This small non-randomized study is the first end-of-life care in dementia intervention to report an increase in family satisfaction with a reduction in hospital deaths. This is promising but requires further evaluation in diverse care homes.

The staff require education and support about discussing and implementing plans around care at the end of life in dementia and about cultural issues around death to improve practice. This would enable the staff to implement advance care plans, knowing that they will be supported. Education would encompass communicating the complicated, unpredictable path of dementia near the time of death explicitly but sensitively, including recognising that people often do not hear difficult messages and are unable to take on large quantities of information at once. The staff need to know about the resident's religious and cultural ideas as well as ritual practice.

All studies were either small or used instruments with unsatisfactory psychometric properties and so our conclusions are limited by the lack of good quality evidence. The preliminary evidence suggests that most staff who remain working in homes do not have a high prevalence of psychological stress or level of symptoms.

Background: A long-acting somatostatin analogue (lanreotide) is used in the management of a diazoxide-unresponsive diffuse form of congenital hyperinsulinism (CHI). However, no reports of its use in patients with the focal form of CHI exist. Case 1: A 1-month-old boy diagnosed with diazoxide-unresponsive CHI due to a paternal heterozygous ABCC8 gene mutation showed partial response to octreotide. ¹⁸F-DOPA-PET/CT scan revealed a focal lesion in the pancreatic head. Surgical removal of the lesion was unsuccessful. He was switched to monthly lanreotide treatment at the age of 11 months, which stabilised his blood glucose over a 12-month period. Case 2: A 1-month-old boy with diazoxide-unresponsive CHI due to a paternal heterozygous KCNJ11 gene mutation was partially responsive to octreotide. ¹⁸F-DOPA-PET/CT scan confirmed a focal pancreatic head lesion. Over 6 months, he underwent 3 lesionectomies and afterwards responded to octreotide. At the age of 9 months, treatment was switched to monthly lanreotide. Currently, he is aged 3, with stable glycaemia, and improved fasting tolerance. Case 3: A 3-week-old girl with a paternal heterozygous ABCC8 gene mutation was unresponsive to diazoxide. ¹⁸F-DOPA-PET/CT scan confirmed a focal pancreatic head lesion. She responded to octreotide, and her parents preferred to avoid pancreatic surgery. At the age of 20 months, treatment was switched to monthly lanreotide, resulting in euglycaemia over the last 7 months. Conclusion: CHI patients with focal pancreatic head lesions are challenging, especially if not surgically amenable. Conservative treatment is preferable, and lanreotide might be an option. The therapeutic impact of lanreotide treatment in patients with the focal forms of CHI should be confirmed in prospective studies with close monitoring of the side effects.

Introduction Dementia is associated with shortened life expectancy. Death may occur unexpectedly without end of life care planned. Most people would prefer to die at home, if possible, rather than in hospital. However, many with advanced dementia lack explicit end of life plans. Aims and MethodsThe project aimed to increase the number of residents with dementia (RWD) receiving their end of life care in the way that they and their relatives planned. We trained staff interactively, using case scenarios and encouraging refl ection on their work, to enable end of life discussions with relatives. Our evaluation included residents' quality of life (QoL), and measures of staff's job demands. We implemented a training package addressing staff concerns, knowledge and communication skills. In depth interviews were carried out with staff and relatives, and collected QoL measures from 53 relatives of RWD, and retrospectively if their relative died. Staff job demand was measured. Results Interview analysis showed improvements in end-oflife planning and communication, and QoL improved at RWD's end-of-life. Staff's experience of job demand improved. Conclusion The intervention improved end-of-life communication, planning and care, as shown by themes in qualitative analysis and QoL measures.

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