Spatial multi-criteria decision analysis for the selection of sentinel regions in tick-borne disease surveillance.

BACKGROUND: The implementation of cost-effective surveillance systems is essential for tracking the emerging risk of tick-borne diseases. In Canada, where Lyme disease is a growing public health concern, a national sentinel surveillance network was designed to follow the epidemiological portrait of this tick-borne disease across the country. The surveillance network consists of sentinel regions, with active drag sampling carried out annually in all regions to assess the density of Ixodes spp. ticks and prevalence of various tick-borne pathogens in the tick population. The aim of the present study was to prioritize sentinel regions by integrating different spatial criteria relevant to the surveillance goals. METHODS: We used spatially-explicit multi-criteria decision analyses (MCDA) to map priority areas for surveillance across Canada, and to evaluate different scenarios using sensitivity analyses. Results were shared with stakeholders to support their decision making for the selection of priority areas to survey during active surveillance activities. RESULTS: Weights attributed to criteria by decision-makers were overall consistent. Sensitivity analyses showed that the population criterion had the most impact on rankings. Thirty-seven sentinel regions were identified across Canada using this systematic and transparent approach. CONCLUSION: This novel application of spatial MCDA to surveillance network design favors inclusivity of nationwide partners. We propose that such an approach can support the standardized planning of spatial design of sentinel surveillance not only for vector-borne disease BDs, but more broadly for infectious disease surveillance where spatial design is an important component.

Thematic synthesis of the experiences of people with hidradenitis suppurativa: a systematic review.

BACKGROUND: Although hidradenitis suppurativa (HS) is known to affect quality of life, little summative knowledge exists on how HS impacts people living with the condition. OBJECTIVES: To synthesize experiences of people with HS within published qualitative research. METHODS: Searches on databases MEDLINE, PsycINFO, Embase and CINAHL were conducted on 17 April 2020. Two independent reviewers screened 5512 publications. Study quality was assessed using the National Institute for Health and Care Excellence quality appraisal checklist for qualitative studies. Thematic synthesis generated descriptive and analytic themes. RESULTS: Fourteen studies were included: four studies fulfilled most quality criteria, eight fulfilled some quality criteria, and two fulfilled few quality criteria. There were three final themes. (i) Putting the brakes on life. The physical, psychological and social consequences of HS resulted in people missing out on multiple life events. This could have a cumulative effect that influences the trajectory of someone's life. (ii) A stigmatized identity: concealed and revealed. People try to conceal their HS, visually and verbally, but this results in anticipation and fear of exposure. Social support and psychological acceptance helped people cope. Connecting to others with HS may have a specific role in preserving a positive self-identity. (iii) Falling through the cracks. Delayed diagnosis, misdiagnosis and lack of access to care were reported. People felt unheard and misunderstood by healthcare professionals, and healthcare interactions could enhance feelings of shame. CONCLUSIONS: There need to be improvements to clinical care to allow people with HS to live their life more fully.

Contamination in complex healthcare trials: the falls in care homes (FinCH) study experience.

BACKGROUND: Trials are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. This is a particular risk in rehabilitation studies where it is easy for trial interventions to be either intentionally or inadvertently adopted in control settings. The Falls in Care Homes (FinCH) trial is used in this paper as an example of a large randomised controlled trial of a complex intervention to explore the potential risks of contamination bias. We outline the FinCH trial design, present the potential risks from contamination bias, and the strategies used in the design of the trial to minimise or mitigate against this. The FinCH trial was a multi-centre randomised controlled trial, with embedded process evaluation, which evaluated whether systematic training in the use of the Guide to Action Tool for Care Homes reduced falls in care home residents. Data were collected from a number of sources to explore contamination in the FinCH trial. Where specific procedures were adopted to reduce risk of, or mitigate against, contamination, this was recorded. Data were collected from study e-mails, meetings with clinicians, research assistant and clinician network communications, and an embedded process evaluation in six intervention care homes. During the FinCH trial, there were six new falls prevention initiatives implemented outside the study which could have contaminated our intervention and findings. Methods used to minimise contamination were: cluster randomisation at the level of care home; engagement with the clinical community to highlight the risks of early adoption; establishing local collaborators in each site familiar with the local context; signing agreements with NHS falls specialists that they would maintain confidentiality regarding details of the intervention; opening additional research sites; and by raising awareness about the importance of contamination in research among participants. CONCLUSION: Complex rehabilitation trials are at risk of contamination bias. The potential for contamination bias in studies can be minimized by strengthening collaboration and dialogue with the clinical community. Researchers should recognise that clinicians may contaminate a study through lack of research expertise.

