasions but only 2 patients required hospital admission. 73 acute bed days were saved through admission avoidance and early supported discharge (17 patients). At least 38 interactions with other healthcare services were avoided. Patients reported 100% service satisfaction and were keen to see the service continued and expanded. 126 hours of clinical time was spent managing patients but most of this was done in addition to existing clinical commitments.
CONCLUSIONS	Clinically supervised patient self monitoring in a virtual ward is a safe model of care, resulting in a significant number of acute bed days saved, reduced impact on primary and unscheduled care services and active patient engagement in co-management of their acute illness. The service must be staffed appropriately for anticipated patient acuity and caseload. There must be realistic expectations about the clinical time required to manage patients in a virtual ward. This must be appropriately accounted for in contracted hours of clinical work and cannot be added onto to existing clinical workloads.
REFERENCES	1. Thornton J. The “virtual wards” supporting patients with covid-19 in the community BMJ 2020; 369 :m2119 doi:10.1136/bmj.m2119 2. Vindrola-Padros C, Singh KE, Sidhu MS, et al. Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review. EClinical Medicine. 2021 Jul;37:100965. doi: 10.1016/j.eclinm.2021.100965.

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TITLE	Detection of ischaemic strokes in patients using field cycling imaging below 0.2 T
AUTHORS	Vasiliki Mallikourti, Oliver Maier, Markus Bödenler, P. James Ross, Lionel M. Broche, Mary-Joan MacLeod
CURRENT POST (e.g. medical student, ST3, consultant) / DEPT/HOSPITAL (all authors)	1. Research Fellow, Aberdeen Biomedical Imaging Centre, University of Aberdeen 2. Institute of Medical Engineering, Graz University of Technology 3. Institute of eHealth, University of Applied Sciences FH JOANNEUM, Graz, Austria 4. Lecturer, Aberdeen Biomedical Imaging Centre, University of Aberdeen 5. Lecturer, Aberdeen Biomedical Imaging Centre, University of Aberdeen 6. Consultant, Institute of Medical Sciences, University of Aberdeen
INTRODUCTION	Computed tomography in acute stroke is a ‘blunt’ tool that gives limited information in early infarction while conventional magnetic resonance imaging is of limited practical use due to access, time and safety issues. Low-field MRI offers interesting prospects in this field but little is known in this regime. Field-Cycling imaging1,2 (FCI) is a novel modality that can image over a range of magnetic field strengths through rapid switching between magnetic field levels during acquisition, to explore a new endogenous contrast through T1 dispersion measurements. Here we show how T1 relaxation times change with field strengths and informs on molecular dynamics at low fields, in the first in vivo study of this type for ischaemic strokes.
PATIENTS AND METHODS	38 patients with ischaemic stroke were scanned on whole-body FCI system within 24–96h of presentation and 9 patients (age, 62 ± 15 years) were included. Patients were identified on either admission CT or 3 T MRI scan. Multiple images were obtained at a range of magnetic field strengths (3 to 6 fields used) ranging from 0.2 T to 0.2 mT. The T1 relaxation times across fields were quantified using the Total Generalized Variation (TGV) algorithm3 and T1 maps, showing the T1 values across brain, were generated. T1 dispersions were extracted from two regions of interest (ROIs) in T1 maps: infarct region and contralateral normal brain. Clinical images were used for comparison. The T1 contrast (stroke to normal brain) was calculated across fields.
RESULTS	Ischaemic stroke appeared as hyperintense T1 contrast in the images acquired at the low-field regime (below 0.2 T) while poorly visible from the images taken at 0.2 T. The infarct region in our images corresponded with the CT and 3 T MRI images. The T1 maps exhibited visible T1 contrast mainly below 0.2 T. The T1 dispersion profiles showed minimal differences at 0.2 T between the infarct and healthy brain with an increasing trend as the field decreases. The T1 contrast increased markedly as the magnetic field decreased.
CONCLUSIONS	This is the first-ever measurement of T1 dispersion in patients with acute stroke. The results showed that significant contrast is available below 0.2 T in patients with stroke, which discriminates between healthy and ischemic brain regions but also shows the limitations in T1 contrast at 0.2 T and above. These changes may reflect modifications of water diffusion across cell membranes due to cellular adaptation or death4. We have demonstrated the potential of low fields in ischaemic stroke and created a new tool to understand the pathophysiology of diseases, in vivo. We hope these results will help to better understand disease mechanisms in stroke and to guide the design process of dedicated low-field devices.
REFERENCES	1. Lurie, D. J. et al. Comptes Rendus Phys. 11, 136–148 (2010). 2. Broche LM, er al. Sci. Rep. 2019;9(1):10402. 3. Bodenler et al, Magn. Reson. Med. 86:2049–2063 (2021). 4. Ruggiero MR et al., Angew Chem Int Ed Engl. 57(25):7468–7472, (2018).

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TITLE	Improving outcomes for older people living with Frailty by implementing an integrated frailty service in the remote and rural setting of Orkney
AUTHORS	Dr. Nasrin Razzaq, Sulaiman Hussain, Charlie Siderfin
CURRENT POST (e.g. medical student, ST3, consultant) / DEPT/HOSPITAL (all authors)	Dr. Nasrin Razzaq (Clinical Lead, Hospital without Walls/NHS Orkney) Sulaiman Hussain (Undergraduate Medical Student/ Kings College London) Charlie Siderfin (Rural Emergency Physician/NHS Highland)
INTRODUCTION	Taking a population health approach in Orkney, recognising an older age profile than both the Highlands and Islands and Scotland1, we set up an Integrated Frailty Service with the aim of delivering Hospital at Home: to provide intensive hospital level care for acute conditions in a patient's home for a short episode through multidisciplinary healthcare teams2. Our project was called Hospital without Walls (HwW).
PATIENTS AND METHODS	Staff from community, primary and secondary care were trained to identify Frailty as a clinical syndrome through a ‘Train the Trainer’ program to ensure a standardised approach for Frailty identification and assessment across services. Clinical pathways were developed based on the five Frailty Syndromes: falls, delirium, immobility, medication side effects, incontinence ensuring robust clinical governance. Workforce training was in multidisciplinary teams to embed the ethos of ‘learning together to care better’. Interventions from the HwW team was evaluated by examining patient journeys and defining the value added by integrating Frailty care provision and impact on acute spend by counting the number of bed days saved.
RESULTS	The HwW project demonstrated that systematic Frailty identification and assessment of patients presenting in the ED or via referral from the GP resulted in 16 admissions avoided with 63 bed days saved, equating to savings of £53, 487. Conservative estimates suggest this could result in savings of more than £3 m over a year.
CONCLUSIONS	It is recognised that hospital admission for those with Frailty leads to a higher risk of falls, de-conditioning, longer lengths of stay and death3. Our project demonstrates that systematic identification and assessment of patients with Frailty not only improves outcomes by reducing lengths of stay in hospital, but also results in savings for the system as the cost of care is lower compared to inpatient care4.
REFERENCES	1. www.nrscotland.gov.uk/files/statistics/council-area-data-sheets/orkney-islands-council-profile 2. www.ihub.scot/project-toolkits/hospital-at-home/hospital-at-home/ 3. wwwihub.scot/media/9055/20220309-spsp-aa-falls-webinar-presentation-v10.pdf 4. www.healthcareimprovementscotland.org/evidence/rapid_response/