Introduction Recurrent atrial fibrillation (AF) after ablation is associated with reconnection of initially isolated pulmonary vein (PV) trigger sites. Substrates are often targeted in addition to PVI, but it is unclear how substrates progress over time. We studied if substrates in recurrent AF are conserved or have developed de novo from pre-ablation AF. Methods and Results Of 137 patients undergoing Focal Impulse and Rotor Mapping (FIRM) at their index procedure for AF, 29 consecutive patients (60 ± 8 years, 79% persistent) recurred and were also mapped at repeat procedure (21 ± 20 months later) using carefully placed 64-pole baskets and RhythmView™ (Topera, Menlo Park, CA, USA) to identify AF sources and disorganized zones. Compared to index AF, recurrent AF had a longer cycle length (177 ± 21 vs. 167 ± 19 milliseconds, P = 0.01). All patients (100%) had 1 or more conserved AF rotors between procedures with surrounding disorganization. The number of sources was similar for recurrent AF post-PVI versus index AF (3.2 ±1.4 vs. 3.1 ± 1.0, P = 0.79), but was lower for recurrent AF after FIRM+PVI versus index AF (4.4 ± 1.4 vs. 2.9 ± 1.7, P = 0.03). Overall, 81% (61/75) of AF sources lay in conserved regions, while 19% (14/75) were detected de novo. Conclusion Electrical propagation patterns for recurrent AF after unsuccessful ablation are similar in individual patients to their index AF. These data support temporospatial stability of AF substrates over 1–2 years. Trials should determine the relative benefit of adding substrate mapping and ablation to PVI for recurrent AF.

ObjectivesNeurological practice has previously been highlighted as a high-risk speciality with regard to malpractice claims. We set out to study the nature of these claims in order to inform physicians about hazardous areas within their speciality and potentially alter clinical practice.DesignNationwide retrospective analysis of successful neurology and neurosurgery claims over a 17-year period.SettingWe studied all successful claims occurring between 1995 and 2012 using the NHS Litigation Authority database, which collects data on claims made against clinicians practising in England and Wales.ParticipantsFour hundred and twenty-three successful claims were identified during the study period.Main outcome measuresThe errors involved, the patient groups affected, the resulting mortality and the litigation payments.Results63.1% of claims were due to negligence in neurosurgical care, whilst 36.9% were due to negligence in neurological care. Litigation payments were significantly higher in neurosurgery compared to neurology cases. Diagnostic error was the most common cause of litigation. The disease categories with the highest numbers of successful litigation claims were spinal pathology, cerebrovascular disease including subarachnoid haemorrhage, intracranial tumours, hydrocephalus and neuropathy/neuromuscular disease.ConclusionsThis is the first study of successful litigation claims against the NHS for negligent neurological or neurosurgical care and provides data to help reduce risk and improve patient safety.

Introduction Medication errors are the commonest critical incidents in neonatal care. NPSA report frequent errors with gentamicin prescription, administration and monitoring. We developed a pathway to promote the safe use of gentamicin in our unit. Abstract PF.40 Table 1 Pre-pathway Post-pathway p* Dose given within 1 h of prescribed time 39 (73%) 46 (82%) 0.02 Documentation of gentamicin level 33 (62%) 41 (78%) 0.04 Appropriate action following gentamicin level result 32 (61%) 43 (77%) 0.04 Documentation of length of gentamicin therapy 22 (42%) 34 (61%) 0.045 *χ2 or Fisher's Exact test. Aim The aim of the project was to compare standards of prescription, administration and monitoring of gentamicin before and after implementation of the pathway. Standards were derived from national NPSA recommendations and local guidelines. Methodology We studied two time periods, before and after the introduction of the pathway. The dosing regimen was similar during both periods. Data was obtained from the electronic patient data management system, the drug prescription chart (pre-pathway) or the dedicated pathway documentation (post-pathway). Results 53 cases (pre-pathway) and 56 cases (post-pathway) were analysed. There were 418 doses of gentamicin administered over the two time periods. Median gestation and birth weight was lower in pre-pathway infants compared to those in post-pathway (30 vs 31 weeks, p=0.04; 1.24 vs 1.51 kg, p=0.04). Conclusion The introduction of a dedicated antibiotic pathway enhanced practice around gentamicin therapy with fewer delays in antibiotic administration, improved documentation and better practice around monitoring of gentamicin levels.

The investigation of children with early developmental impairment (EDI) is challenging in terms of selecting investigations and supporting families through the diagnostic pathway. Modern genomic sequencing has the potential to greatly improve yield of investigation, but produces challenges in terms of timing and explaining its strengths/weaknesses to families. We present an evidence-based and practical guideline to help the paediatrician through all stages of investigation. We emphasise the importance of a really good history and examination, allowing targeted investigation for specific disorders and outline an approach for isolated EDI when this is not possible. This prioritises genetic investigation- after appropriate counselling to families, and balances the very low yield of biochemical/radiological investigations in isolated EDI, with the need to detect extremely rare, but potentially treatable disorders. Collaboration with both families and regional specialists to ensure appropriate testing is likely to reduce parental and clinician anxiety.

BackgroundIn a landmark case in August 2016 an optometrist was found guilty of missing papilloedema. We examined the current referral pathway for managing papilloedema to determine whether initial assessment by an optician impacted resource use.MethodsDischarge summaries from St Marys Hospital (SMH) between 1/1/17 and 16/5/17 the referral centre for the Western Eye Hospital (WEH) accident and emergency (A and E) were searched to identify subjects with suspected papilloedema. Analysis of the patients journey was performed.ResultsOf 76 patients identified, 26 were excluded either due to being<18 years old or were treated elsewhere. Of the 50 included, 25/50 were seen by an optician prior to a WEH A and E ophthalmologist, 75% of these were referred for urgent hospital assessment with an admission rate of 45.8%. Of 19/50 assessed by WEH A and E only there was a significantly lower urgent assessment referral rate (75% vs 52.6%, p=0.02) and admission rate (45.8% vs 21%, p=0.02). Of the 6/50 patients finally found to have normal discs, 5 were initially referred by opticians.ConclusionReferral by optician prior to ophthalmology A and E assessment is more likely to result in rapid referral for urgent hospital assessment and inpatient admission.