Differential impact of COVID-19 on mental health and burnout.

BACKGROUND: There may be differential impact of the COVID-19 pandemic on mental health and burnout rates of healthcare professionals (HCPs) performing different roles. AIMS: To examine mental health and burnout rates, and possible drivers for any disparities between professional roles. METHODS: In this cohort study, online surveys were distributed to HCPs in July-September 2020 (baseline) and re-sent 4 months later (follow-up; December 2020) assessing for probable major depressive disorder (MDD), generalized anxiety disorder (GAD), insomnia, mental well-being and burnout (emotional exhaustion and depersonalization). Separate logistic regression models (at both phases) compared the risk of outcomes between roles: healthcare assistants (HCAs), nurses and midwives (nurses), allied health professionals (AHPs) and doctors (reference group). Separate linear regression models were also developed relating the change in scores to professional role. RESULTS: At baseline (n = 1537), nurses had a 1.9-fold and 2.5-fold increased risk of MDD and insomnia, respectively. AHPs had a 1.7-fold and 1.4-fold increased risk of MDD and emotional exhaustion, respectively. At follow-up (n = 736), the disproportionate risk between doctors and others worsened: nurses and HCAs were at 3.7-fold and 3.6-fold increased risk of insomnia, respectively. Nurses also had a significantly increased risk of MDD, GAD, poor mental well-being and burnout. Nurses also had significantly worsened anxiety, mental well-being and burnout scores over time, relative to doctors. CONCLUSIONS: Nurses and AHPs had excess risk of adverse mental health and burnout during the pandemic, and this difference worsened over time (in nurses especially). Our findings support adoption of targeted strategies accounting for different HCP roles.

A technician-delivered 'virtual clinic' for triaging low-risk glaucoma referrals.

PurposeThe purpose of this study is to describe the outcomes of a technician-delivered glaucoma referral triaging service with 'virtual review' of resultant data by a consultant ophthalmologist.Patients and methodsThe Glaucoma Screening Clinic reviewed new optometrist or GP-initiated glaucoma suspect referrals into a specialist ophthalmic hospital. Patients underwent testing by three ophthalmic technicians in a dedicated clinical facility. Data were reviewed at a different time and date by a consultant glaucoma ophthalmologist. Approximately 10% of discharged patients were reviewed in a face-to-face consultant-led clinic to examine the false-negative rate of the service.ResultsBetween 1 March 2014 and 31 March 2016, 1380 patients were seen in the clinic. The number of patients discharged following consultant virtual review was 855 (62%). The positive predictive value of onward referrals was 84%. Three of the 82 patients brought back for face-to-face review were deemed to require treatment, equating to negative predictive value of 96%.ConclusionsOur technician-delivered glaucoma referral triaging clinic incorporates consultant 'virtual review' to provide a service model that significantly reduces the number of onward referrals into the glaucoma outpatient department. This model may be an alternative to departments where there are difficulties in implementing optometrist-led community-based referral refinement schemes.

Bone metastases of the hand.

Introduction The aim of this study was to identify patients with malignant hand lesions, establish the proportions of those that were metastases and review their clinical course. Methods A retrospective search of a prospective tumour database was carried out to identify all patients treated at our unit with hand metastases. Patient demographics were recorded including site of primary malignancy, region of the hand involved, management of their metastasis and clinical outcome. Results Overall, 149 patients were identified with a malignant tumour of the hand. Ten had a metastatic lesion. There were 3 women and 7 men with a median age of 68 years (range: 28-91 years) at presentation. All presented with non-mechanical hand pain while four had pain and swelling. The median interval from symptom onset to diagnosis was eight weeks. The minimum follow-up duration was four months. Three patients had no history of malignancy. Of the remaining seven patients, three had other known metastases. Six patients underwent solely palliative radiotherapy. Three patients had amputation. One was treated with surgical excision and radiotherapy. One had an amputation and axillary node clearance. All but one patient had died by the time of the latest follow-up appointment. The median time to death following identification of acrometastases was 18 months. Sites of primary disease were skin (n=4), lung (n=3), kidney (n=2) and neuroendocrine system (n=1). The thumb was the most commonly affected location. Conclusions This study demonstrates that patients presenting with non-mechanical hand pain should be considered to have a malignant process until proved otherwise, particularly in patients with thumb symptoms and a history of prior malignancy.

Age-related changes in the thickness of the human lamina cribrosa.