What is the real number of Lyme disease cases in Canada?

BACKGROUND: Lyme disease is emerging in Canada due to expansion of the range of the tick vector Ixodes scapularis from the United States. National surveillance for human Lyme disease cases began in Canada in 2009. Reported numbers of cases increased from 144 cases in 2009 to 2025 in 2017. It has been claimed that few (< 10%) Lyme disease cases are reported associated with i) supposed under-diagnosis resulting from perceived inadequacies of serological testing for Lyme disease, ii) expectation that incidence in Canadian provinces and neighbouring US states should be similar, and iii) analysis of serological responses of dogs to the agent of Lyme disease, Borrelia burgdorferi. We argue that performance of serological testing for Lyme disease is well studied, and variations in test performance at different disease stages are accounted for in clinical diagnosis of Lyme disease, and in surveillance case definitions. Extensive surveillance for tick vectors has taken place in Canada providing a clear picture of the emergence of risk in the Canadian environment. This surveillance shows that the geographic scope of I. scapularis populations and Lyme disease risk is limited but increasing in Canada. The reported incidence of Lyme disease in Canada is consistent with this pattern of environmental risk, and the differences in Lyme disease incidence between US states and neighbouring Canadian provinces are consistent with geographic differences in environmental risk. Data on serological responses in dogs from Canada and the US are consistent with known differences in environmental risk, and in numbers of reported Lyme disease cases, between the US and Canada. CONCLUSION: The high level of consistency in data from human case and tick surveillance, and data on serological responses in dogs, suggests that a high degree of under-reporting in Canada is unlikely. We speculate that approximately one third of cases are reported in regions of emergence of Lyme disease, although prospective studies are needed to fully quantify under-reporting. In the meantime, surveillance continues to identify and track the ongoing emergence of Lyme disease, and the risk to the public, in Canada.

Chair based exercise in community settings: a cluster randomised feasibility study.

BACKGROUND: Some older people who find standard exercise programmes too strenuous may be encouraged to exercise while remaining seated - chair based exercises (CBE). We previously developed a consensus CBE programme (CCBE) following a modified Delphi process. We firstly needed to test the feasibility and acceptability of this treatment approach and explore how best to evaluate it before undertaking a definitive trial. METHODS: A feasibility study with a cluster randomised controlled trial component was undertaken to 1. Examine the acceptability, feasibility and tolerability of the intervention and 2. Assess the feasibility of running a trial across 12 community settings (4 day centres, 4 care homes, 4 community groups). Centres were randomised to either CCBE, group reminiscence or usual care. Outcomes were collected to assess the feasibility of the trial parameters: level of recruitment interest and eligibility, randomisation, adverse events, retention, completion of health outcomes, missing data and delivery of the CCBE. Semi- structured interviews were conducted with participants and care staff following the intervention to explore acceptability. RESULTS: 48% (89 out of 184 contacted) of eligible centres were interested in participating with 12 recruited purposively. 73% (94) of the 128 older people screened consented to take part with 83 older people then randomised following mobility testing. Recruitment required greater staffing levels and resources due to 49% of participants requiring a consultee declaration. There was a high dropout rate (40%) primarily due to participants no longer attending the centres. The CCBE intervention was delivered once a week in day centres and community groups and twice a week in care homes. Older people and care staff found the CCBE intervention largely acceptable. CONCLUSION: There was a good level of interest from centres and older people and the CCBE intervention was largely welcomed. The trial design and governance procedures would need to be revised to maximise recruitment and retention. If the motivation for a future trial is physical health then this study has identified that further work to develop the CCBE delivery model is warranted to ensure it can be delivered at a frequency to elicit physiological change. If the motivation for a future trial is psychological outcomes then this study has identified that the current delivery model is feasible. TRIAL REGISTRATION: ISRCTN27271501 . Date registered: 30/01/2018.

