ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats.

Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.

Collagen fiber centerline tracking in fibrotic tissue via deep neural networks with variational autoencoder-based synthetic training data generation.

The role of fibrillar collagen in the tissue microenvironment is critical in disease contexts ranging from cancers to chronic inflammations, as evidenced by many studies. Quantifying fibrillar collagen organization has become a powerful approach for characterizing the topology of collagen fibers and studying the role of collagen fibers in disease progression. We present a deep learning-based pipeline to quantify collagen fibers' topological properties in microscopy-based collagen images from pathological tissue samples. Our method leverages deep neural networks to extract collagen fiber centerlines and deep generative models to create synthetic training data, addressing the current shortage of large-scale annotations. As a part of this effort, we have created and annotated a collagen fiber centerline dataset, with the hope of facilitating further research in this field. Quantitative measurements such as fiber orientation, alignment, density, and length can be derived based on the centerline extraction results. Our pipeline comprises three stages. Initially, a variational autoencoder is trained to generate synthetic centerlines possessing controllable topological properties. Subsequently, a conditional generative adversarial network synthesizes realistic collagen fiber images from the synthetic centerlines, yielding a synthetic training set of image-centerline pairs. Finally, we train a collagen fiber centerline extraction network using both the original and synthetic data. Evaluation using collagen fiber images from pancreas, liver, and breast cancer samples collected via second-harmonic generation microscopy demonstrates our pipeline's superiority over several popular fiber centerline extraction tools. Incorporating synthetic data into training further enhances the network's generalizability. Our code is available at https://github.com/uw-loci/collagen-fiber-metrics.

"It's a big added stress on top of being so ill": The challenges facing people prescribed cannabis in the UK.

BACKGROUND: This paper reports on the first qualitative study to interview people prescribed cannabis in the UK. Cannabis is a class B controlled substance under the 1971 Misuse of Drugs (MoD) Act, but a 2018 change to UK regulations provided for the prescription of cannabis for medical purposes. Relatively few people have been able to access a prescription, despite this policy change. This paper examines their experiences. METHODS: Qualitative, semi-structured interviews were conducted with 24 people with a prescription for cannabis, or their carers. Data was analysed using a reflextive thematic analysis approach. The findings are discussed using a zemiology (social harms) perspective which provides a language for critical reflection on the current cannabis policy context. RESULTS: All participants reported that cannabis had significantly improved their mental and/or physical health, across a broad range of conditions. Many had been able to reduce their use of conventional medicines and reported that cannabis had relatively few side effects. Despite the potentially life-enhancing benefits of cannabis medicine, patients in the UK face multiple barriers to access. These include a lack of funding streams, bureaucratic supply problems, and a lack of training for doctors and police. Even for the few people able to obtain a prescription, the ongoing criminalisation of cannabis in the UK contributed to their experiences of stigmatisation. This often made it difficult and anxiety-inducing to take their medicine in public spaces. CONCLUSION: The UK government's lack of implementation of medical cannabis legalisation, combined with their ongoing prohibition position, is producing multiple harms to people who need cannabis medicine. The policy context is perpetuating stigmatising attitudes to cannabis which, as we demonstrate, contribute to social harms. We make recommendations on equality of patient access, and highlight the importance of education and policy change as means of combatting stigma.

Evaluation of Therapeutic Use of Antifibrinolytics in Cats.

Limited data are available regarding the use of the antifibrinolytic drugs tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) in cats. This study aimed to evaluate the indications for the use of TXA and EACA in cats and to describe dosing regimens used, occurrence of adverse events, and patient outcomes. This was a retrospective multicenter study. Medical databases were searched for feline patients billed for TXA or EACA between 2015 and 2021. Thirty-five cats met the inclusion criteria; 86% received TXA and 14% received EACA. The most common indication was nontraumatic hemorrhage (54%), followed by traumatic hemorrhage (17%) and elective surgery (11%). The median dose was 10 mg/kg for TXA and 50 mg/kg for EACA. Overall, 52% of cats survived to discharge. Potential adverse events were noted in 7/35 (20%) patients. Of these, 29% survived to discharge. No standardized dosing regimen was identified; rather, dose, dosing interval, and duration of administration varied markedly between patients. Administration was potentially associated with severe adverse events, although the retrospective design makes it difficult to establish a causal association with antifibrinolytic use. This study provides a base for future prospective studies by giving an insight into the use of antifibrinolytic drugs in cats.

