Antithrombin deficiency is identified as one of the most potent risk factors for venous thromboembolism during pregnancy. Therapeutic low molecular weight heparin is recommended, but it can be difficult to attain sufficient anticoagulation since low molecular weight heparin requires antithrombin to exert its anticoagulant effect. We carried out a multicentre case-series assessing the dose of low molecular weight heparin required to achieve therapeutic anti-activated factor X levels in pregnant women with antithrombin deficiency. We assessed 27 pregnancies in 18 women with severe antithrombin deficiency, which we defined as an antithrombin level of <0.55 IU/ml (with or without prior venous thromboembolism) or an antithrombin level < 0.8 IU/ml and a personal history of venous thromboembolism. Our data illustrate the need for high doses of low molecular weight heparin to achieve therapeutic anti-activated factor X levels (average 20,220 IU/day). All pregnancies ended in live birth (excluding one elective termination), although intrauterine growth restriction occurred in five (18%).

A 74-year-old man with B-cell chronic lymphocytic leukaemia and anaemia due to stage C disease, commenced treatment with intravenous bendamustine 100 mg/m 2 on days 1 and 2. A full blood count (FBC) at the time of treatment showed Hb 90 g/l, white blood cells (WBC) 71Á4 9 10 9 /l and platelets 158 9 10 9 /l with impaired renal function [urea 3Á2 mmol/l, creatinine 118 lmol/l, estimated glomerular filtration rate (eGFR) 52 ml/min]. A recent computerized tomography (CT) scan had shown no significant lymphadenopathy, organomegaly or renal abnormality. He had a long history of gout treated intermittently with analgesics. He was not given allopurinol because of the perceived high incidence of rashes when this drug is used together with bendamustine. The patient was admitted 1 week later with profound fatigue, vomiting and oliguria. The FBC now showed pancytopenia (WBC 1Á3 9 10 9 /l, Hb 67 g/l, platelets 115 9 10 9 /l) with serum creatinine 846 lmol/l, potassium 5Á9 mmol/l, calcium 2Á14 mmol/l, phosphate 2Á91 mmol/l, urate 1Á24 mmol/l and eGFR 5 ml/min. The acute kidney injury was deemed secondary to tumour lysis syndrome. Non-contrast CT imaging showed dilatation of the collecting systems of both kidneys (long arrows) and significant perinephric stranding bilaterally. There were foci of high density in the bladder (short arrows) and distal ureters suggestive of uric acid crystallization. He was treated with intravenous fluids, insulin, dextrose and rasburicase. Within hours his urine output recovered, following which there was a polyuric phase with progressive recovery of renal function (creatinine 93 lmol/l, potassium 3Á6 mmol/l, urate < 0Á06 mmol/l and eGFR > 60 ml/min by day 5 of admission).This patient illustrates the potential danger of administering chemotherapy in the absence of allopurinol or rasburicase prophylaxis. The case is unusual in that, in addition to direct renal damage from hyperuricaemia, there was also an element of post-renal obstructive uropathy from urate crystalluria, which was visible on imaging. The patient was very close to requiring renal dialysis, but with the recovery of urine output following rasburicase treatment, this was not ultimately required.

Vitamin D is essential for the maintenance of musculoskeletal health through the regulation of calcium and phosphate homeostasis. Severe prolonged deficiency of vitamin D can lead to rickets in children and osteomalacia in adults. Both conditions are now rare in the UK, except in high-risk groups such as those with malabsorption and reduced exposure to sunlight. A much more common situation is ‘biochemical’ vitamin D deficiency, where circulating 25(OH)D concentrations fall below pre-defined thresholds in the absence of osteomalacia or rickets, making vitamin D deficiency and insufficiency very common in the UK particularly during the winter months and early spring. Biochemical vitamin D deficiency has been associated with various non-skeletal disorders, but it seems likely that the low vitamin D levels in these situations are the result of the underlying condition, rather than the cause.

AimsFeedback from doctors in training (DiT) through the Scottish Training Survey has highlighted poor trainee experience within Psychiatry at St. John's Hospital, Livingston. Research suggests that a healthy, happy and engaged workforce experiences lower levels of burnout and provides higher quality patient care. Our aim was to improve the experience of DiT working within the department and thereby improve patient care.MethodsWe utilised the Wellbeing, Conditions and Rota Evaluation (WeCaRE) framework. This is a user-friendly quality improvement (QI) framework designed to improve trainee experience. As part of WeCaRE, questionnaires and ‘what matters to you’ conversations were undertaken with ten DiT (foundation doctors, GP trainees, and core psychiatry trainees). From the issues raised, trainees were empowered to co-create change ideas and use Plan-Do-Study-Act (PDSA) cycles to address the issues. Finally, the questionnaire was repeated to complete the loop.This approach created an open, listening environment with clear communication channels from trainees to consultants and management. This allowed us to identify themes for improvement. These included induction, education opportunities, clinical supervision and escalation policies.In collaboration with trainees, three improvement teams were formed, each of which addressed an issue through a PDSA cycle. These were: 1.Unclear referral pathway to Psychiatry resulting in inefficiency. The team co-created a flowchart identifying how to appropriately refer to Psychiatry, which has reduced the number of inappropriate bleeps.2.Unclear escalation policies and consultant cover. The trainees worked with the multidisciplinary team to generate a clear escalation pathway.3.Significant variation in content and documentation of clerking – the data collected helped drive change through the utilisation of an electronic clerking checklist.Other issues were raised and quickly addressed without requiring a PDSA cycle. Such issues included provision of on-call rooms, parking spaces, improvements to induction, starting a Balint Group for trainees, and changing the mode of administration of Pabrinex.ResultsDuring the five-month period those who experienced joy in work several times a week or more increased from 0%-86%. Those who always felt a valued member of the team increased from 29%- 86%. Those with overall job satisfaction increased from 0%-75%ConclusionDiT experience comprises more than rota compliance. It includes well-being, psychological support, professional development, teamship and more. This project has demonstrated considerable improvement in trainee experience through utilising the WeCaRE framework. This highlights the power of listening to, valuing and empowering trainees, whilst utilising data as a vehicle to drive change.