Imaging correlates of neural control of ocular movements.

The purpose of oculomotor movements is maintenance of clear images on the retina. Beyond this oversimplification, it requires several different types of ocular movements and reflexes to focus objects of interest to the fovea-the only portion of retina capable of sharp and clear vision. The different movements and reflexes that execute this task are the saccades, smooth pursuit movements, fixation, accommodation, and the optokinetic and vestibulo-ocular reflexes. Many different centres in the cerebrum, cerebellum, brainstem and thalami, control these movements via different pathways. At the outset, these mechanisms appear dauntingly complex to a radiologist. However, only a little effort could make it possible to understand these neural controls and empower the reading session. The following review on ocular movements and their neural control will enable radiologists and clinicians to correlate lesions with clinical deficits effectively without being swamped by exhaustive detail. Key Points • Knowledge of cortical and subcortical areas controlling ocular movements is important. • Understanding of neural control of ocular movements makes a good foundation. • Awareness of anatomic areas controlling ocular movements helps in clinico-radiologic correlation.

Imaging of Cerebrovascular Disease in Pregnancy and the Puerperium.

OBJECTIVE: The purpose of this article is to review the unique physiologic changes that characterize pregnancy and the puerperium, some that substantially affect the cerebrovascular system. Conditions that can cause neurologic deterioration and share features with preeclampsia-eclampsia include postpartum angiopathy, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and amniotic fluid embolism. Other conditions not specific to this patient group include cerebral venous thrombosis, cervicocephalic arterial dissection, ischemic stroke, and hemorrhagic stroke, which can pose specific diagnostic and therapeutic challenges. CONCLUSION: Radiologists must be familiar with the imaging findings of cerebrovascular complications and pathologic entities encountered during pregnancy and the puerperium. Ongoing improvements in understanding of molecular changes during pregnancy and the puerperium and advances in diagnostic tests should allow radiologists to continue to make important contributions to the care of this patient population.

Evolutionary aspects of emerging Lyme disease in Canada.

In North America, Lyme disease (LD) is a tick-borne zoonosis caused by the spirochete bacterium Borrelia burgdorferi sensu stricto, which is maintained by wildlife. Tick vectors and bacteria are currently spreading into Canada and causing increasing numbers of cases of LD in humans and raising a pressing need for public health responses. There is no vaccine, and LD prevention depends on knowing who is at risk and informing them how to protect themselves from infection. Recently, it was found in the United States that some strains of B. burgdorferi sensu stricto cause severe disease, whereas others cause mild, self-limiting disease. While many strains occurring in the United States also occur in Canada, strains in some parts of Canada are different from those in the United States. We therefore recognize a need to identify which strains specific to Canada can cause severe disease and to characterize their geographic distribution to determine which Canadians are particularly at risk. In this review, we summarize the history of emergence of LD in North America, our current knowledge of B. burgdorferi sensu stricto diversity, its intriguing origins in the ecology and evolution of the bacterium, and its importance for the epidemiology and clinical and laboratory diagnosis of LD. We propose methods for investigating associations between B. burgdorferi sensu stricto diversity, ecology, and pathogenicity and for developing predictive tools to guide public health interventions. We also highlight the emergence of B. burgdorferi sensu stricto in Canada as a unique opportunity for exploring the evolutionary aspects of tick-borne pathogen emergence.

Forming a consensus opinion on exercise prehabilitation in elderly colorectal cancer patients: a Delphi study.