Co-creation to Develop Interventions to Facilitate Deep Reflection for Dental Students.

Background: Deep reflective practice is important in healthcare education to allow students to explore emotions associated with the learning experience, access deeper learning and develop their personal and professional identity. Previous research demonstrated that the current methods of reflective practice using logbooks at the end of a clinical session to facilitate reflection within this setting were viewed as suboptimal by staff and student users. To address this problem co-creation, or a 'students as partners' approach, was used to develop and implement a comprehensive intervention to facilitate deep reflection for undergraduate dental students. This included the production of educational resources, and development of an online safe space to reflect. Approach: In this paper we discuss the process of using co-creation with undergraduate dental students as a research methodology to successfully produce curricular change with respect to reflective practice by involving the voice and experience of student partners. These student partners were part of a team that included researchers and teaching staff and worked with other stakeholders within the institution within a wider team. Evaluation: This paper demonstrates the positive benefits of using co-creation with undergraduate dental students for students such as increased confidence, developing professional and personal skills and impacting meaningful change. Reflection: For researchers and educators, the process gave motivation and enjoyment in curricular development to address pedagogical problems and ensured that the developed intervention was sustainable and appropriate. The paper discusses benefits and challenges of co-creation to develop curricular change. This co-creation approach is recommended for solving similar problems in healthcare education.

Iteron control of oriV function in IncP-1 plasmid RK2.

Replication control of many plasmids is mediated by the balance between the positive and negative effects of Rep protein binding repeated sequences (iterons) associated with the replication origin, oriV. Negative control is thought to be mediated by dimeric Rep protein linking iterons in a process termed "handcuffing". The well-studied oriV region of RK2 contains 9 iterons arranged as a singleton (iteron 1), a group of 3 (iterons 2-4) and a group of 5 (iterons 5-9), but only iterons 5 to 9 are essential for replication. An additional iteron (iteron 10), oriented in the opposite direction, is also involved and reduces copy-number nearly two-fold. Since iterons 1 and 10 share an identical upstream hexamer (5' TTTCAT 3') it has been hypothesised that they form a TrfA-mediated loop facilitated by their inverted orientation. Here we report that contrary to the hypothesis, flipping one or other so they are in direct orientation results in marginally lower rather than higher copy-number. In addition, following mutagenesis of the hexamer upstream of iteron 10, we report that the Logo for the hexamer "upstream" of the regulatory iterons (1 to 4 and 10) differs from that of the essential iterons, suggesting functional differences in their interaction with TrfA.

Clinical and clinicopathological features and outcomes of cats with suspected dietary induced pancytopenia.

BACKGROUND: After a strong epidemiological link to diet was established in an outbreak of pancytopenia in cats in spring 2021 in the United Kingdom, 3 dry diets were recalled. Concentrations of the hemato- and myelotoxic mycotoxins T-2, HT-2 and diacetoxyscirpenol (DAS) greater than the European Commission guidance for dry cat foods were detected in the recalled diets. OBJECTIVES: To describe clinical and clinicopathological findings in cats diagnosed with suspected diet induced pancytopenia. ANIMALS: Fifty cats presenting with pancytopenia after exposure to a recalled diet. METHODS: Multicenter retrospective case series study. Cats with known exposure to 1 of the recalled diets were included if presented with bi- or pancytopenia and underwent bone marrow examination. RESULTS: Case fatality rate was 78%. Bone marrow aspirates and biopsy examination results were available in 23 cats; 19 cats had a bone marrow aspirate, and 8 cats had a biopsy core, available for examination. Bone marrow hypo to aplasia-often affecting all cell lines-was the main feature in all 31 available core specimens. A disproportionately pronounced effect on myeloid and megakaryocytic cells was observed in 19 cats. Myelofibrosis or bone marrow necrosis was not a feature. CONCLUSION AND CLINICAL IMPORTANCE: Mycotoxin induced pancytopenia should be considered as differential diagnosis in otherwise healthy cats presenting with bi- or pancytopenia and bone marrow hypo- to aplasia.

