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Right Decision Service newsletter: October 2024

Welcome to the Right Decision Service (RDS) newsletter for October 2024.

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Mild Ventriculomegaly on Antenatal Ultrasound (916)

Please report any inaccuracies or issues with this guideline using our online form

Fetal ventriculomegaly is a common finding on antenatal ultrasound and is defined as an atrial measurement of ≥ 10mm of the posterior horn of the lateral ventricle (1). It can be further subdivided into mild 10-12mm, moderate 13- 15mm and severe >15mm (2). It has a prevalence of approximately 1% (3). Ventriculomegaly has a range of causes; normal variation, aneuploidy, genetic syndromes, primary brain structural abnormalities, congenital infections, cerebrovascular accidents and intracranial haemorrhage. Prognosis and corresponding counselling of the parents is dependent on the cause of the ventriculomegaly, the antenatal progression and any co-existing abnormalities(4). It is therefore vitally important to look for  any underlying aetiologies and co-existing CNS and non-CNS abnormalities in order to present the parents with the most relevant and accurate information.

Diagnosis

Accurate measurement of the ventricles is important in both defining ventriculomegaly and also assessing progression. The fetal head should be scanned in the axial plane at the level of the frontal horns and the cavum septum pellucidum (CSP) (the same level at which a head circumference is taken), at an appropriate magnification that the head fills the screen. The callipers should be placed at the internal margins of the atrial walls at the level  of the parietal occipital groove and the glomus of the choroid plexus, perpendicular to the axis of the ventricle.

Although the distal ventricle is always easier to see than the proximal one because of reflection of the ultrasound beams from the fetal skull, both ventricles should be checked; ventriculomegaly is unilateral in 50-60% cases and bilateral in 40-50% (5).

Ultrasonography

Once ventriculomegaly has been diagnosed, there should be a detailed, sonographic evaluation of the neuroanatomy by a medical sonographer. Whether this is by transabdominal or transvaginal ultrasound will depend on the preference of the patient, the sonographer and the fetal position.

Other, non-CNS structures should also be carefully assessed including fetal biometry looking for evidence of growth restriction, the heart and any markers of intrauterine infection.

Testing for genetic disorders

Parents should be offered invasive, diagnostic testing and chromosomal microarray (CMA). 

Between 0-5% (2, 5) of fetuses with apparently isolated m i l d ventriculomegaly will have an underlying abnormal karyotype, most commonly Trisomy 21 and a further 10-15% will have abnormalities found on CMA.  

Testing for fetal infection

Congenital infections, most commonly cytomegalovirus (CMV), toxoplasmosis, parvovirus and Zika have been associated with mild ventriculomegaly in around 8% of cases (5). Parents should be offered tests for CMV, toxoplasmosis and parvo virus (regardless of history of known exposure or symptoms). Women with mild fetal ventriculomegaly who have been to a Zika area and not yet tested should be offered a test.

Fetal MRI

Fetal MRI (fMRI) can be a useful adjunct to ultrasound if the relevant radiological expertise and technology is available. The additional information will depend on the size of the ventricles as well as the quality of the original ultrasound and the level of expertise in the practitioner. The chance that fMRI will find important, clinically relevant additional brain abnormalities not picked up on ultrasound varies in the literature from 1-14% with the most recent studies putting the figure at 5-6% (5). The most common abnormality picked up on fMRI after being missed on ultrasound is agenesis of the corpus callosum.

Women wishing to have a fetal MRI, to look for additional brain abnormalities that may affect the prognosis, after appropriate counselling should be referred to fetal medicine department for review.

  • The fetal medicine department will arrange the MRI
  • Fetal medicine will review again after MRI to discuss results.
  • Thereafter the patient will go back to their own unit, unless otherwise indicated and delivery will be planned in their own unit.

Follow up antenatal ultrasound examinations

There are no data on optimal timings of follow up assessments once a diagnosis has been made. A suggested pragmatic approach would be 4-weekly assessments. Progression of ventriculomegaly is an important prognostic indicator; evidence suggests that 5% progress during pregnancy (5).

Delivery

The timing and mode of delivery should be planned as per normal obstetric indications. An alert should be placed on the electronic BadgerNet record to ensure that neonatologists are made aware of the antenatal diagnosis.

Cord bloods should be taken with parental consent for chromosomal analysis and congenital viral infections from those infants who didn’t have antenatal testing.

Postnatal follow up should be arranged by the neonatologists prior to discharge from hospital.

Prognosis

Most of the statistics quoted in the literature are based on whether the ventriculomegaly is apparently isolated or not; true isolation will only be able to be confirmed postnatally. Neurodevelopmental delay in case of isolated unilateral mild or moderate ventriculomegaly is thought to be 6% (5); in bilateral isolated ventriculomegaly this rises to 8-12% (7). This may not be dramatically higher than the background population risk. Long-term prognosis also depends on associated findings and the positive results of any investigations. 

Parents should be offered antenatal counselling by paediatricians to discuss prognosis and postnatal care in greater detail. A patient information leaflet from ISUOG and a link to further information is below.

Further information

Melchiorre, K & Bhide, Amarnath & Gika, Artemis & Pilu, G & Papageorghiou, A.T. (2009). Counseling in isolated mild ventriculomegaly. Ultrasound in Obstetrics & Gynecology

Patient Information:

ISUOG. Ventriculomegaly
"This leaflet is to help you understand what Ventriculomegaly is, what tests you need, and the implication of having been diagnosed with Ventriculomegaly for you, your baby and your family."

Editorial Information

Last reviewed: 01/04/2021

Next review date: 01/04/2024

Author(s): Rachel Bradnock.

Approved By: Obstetrics Clinical Governance Group

Document Id: 916

References
  1. International Society of Ultrasound in Obstetrics and Gynecology Education Committee. Sonographic examination of the fetal central nervous system: guidelines for performing the ‘basic examination’ and the ‘fetal neurosonogram’. Ultrasound Obstet Gynecol 2007; 29: 109 – 116.
  2. Society for Maternal-Fetal Medicine (SMFM): Fox NS et al. Mild Fetal Ventriculomegaly: diagnosis, evaluation and management. SMFM Consult Series 45 2018.
  3. Pilu G, Hobbins JC. Sonography of fetal cerebrospinal anomalies. Prenat Diagn 2002; 22: 321 – 330.
  4. Scala C, Familiari A, Pinas A, Papageorghiou T, Bhide A, Thilaganathan B, Khalil A. Perinatal and long-term outcomes in fetuses diagnosed with isolated unilateral ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 49: 450–459
  5. Griffiths PD, Brackley K, Bradburn M, et al. Anatomical subgroup analysis of the MERIDIAN cohort: ventriculomegaly. Ultrasound Obstet Gynecol 2017;50:736-44.
  6. RCOG/RCM/PHE/HPS Clinical Guidelines. Zika Virus Infection and Pregnancy. Updated Feb 2019.
  7. Pagani G, Thilaganathan B, Prefumo F. Neurodevelopmental outcome in isolated mild fetal ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014; 44: 254 – 260.