BACKGROUND: There is no consensus amongst colorectal surgeons as to whether preoperative exercise is beneficial in the management of colorectal cancer patients. Research has shown higher rates of postoperative complications in patients who are less fit. Agreement needs to be sought on whether improving fitness via exercise should be a part of preoperative care. The Delphi process is an iterative process designed to refine opinions on a subject, until consensus agreement is reached within an expert group. METHODS: We performed a Delphi survey with a group of consultant colorectal surgeons. Statements achieving >80% agreement were taken as consensus, those achieving >80% disagreement were removed, and those in between were revised in the following round. The process ended with a group of statements which achieved consensus. RESULTS: Thirty-two statements were included in the first round of the survey. After three rounds of the survey, 21 statements were accepted as consensus, six statements were rejected, and seven statements did not reach consensus. It was agreed that exercise training should form part of preoperative care and would be supported by surgeons. That suitable programmes pose significant risk to patients was rejected. There was no consensus reached on the strength of current available evidence or whether it would be possible to deliver exercise programmes. CONCLUSIONS: This work is the first to produce a set of statements on which expert consensus opinion has been agreed regarding preoperative exercise in colorectal cancer patients. Future work, informed by this study, will design interventions to produce rapid improvements in fitness before surgery.

Effect of a novel steak fabrication method by trimming subcutaneous and intermuscular fats on palatability and calorie content of beef ribeye steaks.

This study investigated the effects of a novel steak fabrication method, involving removal of both subcutaneous and intermuscular fats between the longissimus thoracis (LT) and spinalis dorsi (SD) muscles before cooking, on beef ribeye steak palatability and calorie content. Canada AA (n = 10) and AAA (n = 10) ribeyes were fabricated into steaks either with (fat-on) or without (fat-off) subcutaneous and intermuscular fats. Fat-on steaks had shorter cooking times and lower cooking losses than fat-off steaks (P < 0.001), regardless of quality grade. There were treatment × quality grade interactions for initial (P < 0.01) and sustainable juiciness (P < 0.05) of the LT samples and initial juiciness (P < 0.05) of the SD samples, with the fat-on AA samples being more juicy than the fat-off AA samples, but the AAA treatments were not different from each other. Regardless of quality grade, fewer panelist responses indicated livery flavour (P < 0.05) for fat-on compared to fat-off LT samples. Regardless of fat-on/fat-off treatment, AA compared to AAA samples had more responses for bloody/serumy (P < 0.01) and unidentified off-flavours (P < 0.05) in LT samples. However, AAA samples had more responses for metallic off-flavour in LT (P = 0.059) and SD (P < 0.05). There were no differences in calorie content between fat-on compared to fat-off steaks (P > 0.1) regardless of quality grade and muscle type, or between AA and AAA steaks regardless of cooking with fat-on or off (P > 0.1). Maintaining the subcutaneous and intermuscular fats while cooking will improve ribeye steak palatability without increasing calorie content, especially for leaner steaks.

Effect of different electrical stimulation systems on beef quality and palatability: Constant current compared to constant voltage.

This study examined the effects of constant current electrical stimulation (CCES) compared to constant voltage electrical stimulation (CVES), when applied within the same beef carcass (n = 79), on longissimus thoracis et lumborum (LTL) quality and palatability. There was a stimulation method × time interaction for pH, with CCES reducing the 3 h post-mortem pH, but increasing the 72 h post-mortem pH compared to CVES (P < 0.001). The CCES decreased the meat subjective Japanese Meat Grading Agency (JMGA) colour scores (P < 0.05) and increased the objective L⁎ (P < 0.01), a⁎ (P < 0.05) and b⁎ (P < 0.05) colour values at 3 d post-mortem and L⁎ and b⁎ values (P < 0.05) during retail display compared to CVES, although the objective values from both stimulation methods were above established consumer acceptability thresholds. Additionally, CCES reduced the purge (P < 0.05) and drip (P < 0.01) losses, and tended to reduce shear force values (P = 0.089) compared to CVES, although these did not translate into differences in juiciness or tenderness evaluated by trained panelists (P > 0.1). Regarding flavour, the CCES meat had greater bloody/serumy flavour (P < 0.05) and corn aroma (P < 0.05), less unidentified aroma (P < 0.05), and tended to have greater corn flavour (P = 0.077) and less barnyard aroma (P = 0.079) than CVES meat. There were also increased concentrations of flavour-related volatile compounds including 2-methyl-butanal, 3-methyl-butanal and 2-5-dimethyl pyrazine levels (P < 0.05) with CCES. Overall, the CCES system slightly improved meat quality and flavour compared to CVES when applied to the same beef carcasses. Further consumer studies would be warranted to determine whether these differences translate into more acceptable meat.

