The UK clinical eye research strategy: refreshing research priorities for clinical eye research in the UK.

OBJECTIVES: To validate and update the 2013 James Lind Alliance (JLA) Sight Loss and Vision Priority Setting Partnership (PSP)'s research priorities for Ophthalmology, as part of the UK Clinical Eye Research Strategy. METHODS: Twelve ophthalmology research themes were identified from the JLA report. They were allocated to five Clinical Study Groups of diverse stakeholders who reviewed the top 10 research priorities for each theme. Using an online survey (April 2021-February 2023), respondents were invited to complete one or more of nine subspecialty surveys. Respondents indicated which of the research questions they considered important and subsequently ranked them. RESULTS: In total, 2240 people responded to the survey (mean age, 59.3 years), from across the UK. 68.1% were female. 68.2% were patients, 22.3% healthcare professionals or vision researchers, 7.1% carers, and 2.1% were charity support workers. Highest ranked questions by subspecialty: Cataract (prevention), Cornea (improving microbial keratitis treatment), Optometric (impact of integration of ophthalmic primary and secondary care via community optometric care pathways), Refractive (factors influencing development and/or progression of refractive error), Childhood onset (improving early detection of visual disorders), Glaucoma (effective and improved treatments), Neuro-ophthalmology (improvements in prevention, diagnosis and treatment of neurodegeneration affecting vision), Retina (improving prevention, diagnosis and treatment of dry age-related macular degeneration), Uveitis (effective treatments for ocular and orbital inflammatory diseases). CONCLUSIONS: A decade after the initial PSP, the results refocus the most important research questions for each subspecialty, and prime targeted research proposals within Ophthalmology, a chronically underfunded specialty given the substantial burden of disability caused by eye disease.

Effects of monitoring strategies on seizures in pregnant women on lamotrigine: a meta-analysis.

OBJECTIVES: Pregnant women with epilepsy have a significantly increased risk of mortality and morbidity compared to non-pregnant women. At least one in 250 pregnancies is exposed to anti-epileptic drugs (AED). Seizure deterioration occurs in up to a third of pregnant women. AED levels fall in most pregnant women, although it is uncertain that this is responsible for seizure deterioration rather than a hormonal effect. Current practice of AED monitoring is either therapeutic drug monitoring (TDM) or clinical features monitoring (CFM) to adjust the AED dose. We have systematically reviewed the effectiveness of the two monitoring regimens for AEDs, especially lamotrigine, the most commonly used AED in pregnancy on maternal and fetal outcomes. STUDY DESIGN: We searched MEDLINE (1966-2012), EMBASE (1980-2012) and Cochrane, for relevant citations on the effectiveness of different monitoring strategies on seizure deterioration in pregnant women with epilepsy on lamotrigine. Study selection, quality assessment and data extraction were carried out by two independent reviewers. We calculated the rates of deterioration in seizures with the two strategies and pooled the estimates with random effects meta-analysis. RESULTS: Six observational studies (n=132) evaluated the effectiveness of the two monitoring strategies on pregnant women with epilepsy on lamotrigine. There were no randomised controlled trials. The rate of seizure deterioration was 0.30 (95% CI 0.21-0.41) in women monitored by therapeutic drug monitoring (TDM) compared to 0.73 (95% CI 0.56-0.86) in those receiving clinical feature monitoring (CFM) alone. CONCLUSION: Evidence based on observational data suggests that monitoring of AED levels in pregnancy reduces seizure deterioration, although the included studies have numerous sources of bias. There is paucity of evidence to make firm recommendations on optimal monitoring of AED drugs in pregnancy. Further research is needed to advise on the best clinical practice in managing AED in pregnancy.

Moving general practitioner training into primary care with cluster-based learning: a qualitative study in the West Midlands.

This study sought to explore the early implementation of cluster-based learning (CBL) pilots in one part of the UK. A qualitative study using semi-structured one-to-one interviews was conducted with 10 key informants responsible for managing and delivering local training programmes across 14 general practice specialty training schemes. Data were analysed using thematic content analysis using the constant comparative method. Wide variation existed in the running of CBL pilots between different schemes. The principal reasons for trialling CBL were the high numbers of general practitioner trainees, resulting in extra pressure placed on postgraduate education facilities. Training programme directors (TPDs) managed and facilitated the current pilots. Effective facilitation of the groups was considered essential, along with good organisation and planning, and enthusiastic facilitators. Having a mixture of specialist trainees from different stages of training promoted shared learning in the group. The cluster-based approach was also judged to enable the targeting of training to meet the needs of learners and to address specific local needs. Responders considered that CBL should ultimately comprise learner-led sessions facilitated by educational supervisors, with TPDs being responsible for leading the improvement of the quality of educational and clinical supervision. The main reasons why CBL was not implemented were anxieties about the risks of losing the perceived benefits of the current training format in the absence of evidence of the added value of CBL. The reluctance of trainers to get involved was a major barrier - this resulted mainly from a lack of confidence with facilitating small groups and funding for their time.