BACKGROUND: Anaemia during pregnancy is common worldwide. In Australia, approximately 17% of non-pregnant women of reproductive age have anaemia, increasing to a rate of 25% in pregnant women. This study sought to determine the rate of screening for anaemia in pregnancy in regional New South Wales, and to determine whether screening and treatment protocols followed the recommended guidelines.
METHODS: This retrospective study reviewed antenatal and postnatal (48 h) data of women (n = 150) who had a live birth at Bathurst Hospital between 01/01/2020 and 30/04/2020. Demographic data, risk factors for anaemia in pregnancy, antenatal bloods, treatments provided in trimesters one (T1), two (T2) and three (T3), and postpartum complications were recorded. These were compared to the Australian Red Cross Guidelines (ARCG) using descriptive statistics.
RESULTS: Of the women with screening data available (n = 103), they were mostly aged 20-35yrs (79.6%), 23.3% were obese, 97.1% were iron deficient, 17% were anaemic and only a few (5.3%) completed the full pregnancy screening as recommended by the ARCG while a majority completed only partial screenings specifically Hb levels in T1 (56.7%), T2 (44.7%) and T3 (36.6%). Compliance to oral iron was largely undocumented, but constipation was a common side effect among the women. IV iron was administered in 14.0% of women, approximately 1.75x higher than the recommended rate.
CONCLUSIONS: This study provided useful information about compliance to screening and treatment guidelines for anaemia in pregnancy. We identified the need for improved documentation and communication between various health providers to ensure adequate antenatal care to prevent maternal complications during pregnancy. This will improve patient care and encourage further developments in maternal care, bridging the rural health gap.

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 Objective: To determine the frequency of adherence of laparoscopic appendectomy operative notes with the Royal College of Surgeons (RCS) guidelines at the tertiary care centre.  Study Design: A clinical audit report.
METHODS: The Aga Khan University Hospital, Karachi between January and June 2018.
METHODS: Operative notes of laparoscopic appendectomy, written by residents of general surgery from trainee levels R1 to R5 during the study period, were included in the study. Each component from RCS guidelines, was assessed. The response to every question in proforma was marked either as Y=Yes or N=No. Overall score of more than 70% was chosen arbitrarily as a qualifying standard for an adequate operative note. Data were analysed by using SPSS (version 21). A p-value of <0.05 was considered significant.
RESULTS: A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Most of these, i.e. 46% notes, were written by year one residents; 47.1% operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intraoperative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.    Conclusion: Only a quarter of the studied documentation fulfilled the criteria for adequacy of practice. Residents need to be educated and familiarised with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve the performance.           Key Words: Operative notes, Good medical practice, Acute appendicitis, Laparoscopic appendectomy, RCS guidelines.

To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD).
Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with \'Yes\' or \'No\' responses for adherence, which were scored \'Yes\'. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes.
Adherence with guidelines was high at 83.6% (95% CI: 77.7-88.5) with pediatricians (90.1%; 95% CI: 73.0-98.1) higher than GPs (68.3%; 95% CI: 46.0-85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6-99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6-91.4) and GPs (18.7%; 95% CI: 4.1-45.5).
Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement.

Malnutrition is highly prevalent in patients with foregut tumors comprising head and neck (HNC) and esophageal (EC) cancers, negatively impacting outcomes. International evidence-based guidelines (EBGs) for nutrition care exist; however, translation of research evidence into practice commonly presents considerable challenges and consequently lags. This study aimed to describe and evaluate current international nutrition care practices compared with the best-available evidence for patients with foregut tumors who are at high risk of malnutrition. A multi-centre prospective cohort study enrolled 170 patients commencing treatment of curative intent for HNC (n = 119) or EC (n = 51) in 11 cancer care settings in North America, Europe and Australia between 2016 and 2018. Adherence criteria were derived from relevant EBG recommendations with pooled results for participating centres reported according to the Nutrition Care Model at either system or patient levels. Adherence to EBG recommendations was: good (≥80%) for performing baseline nutrition screening and assessment, perioperative nutrition assessment and nutrition prescription for energy and protein targets; moderate (≥60 to 80%) for utilizing validated screening and assessment tools and pre-radiotherapy dietitian consultation; and poor (60%) for initiating post-operative nutrition support within 24 h and also dietetic consultation weekly during radiotherapy and fortnightly for 6 weeks post-radiotherapy. In conclusion, gaps in evidence-based cancer nutrition care remain; however, this may be improved by filling known evidence gaps through high-quality research with a concurrent evolution of EBGs to also encompass practical implementation guidance. These should aim to support multidisciplinary cancer clinicians to close evidence-practice gaps throughout the patient care trajectory with clearly defined roles and responsibilities that also address patient-reported concerns.

To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published BSR guideline for the management of adults with SLE, the NICE technology appraisal for belimumab, and NHS England\'s clinical commissioning policy for rituximab.
SLE cases attending outpatient clinics during any 4-week period between February and June 2018 were retrospectively audited to assess care at the preceding visit. The effect of clinical environment (general vs dedicated CTD/vasculitis clinic and specialized vs non-specialized centre) were tested. Bonferroni\'s correction was applied to the significance level.
Fifty-one units participated. We audited 1021 episodes of care in 1003 patients (median age 48 years, 74% diagnosed >5 years ago). Despite this disease duration, 286 (28.5%) patients had active disease. Overall in 497 (49%) clinic visits, it was recorded that the patient was receiving prednisolone, including in 28.5% of visits where disease was assessed as inactive. Low documented compliance (<60% clinic visits) was identified for audit standards relating to formal disease-activity assessment, reduction of drug-related toxicity and protection against comorbidities and damage. Compared with general clinics, dedicated clinics had higher compliance with standards for appropriate urine protein quantification (85.1% vs 78.1%, P ≤ 0.001). Specialized centres had higher compliance with BILAG Biologics Register recruitment (89.4% vs 44.4%, P ≤ 0.001) and blood pressure recording (95.3% vs 84.1%).
This audit highlights significant unmet need for better disease control and reduction in corticosteroid toxicity and is an opportunity to improve compliance with national guidelines. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery model.

COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved.
METHODS: An audit was designed around fracture immobilisation, type of initial fracture clinic assessment, default virtual follow up clinic and late imaging. Interventions were implemented and re-audited.
RESULTS: Initially 223 patients were identified over 4 weeks. Of these, 100% had removable casts and 99% did not have late imaging. 96% of patients were initially assessed virtually or had initial orthopaedic approval to be seen in face to face clinic. 97% had virtual follow up or had documented reasons why not. The 26 patients who were initially seen face to face were put through a simulated virtual fracture clinic. 22 appointments and 13 Xray attendances could have been avoided. We implemented a change of requiring all patients to be assessed at consultant level before having a face to face appointment. The re-audit showed over 99% achievement in all areas.
CONCLUSIONS: Virtual fracture clinics, both triaging new patients and follow-up clinics have dramatically changed our outpatient management, helping the most appropriate patients to be seen face to face. Despite their limitations, they have been well tolerated by patients and improved patient safety and treatment.

This nationwide study assessed the impact of Lynch syndrome-related risk management guidelines on clinicians\' recommendations of risk management strategies to carriers of pathogenic variants in mismatch repair genes and the extent to which carriers took up strategies in concordance with guidelines.
Clinic files of 464 carriers (with and without colorectal cancer) were audited for carriers who received their genetic testing results in July 2008-July 2009 (i.e. before guideline release), July 2010-July 2011 and July 2012-July 2013 (both after guideline release) at 12 familial cancer clinics (FCCs) to ascertain the extent to which carriers were informed about risk management in accordance with guidelines. All carriers captured by the audit were invited to participate in interviews; 215 were interviewed to assess adherence to recommended risk management guidelines.
The rates of documentation in clinic files increased significantly from pre- to post-guideline for only two out of eight risk management strategies. The strategies with the highest compliance of carriers post-guidelines were: uptake of one or two-yearly colonoscopy (87%), followed by hysterectomy to prevent endometrial cancer (68%), aspirin as risk-reducing medication (67%) and risk-reducing salpingo-oophorectomy (63%). Interrater reliability check for all guidelines showed excellent agreement (k statistics = 0.89).
These results indicate that there is scope to further increase provision of advice at FCCs to ensure that all carriers receive recommendations about evidence-based risk management. A multi-pronged behaviour change and implementation science approach tailored to specific barriers is likely to be needed to achieve optimal clinician behaviours and outcomes for carriers.

In the UK, guidelines from the Royal College of Pathologists (RCPath) facilitate consistent and reproducible reporting and classification of fine needle aspiration cytology (FNAC) thyroid specimens. The aim was to audit our department against RCPath guidelines to refine and improve our reporting process.
Two-cycle retrospective observational audit of all patients undergoing thyroid FNAC over a 2-year period (1 year for each cycle). Final histology was correlated. The positive predictive value (PPV) for malignant neoplastic lesions was calculated; for Thy1, Thy1c, Thy2 and Thy2c all cases without final histology were assumed to be benign, while for Thy3a, Thy3f, Thy4 and Thy5 samples the PPV calculation was based only on those cytology samples with corresponding histology. False positive and false negative cases were reviewed.
In total, 288 cytology samples were included in the first cycle; 96 (33.3%) had corresponding histology. There were 287 samples included in the second cycle; 119 (41.5%) had follow-up histology. The rate of non-diagnostic samples (Thy1/1c) decreased from 39.6% to 30.0%. The PPV for malignant neoplastic lesions was Thy1/1c 2.6%, Thy2/2c 0.0%, Thy3a 40.0%, Thy3f 19.4%, Thy4 75.0%, Thy5 100.0% (first cycle); Thy1/1c 4.7%, Thy2/2c 0.7%, Thy3a 13.3%, Thy3f, 7.7%, Thy4, 50.0%, Thy5 100.0% (second cycle).
Our department was able to reduce the rate of non-diagnostic FNAC samples and improve the diagnostic accuracy of FNAC. Auditing local outcomes helps refine and improve the reporting process. Review of false positive and false negative cases helps examine potential pitfalls of cytology.

OBJECTIVE: To evaluate operative notes in the light of a standard guideline, and to establish a new more precise proforma for future documentation.
METHODS: The retrospective study was conducted at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and comprised audit of consecutive General Surgery elective operation theatre notes from October 2015 to November 2015 according to Royal College of Surgeons (England) guidelines 2014. After the audit, all the doctors were educated about the completion of operation notes and an experimental operation notes template was designed and implemented. Re-audit was done.
RESULTS: A total of 60 operation notes were audited, and of the 20 parameters in the checklist, only 2(10%) were filled up at all times; surgeon\'s name and procedure. In the remaining 18(90%) parameters, the value ranged from 0% to 98.3%. Re-audit showed 100% note-taking across all the 20 parameters.
CONCLUSIONS: The new proforma for operative notes allowed no room for error or missed entries.