Diagnostic criteria for erosive lichen planus affecting the vulva: an international electronic-Delphi consensus exercise.

BACKGROUND: There is no defined set of criteria for diagnosing erosive lichen planus affecting the vulva (ELPV) and there is geographical variation in management. OBJECTIVES: To reach consensus on clinicopathological diagnostic criteria for ELPV. METHODS: This was a three-stage international electronic-Delphi exercise with a subsequent formal feedback process. In the first two rounds participants were asked to rate the importance of a list of clinicopathological criteria. Responses from round 1 were summarized and presented in round 2, along with additional criteria suggested by participants. In round 3, participants were asked to rate the items that had reached consensus as 'essential' or 'supportive' features in diagnosing ELPV. Consensus was defined as being reached if 75% of participants agreed on the importance of an item. RESULTS: A total of 73 experts representing dermatology, gynaecology, histopathology and genitourinary medicine participated; 69 (95%) completed all three rounds. Consensus was achieved for the following 'supportive' diagnostic criteria: (i) well-demarcated erosions/erythematous areas at the vaginal introitus; (ii) presence of a hyperkeratotic border to lesions and/or Wickham striae in surrounding skin; (iii) symptoms of pain/burning; (iv) scarring/loss of normal architecture; (v) presence of vaginal inflammation; (vi) involvement of other mucosal surfaces; (vii) presence of a well-defined inflammatory band involving the dermoepidermo junction; (viii) presence of an inflammatory band consisting predominantly of lymphocytes; and (ix) signs of basal layer degeneration. It was suggested that at least three supportive features should be present to make a diagnosis of ELPV, although this number is subject to further discussion. CONCLUSIONS: This study has identified a diagnostic dataset for ELPV that can be adopted into clinical practice and clinical trials.

Harvested white-tailed deer as sentinel hosts for early establishing Ixodes scapularis populations and risk from vector-borne zoonoses in southeastern Canada.

Due to recent establishment of the blacklegged tick, Ixodes scapularis Say, in southeastern Canada, tick-borne zoonoses (Lyme disease, human granulocytotropic anaplasmosis, and babesiosis) are of growing concern for public health. Using white-tailed deer (Odocoileus virginianus) culled in southwestern Quebec during 2007-2008, we investigated whether hunter-killed deer could act as sentinels for early establishing tick populations and for tick-borne pathogens. Accounting for environmental characteristics of culling sites, and age and sex of deer, we investigated whether their tick infestation levels could identify locations of known tick populations detected in active surveillance, presumed tick populations detected by passive surveillance, or both. We also used spatial cluster analyses to identify spatial patterns of tick infestation and occurrence of tick-borne zoonoses infection in ticks collected from the deer. Adult ticks were found on 15% of the 583 deer examined. Adult male deer had the greatest number (approximately 90%) of adult ticks. Overall, 3, 15, and 0% of the ticks collected were polymerase chain reaction (PCR)-positive for Borrelia burgdorferi, Anaplasma phagocytophilum, and Babesia microti, respectively. Our statistical analyses suggest that sex and age of deer, temperature, precipitation, and an index of tick dispersion by migratory birds were significantly associated with tick infestation levels. Cluster analysis identified significant clusters of deer carrying ticks PCR-positive for A. phagocytophilum, and for deer carrying two or more I. scapularis. Our study suggests that hunter-killed deer may be effective as sentinels for emerging areas of tick-borne anaplasmosis. They may have limited use as sentinels for early emerging I. scapularis tick populations and emerging Lyme disease risk.