OBJECTIVE: To measure the human lamina cribrosa thickness (LCT) in vitro in fully hydrated specimens and to determine whether there is any association between thickness and age or sex. METHODS: 45 fixed human optic nerves, age range 9-90 years, were dissected from the globe and frozen sectioned. The study was divided into two parts: the first investigated the overall change in LCT and cribrosal beam thickness (CBT) with age, and the second divided eyes into two specific age groups (38-49 and 78-87 years) and assessed differences with respect to age and sex. RESULTS: LCT ranged from 345.4 to 555.9 microm between the samples. A positive relationship was found between LCT and age (LCT = 2.41xage+365.5, 95% confidence interval (CI) for slope 1.31 to 3.52; r(2) = 0.30, p<0.001). A regional difference in CBT was observed, with beams being thickest at the posterior cribrosa (mean 14.8 (standard deviation (SD) 2.2) microm) and thinnest at the anterior cribrosa (9.8 (SD 2.4) microm). CBT increased with increasing age. Differences related to sex were also found, with females having relatively thinner LCT than males, irrespective of age, but this was not statistically significant. CONCLUSIONS: This study shows an increase in human LCT with increasing age. This changing structural property of the lamina cribrosa may have implications for its functioning with respect to compliance and reversibility, and has particular relevance to glaucoma, where increasing age has been identified as a strong risk factor for the development of the disease.

The relative effects of corneal thickness and age on Goldmann applanation tonometry and dynamic contour tonometry.

AIMS: To establish the effects of central corneal thickness (CCT) on intraocular pressure (IOP) measured with a prototype Pascal dynamic contour tonometer (DCT), to evaluate the effect of CCT and age on the agreement between IOP measured with the Pascal DCT and Goldmann applanation tonometer (GAT), and to compare the interobserver and intraobserver variation of the DCT with the GAT. METHODS: GAT and DCT IOP measurements were made on 130 eyes of 130 patients and agreement was assessed by means of Bland-Altman plots. The effect of CCT and age on GAT/DCT IOP differences was assessed by linear regression analysis. Interobserver and intraobserver variations for GAT and DCT were assessed in 100 eyes of 100 patients. RESULTS: The mean difference (95% limits of agreement) between GAT and DCT was -0.7 (-6.3 to 4.9) mm Hg. GAT/DCT IOP differences increased with thicker CCT (slope 0.017 mm Hg/microm, 95% CI 0.004 to 0.03, r2 = 0.05, p = 0.01), and with greater age, slope 0.05 mm Hg/year (95% CI 0.012 to 0.084, r2 = 0.05, p = 0.01). The intraobserver variability of GAT and DCT was 1.7 mm Hg and 3.2 mm Hg, respectively. The interobserver variability was (mean difference (95% limits of agreement)) 0.4 (-3.5 to 4.2) mm Hg for GAT and 0.2 (-4.9 to 5.3) mm Hg for DCT. CONCLUSIONS: GAT is significantly more affected than DCT by both CCT and subject age. The effect of age suggests an age related corneal biomechanical change that may induce measurement error additional to that of CCT. The prototype DCT has greater measurement variability than the GAT.

Variable CD7 expression on T cells in the leukemic phase of cutaneous T cell lymphoma (Sézary syndrome).

CD7, a molecule normally expressed on 90% of normal CD4+ T cells, is often deficient on the malignant T cells of cutaneous T cell lymphoma. To investigate the clinical and biologic implications of CD7 expression, blood lymphocytes from 42 patients with the leukemic phase of cutaneous T cell lymphoma (CD4/CD8 ratio of 10 or more with evidence of a T cell clone in the blood) were analyzed for level of expression of CD7 by flow cytometry. CD7 expression by cells did not clearly segregate into two distinct subgroups that are either CD7 positive or CD7 negative as generally thought; however, nine of 17 patients with a predominantly CD4+CD7+ tumor population on early studies became CD4+CD7- over time whereas the converse situation was not observed. In addition, of three patients with evidence of large tumor cells in the blood coexisting with smaller cells, discordant CD7 expression was observed in one instance. In lymph node specimens, the percentage of cells expressing CD7 and other T cell markers did not correlate with histologic evidence of involvement. CD7 expression on blood lymphocytes also did not correlate with patients' survival nor to serum IgE levels or blood eosinophil counts, a finding suggesting that this marker does not identify functional cell subsets that produce serum interleukin-4 or -5, respectively. We speculate that the level of CD7 expression on malignant T cells may be the effect of sustained antigen stimulation in vivo analogous to what has been proposed to occur with normal T cells during aging.