Multiscale Label-Free Imaging of Fibrillar Collagen in the Tumor Microenvironment.

With recent advances in cancer therapeutics, there is a great need for improved imaging methods for characterizing cancer onset and progression in a quantitative and actionable way. Collagen, the most abundant extracellular matrix protein in the tumor microenvironment (and the body in general), plays a multifaceted role, both hindering and promoting cancer invasion and progression. Collagen deposition can defend the tumor with immunosuppressive effects, while aligned collagen fiber structures can enable tumor cell migration, aiding invasion and metastasis. Given the complex role of collagen fiber organization and topology, imaging has been a tool of choice to characterize these changes on multiple spatial scales, from the organ and tumor scale to cellular and subcellular level. Macroscale density already aids in the detection and diagnosis of solid cancers, but progress is being made to integrate finer microscale features into the process. Here we review imaging modalities ranging from optical methods of second harmonic generation (SHG), polarized light microscopy (PLM), and optical coherence tomography (OCT) to the medical imaging approaches of ultrasound and magnetic resonance imaging (MRI). These methods have enabled scientists and clinicians to better understand the impact collagen structure has on the tumor environment, at both the bulk scale (density) and microscale (fibrillar structure) levels. We focus on imaging methods with the potential to both examine the collagen structure in as natural a state as possible and still be clinically amenable, with an emphasis on label-free strategies, exploiting intrinsic optical properties of collagen fibers.

An investigation into the detection of the pulse in conscious and anaesthetized dogs.

OBJECTIVES: To record the success rate of veterinary professionals and students at identifying the pulse in conscious and anaesthetized dogs. To explore the influence of clinical experience, pulse location, anaesthesia and likely confounding variables on the success of pulse palpation. STUDY DESIGN: Prospective, observational, randomized study. ANIMALS: A total of 54 client-owned dogs scheduled for general anaesthesia. METHODS: For each dog, three participants (senior anaesthetist, anaesthesia resident/nurse, veterinary student/animal care assistant) attempted pulse palpation at three locations (femoral, radial and dorsal pedal pulse) in conscious and anaesthetized dogs. The time to pulse palpation was measured with a stopwatch for each attempt and data were modelled using a multivariate Cox regression survival analysis (significance p < 0.05). RESULTS: The overall success rate of pulse palpation was 77%, with a median time of 10.91 seconds (interquartile range 9.09 seconds). Success rate was lower in conscious dogs (67%) than in anaesthetized dogs (87%). There was a 77% lower likelihood of success at the radial than at the femoral pulse [hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.38-0.69, p < 0.001]. Veterinary students/animal care assistants had a 71% lower likelihood of success than senior anaesthetists (HR 0.29, 95% CI 0.22-0.39, p < 0.001). Age, weight and American Society of Anesthesiologists physical status had no significant influence. Premedication/anaesthetic drugs, heart rate or mean arterial pressure had no significant influence on the time to pulse palpation in anaesthetized dogs. The median time to palpation was less than 10 seconds for all experience groups at the femoral location. CONCLUSIONS: Palpation of the femoral location had the greatest likelihood of success with the least amount of time. Monitoring the femoral pulse during induction of anaesthesia is suggested as a method for confirming spontaneous circulation. Pulse palpation improves with clinical experience.

Clinical and cost-effectiveness of paramedic administered fascia iliaca compartment block for emergency hip fracture (RAPID 2)-protocol for an individually randomised parallel-group trial.

BACKGROUND: Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating-with a high associated mortality rate-and survivors likely to be more dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment. METHODS: We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs). DISCUSSION: The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context. TRIAL REGISTRATION: ISRCTN15831813 . Registered on 22 September 2021.

A cluster randomised controlled trial of a ward-based intervention to improve access to psychologically-informed care and psychological therapy for mental health in-patients.