Functional analysis of secreted and transmembrane proteins critical to mouse development.

We describe the successful application of a modified gene-trap approach, the secretory trap, to systematically analyze the functions in vivo of large numbers of genes encoding secreted and membrane proteins. Secretory-trap insertions in embryonic stem cells can be transmitted to the germ line of mice with high efficiency and effectively mutate the target gene. Of 60 insertions analyzed in mice, one-third cause recessive lethal phenotypes affecting various stages of embryonic and postnatal development. Thus, secretory-trap mutagenesis can be used for a genome-wide functional analysis of cell signaling pathways that are critical for normal mammalian development and physiology.

Impact of a constant current electrical stimulation (CCES) system and hormonal growth-promoting (HGP) implants on meat quality and palatability of finished steers.

This study evaluated the effects of a constant current electrical stimulation (CCES) system and hormonal growth-promoting (HGP) implants on the quality and palatability of the longissimus thoracis et lumborum (LTL) from yearling-finished steers. The experiment used a total of 46 Angus cross steers, which were either non-implanted (n = 20) or implanted with trenbolone acetate and estradiol benzoate (n = 26). The CCES was applied to one side of each carcass during the slaughter process, whereas the other side remained unstimulated. Regardless of the application of HGP implants, the CCES reduced pH at 3 and 72 h post-mortem and shear force at all ageing times (P < 0.05), improved colour at 72 h post-mortem and during the retail display (P < 0.05), increased initial and overall tenderness (P < 0.01), and decreased the amount of perceived connective tissue and the proportion of trained panelists detecting spongy texture (P < 0.05) compared to meat from unstimulated carcass sides. Although CCES increased meat purge losses and reduced moisture content (P < 0.05), this did not affect meat juiciness (P > 0.10). CCES interacted with HGP to prevent increase in drip loss (P > 0.10), increase frequency of panelists detecting bloody/serumy flavour and typical texture, and reduce the proportion of panelists detecting rubbery texture in meat (P < 0.05). Regardless of stimulation treatment, meat from implanted animals had a more pronounced pH decline at 72 h post-mortem (P < 0.05) and a higher proportion of panelists finding no off-flavours (P < 0.05) or bloody/serumy flavour (P < 0.01) than non-implanted cattle. The CCES system tested in this study improved LTL quality and palatability of heavier beef carcasses.

Effects of in-the-bag dry-ageing on meat quality, palatability and volatile compounds of low-value beef cuts.

This study evaluated the effects of in-the-bag dry-ageing (BDA) (21 and 42 d) on meat quality, palatability, and volatile compounds of clod heart, brisket, and flat iron cuts from steers. In all cuts, BDA increased moisture losses (P < 0.05), but this did not reduce the juiciness of 21 d BDA versus wet-aged (WA) steaks. In clod heart, BDA increased overall tenderness at 21 d compared to 21 d WA (P < 0.01). Regardless of ageing period, BDA of clod heart increased beef flavour and salty taste and decreased sour-dairy and stale/cardboard flavours and concentrations of volatile compounds derived from lipid oxidation compared to WA (P < 0.05). In brisket, BDA increased salty taste and fatty aroma and reduced bloody/serumy flavour, whereas decreased beef and buttery flavours and intensified some unpleasant aromas/flavours (P < 0.05) for both ageing periods. The BDA of flat iron increased several undesirable aromas/flavours and decreased sweet taste and beef and buttery flavours (P < 0.05), regardless of ageing period. Overall, BDA for 42 d decreased meat quality and palatability and increased concentrations of volatile compounds from lipid oxidation, especially in flat iron cuts. Value could be recovered by customizing BDA periods by cut.

Effect of in-the-bag dry-ageing on meat palatability and volatile compounds of cull cows and youthful steers.