Optic disc changes following trabeculectomy: longitudinal and localisation of change.

AIMS: To determine whether there were any changes in the optic disc at 2 years after trabeculectomy. To determine the factors that most influenced change and whether change was localised to any region of the optic disc. METHODS: 95 patients undergoing routine trabeculectomy as part of the ongoing Moorfields/MRC 5-fluorouracil trial were recruited into the study. Eyes were imaged preoperatively (4 (SD 3) weeks) with the Heidelberg retina tomograph (HRT, Heidelberg Engineering), and at 3 months (SD 2 weeks), 1 year (SD 1 month), and 2 years (SD 1 month) after surgery. Parameters investigated for change were rim area, rim volume, and maximum cup depth. The predefined segment analysis available on the HRT analysis software was used to determine segmental change. RESULTS: The images of 70 patients were analysed. Intraocular pressure reduced from 22.25 (SD 3.76) mm Hg, at the time of preoperative imaging to 15.27 (SD 4.96) mm Hg at 3 months, 14.38 (SD 3.89) mm Hg at 1 year, and 13.80 (SD 3.54) mm Hg at 2 years after trabeculectomy. An increase in rim area and rim volume was present at all time points after surgery, but was only found to be statistically significant at 2 years after surgery. Maximum depth of cup reduced by month 3 and month 12, but showed a slight increase at 2 years after surgery, although this was still lower than the preoperative measure. Segmental analysis found a significant change in rim volume in the nasal, inferonasal, superonasal, and superotemporal regions at 2 years after surgery. No significant regional localisation for change was found at any other time point or in any other parameter investigated. CONCLUSIONS: Reversal of disc cupping is present at 2 years after trabeculectomy. The factor most influencing change is reduction of intraocular pressure. Segmental analysis showed that change in rim volume was greatest in the nasal, inferonasal, superonasal and superotemporal regions at 2 years.

Sponge delivery variables and tissue levels of 5-fluorouracil.

AIM: To study how the delivery of 5-fluorouracil (5-FU) to ocular tissues is affected by altering delivery variables. METHOD: Sponge(s) soaked in radiolabelled 5-FU were placed between the conjunctiva and sclera of pig eyes. Application time, sponge size, sponge make (Altomed, Weck, Merocel), and 5-FU concentration were varied. Conjunctival and scleral tissue levels were determined in samples taken from the application site. RESULTS: Dose-response curves for scleral and conjunctival 5-FU levels against application time showed increasing tissue levels that reached a plateau after 2-3 minutes. Application beyond 3 minutes did not increase tissue levels. There was no difference in tissue levels between 7x4 and 3. 5x2 mm sponges. Altomed sponges produced 5-FU tissue levels that were twice as high as those obtained with Weck-cell (p<0.01) or Merocel (p<0.02) sponges. Changing the 5-FU concentration from 25 mg/ml to 6.25 mg/ml reduced the conjunctival concentration by a factor of 3.5 (p<0.003). CONCLUSION: Application time up to 3 minutes, sponge make, and 5-FU concentration can have a large effect on the tissue delivery of 5-FU. Application time beyond 3 minutes, using 3.5x2 mm or 7x4 mm sponges, and replacing sponges every minute did not have a significant effect on tissue levels. This study models the effect that different variables can have on the ocular tissue levels of an antimetabolite applied intraoperatively.

Anterior chamber flare after trabeculectomy and after phacoemulsification.

AIMS: To evaluate and compare prospectively the anterior chamber inflammatory response after phacoemulsification cataract surgery and after trabeculectomy with peripheral iridectomy. METHODS: Anterior chamber inflammation was measured using the Kowa FM-500 laser flare meter in 131 patients undergoing trabeculectomy and 148 patients undergoing phacoemulsification cataract extraction with intraocular lens implantation. Flare was measured before surgery and on each postoperative visit up to 12 months. RESULTS: Before surgery there was no significant difference in flare readings between the two groups. Following trabeculectomy flare returned to baseline levels 4 weeks after surgery, while following phacoemulsification cataract extraction it remained significantly higher at week 6 (p<0.006) and month 3 (p<0.05). CONCLUSIONS: Anterior chamber inflammation is more prolonged after cataract surgery than after trabeculectomy. This may have implications for the timing of trabeculectomy in relation to cataract surgery.

Superficial keratectomy and conjunctival autograft for Fuchs' superficial marginal keratitis.

