Healing of Chemical Injury-Related Persistent Corneal Epithelial Defects With Topical Insulin.

PURPOSE: The purpose of this study was to evaluate the effectiveness of insulin eye drops for treating refractory persistent epithelial defects (PEDs). METHODS: A prospective, single-center, case series was performed from March 2020 to September 2021. All patients were prescribed insulin eye drops for refractory PEDs that failed on maximum standard medical treatment (including serum eye drops). The drops were used 4 times/day. Patients were followed up at 2 weekly intervals with full slitlamp examination and serial anterior segment photography. The primary end point was resolution of the epithelial defect. RESULTS: Eleven eyes of 10 patients were treated with insulin eye drops. The mean age of the cohort was 45.4 + 25 years with a mean follow-up of 195.7 + 114.3 days after re-epithelization. The most common causative condition was chemical injury (n = 5, 60%). Mean baseline PED defect was 41.3 + 55.2 mm 2 . Nine of 11 eyes (82%) fully re-epithelized within a mean time of 62.3 + 34.6 days (range 14-112). In 2 patients who did not achieve re-epithelization, one had a reduction in size from 12.25 mm 2 to 4.5 mm 2 and the other had no response. No recurrence in defect was observed in the group that had fully re-epithelized. CONCLUSIONS: This study showed that the use of topical insulin eye drops led to a successful resolution of PED in 9 of 11 cases. We demonstrate the use of insulin for closure of PEDs in chemical eye injury. Larger controlled studies are required to further evaluate this novel therapy.

Development of virtual ophthalmic surgical skills training.

BACKGROUND: This study aims to assess whether ophthalmic surgical skills can be taught successfully online to a diverse international and interprofessional student group. METHODS: Mixed methods study involving 20 students and 5 instructors. Each student completed a pre-session and post-session questionnaire to assess their perceptions regarding online instruction. Changes in questionnaire responses were analysed using Wilcoxon signed rank (SPSS 25). Semi-structured interviews were conducted to assess instructor perceptions towards virtual surgical skills teaching. Thematic analysis was undertaken using NVivo 12.0 software. RESULTS: There was a 100% completion rate of pre- and post-session questionnaires. Prior to the session, lack of instructor supervision and inability to provide constructive feedback were emergent themes from students. Pre-session concerns regarding online delivery: 40% of students thought their view of skills demonstration would be negatively impacted, 60% their level of supervision and 55% their interaction with instructors. Following the session 10%, 15% and 5% held this view respectively. All students were 'satisfied' or 'very satisfied' regarding the 'Surgeon's View' camera angle as well as the use of breakout rooms. 75% perceived an improvement in their confidence in instrument handling, 80% in cable knot tying and 70% in suture tying. Overall student rating for the virtual surgical skills session was 8.85 (±1.19) out of 10 (10 being most satisfied). CONCLUSIONS: We demonstrate that successful delivery of a virtual ophthalmic surgical skills course is feasible. We were able to widen accessibility and participation through virtual delivery, which has future implications for ophthalmic surgical teaching and its reach.

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU).

Background: In Greater Manchester (GM), prehospital clinicians use the Face Arm Speech Test (FAST) to identify suspected stroke patients alongside pathway exclusions. Within the centralized stroke service, patients with a suspected stroke are taken directly to a Hyper Acute Stroke Unit (HASU), often bypassing their local emergency department (ED). However, many of these patients are experiencing an illness that looks like a stroke but is not a stroke. The data collected in the prehospital setting is rarely used in research yet could give valuable insights into the performance of the pathway. Aim: To evaluate the presenting symptoms and final diagnoses of prehospital suspected strokes and to evaluate the adherence of prehospital stroke pathway exclusions. Methods: We analyzed data from all patients brought in by ambulance and admitted on the stroke pathway between 01/09/15 and 28/02/17. Patient demographics and all data recorded in the prehospital setting were evaluated to identify differences in stroke, TIA, and mimic patients. Pathway adherence was assessed according to whether the patient was local or out-of-area (OOA) and bypassed their local ED. Results: A total of 4,216 suspected strokes were identified: 2,213 (52.5%) had a final diagnosis of stroke, 492 (11.7%) experienced a transient ischemic attack (TIA), and 1,511 (35.8%) were stroke mimics. There were 714 (16.9%) patients that were identified as having at least one pathway exclusion or were FAST negative, of which 270 (37.8%) experienced a stroke. The proportion of strokes was significantly lower in those with a pathway exclusion (41.8 vs. 53.5%; p < 0.001) and the proportion of breaches tended to be comparable or higher in the local population. Discussion: There are high volumes of stroke mimics but identified differences indicate there is an opportunity to better utilize prehospital data. Ambulance clinicians were able to correctly overrule FAST negative results and the volume of these suggest that FAST alone may be too restrictive.

The management of neurotrophic keratitis.

PURPOSE OF REVIEW: The management of neurotrophic keratitis (NK) has evolved in the last decade. The present article reviews updated management guidelines of this entity, as well as future innovations in the field. RECENT FINDINGS: The advent of confocal microscopy has allowed for the first time to image corneal nerves. In addition, multiple novel topical treatments such as nerve growth factor have improved the prognosis of this disease, with many other in the pipeline. Finally, corneal nerve restoration is now possible with corneal neurotization procedures. SUMMARY: Many novel treatments based on agents that stimulate nerve regrowth are now available to treat NK. Improvement in neurotization procedures could also address advanced stages of this disease with surgery.

Quality Improvement in Atrial Fibrillation detection after ischaemic stroke (QUIT-AF).