This study evaluated the effects of in-the-bag dry-ageing on eating quality and volatile compounds of longissimus lumborum from cows and steers. Compared to wet-ageing, in-the-bag dry-ageing increased purge loss (P < 0.0001), cooking time (P < 0.0001), salty taste (P < 0.05) and sour-dairy flavour (P < 0.01), whereas decreased cooking loss (P < 0.0001), amount of perceptible connective tissue (P < 0.05) and livery flavour (P < 0.05) in both cow and steer meat. This dry-ageing technology also increased juiciness (P < 0.01) and brown-roasted aroma (P < 0.05) in steer meat, whereas decreased the juiciness (P < 0.01) of cow meat. Regardless of the ageing method, cow meat was tougher (P < 0.0001), less juicy (P < 0.001) and sweeter (P < 0.05) and presented higher amount of perceived connective tissue (P < 0.0001) than steer meat, whereas steer meat had higher ratings for beef (P < 0.05) and brown-roasted (P < 0.01) flavours. Volatile compounds were largely affected (P < 0.05) by animal-type, most of them being higher in cow than steer meat. In contrast, in-the-bag dry-ageing affected a few volatile compounds such as alcohols, aldehydes and ketones.

Comparative Assessment of Ergonomic Experience with Heads-Up Display and Conventional Surgical Microscope in the Operating Room.

PURPOSE: Musculoskeletal pain issues are prevalent in ophthalmic surgeons and can impact surgeon well-being and productivity. Heads-up displays (HUD) can improve upon conventional microscopes by reducing ergonomic stress. This study compared ergonomic outcomes between HUD and a conventional optical microscope in the operating room, as reported by ophthalmic surgeons in the US. METHODS: An online questionnaire was distributed to a sample of surgeons who had experience operating with HUD. The questionnaire captured surgeon-specific variables, the validated Nordic Musculoskeletal Questionnaire, and custom questions to compare HUD and conventional microscope. A multivariable model was built to identify variables that were likely to predict improvement in pain-related issues. RESULTS: Analysis was conducted on 64 surgeons (37 posterior-segment, 25 anterior-segment, and two mixed) with a mean 14.9 years of practice and 2.3 years using HUD. Most surgeons agreed or strongly agreed that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%). Of respondents who experienced headaches, or pain and discomfort during operation, 12 (44%) reported their headaches improved and 45 (82%) reported feeling less pain and discomfort since they started using HUD. The multivariable model indicated the odds of reporting an improvement in pain since introducing the HUD in the operating room were 5.12-times greater for those who used HUD in >50% of their cases (P=0.029). CONCLUSION: This study indicates that heads-up display may be an important tool for wellness in the operating room as it can benefit ophthalmic surgeons across several ergonomic measures.

Seeking a practical definition of stable glaucoma: a Delphi consensus survey of UK glaucoma consultants.

BACKGROUND: To generate a practical and clinically useful consensus definition of 'stable glaucoma' to aid provision of glaucoma services in the UK and to provide guidance for the criteria that should be used for monitoring of glaucoma patients in primary care services. METHODS: A Delphi exercise was undertaken to derive consensus through an online questionnaire. Participants were asked to score their strength of agreement for a series of clinical parameters. Results and comments from each round were used to inform subsequent rounds. A total of 3 rounds were undertaken. RESULTS: Thirty-two glaucoma experts participated in the study with over 90% completion rate achieved over three rounds. The consensus was reached for the following parameters: IOP levels to be used for defining stability, visual field-testing techniques to define stability, the number of medication changes acceptable to define stability and the number of treatment medications allowed to define stability. No consensus was reached on the period of time over which stability was defined, however, there was considerable agreement that longer durations of follow up (36-48 months) were required. A combination of optic disc photos and ocular coherence topography (OCT) retinal nerve fibre layer (RNFL) assessment/ OCT disc structural evaluation are the preferred imaging methods for the assessment of structural stability. Oversight by a glaucoma consultant was considered important for glaucoma monitoring schemes. CONCLUSION: The consensus definition of glaucoma stability generated through this Delphi exercise provides guidance for allocation of patients suitable for monitoring in primary care glaucoma monitoring schemes.