PURPOSE: To describe a patient with bilateral, recurrent marginal corneal infiltrates consistent with Fuchs' superficial marginal keratitis who developed bilateral nasal pseudopterygia encroaching on the visual axis, reducing visual acuity in both eyes. METHODS: Bilateral superficial keratectomy combined with conjunctival autografting was performed in each eye. RESULTS: Best corrected visual acuity improved from 20/60 in the left eye and 20/40 in the right eye to 20/25 in both eyes. Our patient has had no disease relapses in her right eye, as of 29 months after the surgery, but experienced a mild flare-up of marginal keratitis in her left eye 8 months after the surgery. Despite this flare-up, disease symptoms in the left eye have markedly diminished. CONCLUSION: Superficial keratectomy combined with conjunctival autograft is a therapeutic alternative in the management of severe, recurrent Fuchs' superficial marginal keratitis. In the present case, it has resulted in an improvement in visual acuity as well as a decrease in the frequency of disease flare-ups. The clinical course of this patient suggests that the conjunctiva may play a role in the etiology of Fuchs' superficial marginal keratitis.

Pars plana vitrectomy for macular holes combined with cataract extraction and lens implantation.

BACKGROUND AND OBJECTIVE: To evaluate the safety and efficacy of cataract extraction and lens implantation at the time of pars plana vitrectomy (PPV) for macular hole (MH) repair. MATERIALS AND METHODS: A retrospective study was conducted of 21 eyes that had PPV for MH combined with cataract extraction and lens implantation. Visual acuities (VA) were followed and complications noted. RESULTS: Of 21 eyes, successful anatomic closure was achieved in 16 (76.2%), and 13 (62.0%) improved in VA by at least 2 Snellen lines. Few complications occurred. CONCLUSION: Procedures that combine PPV for MH with cataract extraction and lens implantation decrease the need for future ophthalmic surgery, allow for clearer intraoperative visualization, and facilitate visual rehabilitation. This combined procedure is a relatively safe and effective alternative to separate pars plana and cataract surgeries.

Extra-hepatic manifestations of autochthonous hepatitis E infection.

BACKGROUND: Autochthonous (locally acquired) hepatitis E is increasingly recognised in developed countries, and is thought to be a porcine zoonosis. A range of extra-hepatic manifestations of hepatitis E infection have been described, but have never been systematically studied. AIM: To report the extra-hepatic manifestations of hepatitis E virus. METHODS: Retrospective review of data of 106 cases of autochthonous hepatitis E (acute n = 105, chronic n = 1). RESULTS: Eight (7.5%) cases presented with neurological syndromes, which included brachial neuritis, Guillain-Barré syndrome, peripheral neuropathy, neuromyopathy and vestibular neuritis. Patients with neurological syndromes were younger (median age 40 years, range 34-92 years, P = 0.048) and had a more modest transaminitis (median ALT 471 IU/L, P = 0.015) compared to cases without neurological symptoms [median age 64 years (range 18-88 years), median ALT 1135 IU/L]. One patient presented with a cardiac arrhythmia,twelve patients (11.3%) presented with thrombocytopenia, fourteen (13.2%) with lymphocytosis and eight (7.5%) with a lymphopenia, none of which had any clinical consequence. Serum electrophoresis was performed in 65 patients at presentation, of whom 17 (26%) had a monoclonal gammopathy of uncertain significance. Two cases developed haematological malignancies, acute myeloid leukaemia and duodenal plasmacytoma, 18 and 36 months after presenting with acute hepatitis E infection. CONCLUSIONS: A range of extra-hepatic manifestations can occur with hepatitis E. Neurological and haematological features of hepatitis E infection are relatively frequent in this UK cohort, and result in significant morbidity which warrants further study.

Surveillance for ocular hypertension: an evidence synthesis and economic evaluation.

OBJECTIVES: To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways. DESIGN: A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model. SETTING: Primary and secondary care. PARTICIPANTS: Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences). INTERVENTIONS: We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community. MAIN OUTCOME MEASURES: Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs). RESULTS: The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence. LIMITATIONS: Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates. CONCLUSIONS: For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment. FUNDING: The National Institute for Health Research Health Technology Assessment Programme.

Reanimation following facial palsy: present and future directions.