BACKGROUND: Paroxysmal atrial fibrillation (PAF) is a frequent cause of recurrent stroke but can be difficult to detect because of its episodic and often asymptomatic nature. We sought to improve rate of PAF detection through a quality improvement project (QIP) to deliver early prolonged inpatient cardiac monitoring on the stroke unit (SU). METHODS: A structured protocol for cardiac monitoring using 5-day event recorders was established. 'In-house' cardiac monitoring was implemented. Performance data on this change in service was analysed prospectively and summary statistics obtained. RESULTS: One-hundred and two ischaemic stroke (IS) patients undertook 5-day event recorder monitoring. Provision of monitors as an inpatient (IP) increased from 20% (pre-QIP pilot 2018) to 65.7% (during QIP). New AF was detected in 15 patients (14.7% vs 8.6% pre-QIP pilot 2018) with majority of new AF (13 patients; 19%) detected when monitors applied early (IP) after IS. CONCLUSION: Although this study had a number of limitations, it did demonstrate that early and prolonged non-invasive IP cardiac monitoring could be delivered 'in-house' on the SU and improve AF detection rates.

Environmental Factors and Hyperacute Stroke Care Activity During the COVID-19 Pandemic: An Interrupted Time-Series Analysis.

BACKGROUND AND AIMS: Concerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors. METHODS: Weekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges. RESULTS: The median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5th March) and the implementation of the Act-FAST campaign (6th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here. CONCLUSION: Despite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes.

Pre-hospital stroke recognition in a UK centralised stroke system: a qualitative evaluation of current practice.

BACKGROUND: A significant number of patients conveyed via ambulance to hyper acute stroke units (HASU) with suspected stroke have other diagnoses. This may delay treatment for non-stroke patients and cause burden to stroke teams. The Greater Manchester (GM) Connected Health Cities (CHC) stroke project links historical North West Ambulance Service NHS Trust (NWAS) data with Salford Royal Hospital electronic data to study stroke pathway compliance and accuracy of paramedic diagnosis and aims to use these data to improve pre-hospital clinicians' accurate recognition of stroke through development of service improvement innovations. We report on supplementary qualitative work required to understand stroke recognition from the pre-hospital clinician's perspective. METHODS: Focus groups and semi-structured interviews were conducted with pre-hospital clinicians of various grades, working in the GM area of NWAS. Focus groups and interviews were audio recorded and transcribed verbatim. We used thematic analysis informed by normalisation process theory (NPT) to analyse the data. This theory helps us to understand how innovations are developed, implemented and sustained into healthcare practice. RESULTS: Sixteen pre-hospital clinicians took part in two focus groups, one dyad interview and five one-to-one interviews. Analysis identified that respondents were unaware of false positive stroke rates entering onto the stroke pathway. Pre-hospital clinicians receive limited feedback from jobs and this impedes their ability to learn from their experiences. Respondents reported difficulty in ruling out stroke in certain patient cohorts and difficulty in recognising differential diagnoses. They expressed a lack of confidence to rule out stroke in the pre-hospital setting. They also expressed greater concern for 'missed strokes'. CONCLUSION: The qualitative findings support the development of innovations to improve accurate recognition of stroke in the pre-hospital setting.An enhanced FAST tool, better relations with HASU clinicians, feedback and education on the stroke pathway and differential diagnoses were all considered useful to improve accurate stroke recognition.

Conserving Quality of Life through Community Paramedics.

The Economic Value of Community Paramedicine Programs Study was a randomized controlled trial in two Eastern Ontario communities ߝ one urban and one rural ߝ to determine whether community paramedicine services (the intervention through home visits) would have a positive economic impact through influencing self-perceived quality of life and determining a monetized value. A total of 200 clients who were high-users of healthcare services and had one or more of five chronic diseases (congestive heart failure, chronic obstructive pulmonary disease, hypertension, stroke and diabetes) were recruited in early 2015. These participants were randomly assigned to either the intervention group (receiving community paramedicine services for 12 months) or the control group (receiving conventional treatment). Study results suggest that although quality of life scores decreased for all groups, those receiving community paramedicine services demonstrated significantly less reduction in their scores. Suggestions to further increase cost efficiency of this novel service are given.

Nmda alters the development of hypoxic pulmonary vasoconstriction and nitric oxide synthetase activity in the isolated perfused rat lung.

Using an isolated salt-perfused rat lung model, the authors investigated whether N-methyl-D-aspartate (NMDA) (1 mM) in the pulmonary circulation effects the pulmonary vascular responses to an acute stimulus of hypoxic insult under baseline, nitric oxide synthetase (NOS)-blocked conditions (N-omega-nitro-L arginine methyl ester; L-NAME, 2 mM), and with an NMDA receptor blocker, MK-801 (0.3 microM) added. NOS activity at baseline, and in response to hypoxia, NMDA, L-NAME, and a combination of these stimuli were also assessed. NMDA did not in itself alter hypoxic pulmonary vasoconstriction (HPV), but did significantly attenuate HPV during VOS blockade. This effect of NMDA was erased by MK-801. Assessment of NOS activity showed that hypoxia alone caused a doubling of NO production within the lung. This effect was erased by the addition of L-NAME. NMDA alone caused a significant, 3-fold increase in NOS activity, which was not further affected by hypoxic chalenge. L-NAME did not depress NOS activity in the hypoxia + NMDA group. These data suggest that NMDA receptor activation results in increased NOS activity and presumably increased production of NO. The increased NOS activity induced by NMDA receptor stimulation is resistant to the blockade effect of L-NAME. The actions of NMDA receptor activation may represent a natural protective mechanism, at least within the pulmonary vasculature, in face of acute, abnormal stimuli such as hypoxia.