BACKGROUND: An understanding of the management of chronic facial palsy is vital for otolaryngologists, due to its common presentation to ENT surgeons. There is currently a lack of consensus on the optimum management of this condition. This article reviews the existing literature and offers a perspective on current management, as well as an insight into future treatments. METHODS: A literature search was performed, using the Medline, Embase and Cochrane databases from 1966 to the present, using the keywords listed below. Articles were reviewed. Selection was limited to English language articles on human subjects. RESULTS AND CONCLUSION: A tailored, multidisciplinary approach using combinatorial therapy should be used for reanimation of the face following facial palsy. Advances in surgical and non-surgical techniques, and the exchange of information from centres of excellence via global databases, will enable objective appraisal of results and the development of an evidence-based approach to facial reanimation.

Development of a competency framework for optometrists with a specialist interest in glaucoma.

PURPOSE: To develop a competency framework, using a modified Delphi methodology, for optometrists with a specialist interest in glaucoma, which would provide a basis for training and accreditation. METHODS: A modified iterative Delphi technique was used using a 16-member panel consisting almost exclusively of sub-specialist optometrists and ophthalmologists. The first round involved scoring the relevance of a draft series of competencies using a 9-point Likert scale with a free-text option to modify any competency or suggest additional competencies. The revised framework was subjected to a second round of scoring and free-text comment. The Delphi process was followed by a face-to-face structured workshop to debate and agree the final framework. The version of the framework agreed at the workshop was sent out for a 4-month period of external stakeholder validation. RESULTS: There was a 100% response to round 1 and an 94% response to round 2. All panel members attended the workshop. The final version of the competency framework was validated by a subsequent stakeholder consultation and contained 19 competencies for the diagnosis of glaucoma and 7 further competencies for monitoring and treatment. CONCLUSIONS: Application of a consensus methodology consisting of a modified Delphi technique allowed the development of a competency framework for glaucoma specialisation by optometrists. This will help to shape the development of a speciality curriculum and potentially could be adapted for other healthcare professionals.

Glaucoma detection: the content of optometric eye examinations for a presbyopic patient of African racial descent.

AIMS: Standardised patient (SP) methodology is the gold standard for evaluating clinical practice. We investigated the content of optometric eyecare for an early presbyopic SP of African racial descent, an "at-risk" patient group for primary open-angle glaucoma (POAG). METHODS: A trained actor presented unannounced as a 44-year-old patient of African racial descent, complaining of recent near vision difficulties, to 100 community optometrists for an audio-recorded eye examination. The eye examinations were subsequently assessed via a checklist based on evidence-based POAG reviews, clinical guidelines and expert panel opinion. RESULTS: Ninety-five per cent of optometrists carried out optic disc assessment and tonometry, which conforms to the UK College of Optometrists' advice that those patients aged >40 years should receive at least two of the following tests: tonometry, optic disc assessment, visual field testing. Thirty-five per cent of optometrists carried out all of these tests and 6% advised the SP of increased POAG risk in those of African racial descent. CONCLUSION: SP encounters are an effective measure of optometric clinical practice. As in other healthcare disciplines, there are substantial differences between optometrists in the depth of their clinical investigations, challenging the concept of a "standard sight test". There is a need for continuing professional development (CPD) in glaucoma screening, in which the increased risk of POAG in those of African racial descent should be emphasised.

Repeatability of intraocular pressure and corneal biomechanical properties measurements by the ocular response analyser.

BACKGROUND: The Ocular Response Analyser (ORA, Reichert Ophthalmic Instruments) is a non-contact applanation tonometer, providing two measures of intraocular pressure (IOP) - IOPg which represents a Goldmann equivalent IOP measure and IOPcc, representing a measure of IOP independent of corneal effects. In addition, the device provides two measures believed to represent corneal biomechanical properties: corneal hysteresis (CH) and corneal resistance factor (CRF). The aim of this study was to assess the repeatability of these measurements. PATIENTS AND METHODS: One randomly chosen eye from 49 healthy volunteers was measured four times consecutively with the ORA prior to Goldmann applanation tonometry (GAT). The repeatability coefficient (RC), the coefficient of variation (CV) and the intraclass correlation coefficient (ICC) were calculated as a measure of intrasession repeatability. RESULTS: CH was the most variable and IOPg the most repeatable measure, with an RC of 2.61 and 1.97, respectively, and ICC of 0.86 and 0.92, respectively. CV ranged between 5.73 % for IOPg and 12.38 % for CH. ORA IOP measurements were higher than GAT (IOPcc = 17.43 +/- 3.23; IOPg = 17.53 +/- 3.0; GAT = 15.75 +/- 2.77 mmHg). CONCLUSIONS: ORA measurements show good short-term repeatability in normal volunteers. Thus, this device appears to be applicable in clinical practice.