BACKGROUND: There is good evidence that psychological interventions improve patient well-being and independent living, but patients on acute mental health wards often do not have access to evidence-based psychological therapies which are strongly advised by NICE guidance for severe mental health problems. The overall aim of this programme of work is to increase patient access to psychological therapies on acute mental health inpatient wards. Stage one of the programme (which is complete) aimed to identify barriers and facilitators to delivering therapy in these settings through a large qualitative study. The key output of stage one was an intervention protocol that is designed to be delivered on acute wards to increase patient access to psychologically-informed care and therapy. Stage two of the programme aims to test the effects of the intervention on patient wellbeing and serious incidents on the ward (primary outcomes), patient social functioning and symptoms, staff burnout, ward atmosphere from staff and patient perspectives and cost effectiveness of the intervention (secondary outcomes). METHODS: The study is a single blind, pragmatic, cluster randomised controlled trial and will recruit thirty-four wards across England that will be randomised to receive the new intervention plus treatment as usual, or treatment as usual only. Primary and secondary outcomes will be assessed at baseline and 6-month and 9-month follow-ups, with serious incidents on the ward collected at an additional 3-month follow-up. DISCUSSION: The key output will be a potentially effective and cost-effective ward-based psychological intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver in inpatient settings and is acceptable to patients. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388.

Transdermal Buprenorphine for Pain Management Following a Neck of Femur Fracture.

INTRODUCTION: Pain management in patients with hip fractures can be challenging. Poor pain control is associated with reduced mobility and increased morbidity. Inadequate analgesia in patients with dementia is a concern. After using several different alternatives, transdermal buprenorphine was chosen as a standardised approach for analgesia in patients with fragility fracture in our hospital. There is limited evidence on the use of buprenorphine in this population. Our aim was to investigate the safety and effectiveness of transdermal buprenorphine in patients with hip fractures. METHODS: A review of consecutive patients presenting with a hip fracture from June 2018 to December 2018 was conducted using medical records. Our primary outcome was the incidence of complications as a consequence of transdermal buprenorphine. Our secondary outcome was adequate analgesia measured by reviewing the requirement for analgesia during the first week following the patient's admission. Analgesia demands were considered adequate if patients required less than 20 mg of oral morphine in total during the first week following injury. RESULTS: In total, 148 patients presented with a hip fracture during the study period. 128 patients had documented evidence of buprenorphine patch application. Complete data was available for the primary outcome of complications in all cases. Data was available for the secondary outcome in 124 patients. Buprenorphine was discontinued in 24 patients (19%), most commonly due to due to concerns about contribution to hypoactive delirium (9%), and when strong analgesia was no longer required (4%). There were no severe complications. Adequate analgesia was achieved using this regime in 68% patients. 38 patients (32%) required more than 20 mg of oral morphine sulphate solution in the first week post-admission. CONCLUSION: This series suggests that transdermal buprenorphine is safe and effective in the management of pain following a neck of femur fragility fracture.

Evaluation of the Manchester COVID-19 Urgent Eyecare Service (CUES).

INTRODUCTION: Pressure on capacity in ophthalmology alongside the coronavirus (COVID-19) pandemic led to the development of the COVID-19 Urgent Eyecare Service (CUES), allowing patients to receive a prompt ophthalmic consultation, including remotely. The aim of this study was to conduct a service evaluation of CUES in Manchester. METHODS: Data were collected both prospectively and retrospectively from both primary and secondary care over an 8-week period from June to August 2020. RESULTS: In primary care CUES in Greater Manchester (GM) 2461 patients were assessed, with a majority self-referring to the service (68.7%, n = 1844). 91.7% of cases initially screened for CUES were deemed eligible and given a telemedicine appointment in GM; 53.3% of these cases required face-to-face consultation. 14.3% of cases seen within in GM CUES (351 out of 2461) were provisionally referred to secondary care. Contemporaneously the main provider emergency eyecare department (EED) attendances were reduced by 37.7% per month between April and December 2020 inclusive, compared to the same months in 2019. Patients attending a CUES face-to-face assessment were more likely to have a diagnosis in agreement with secondary care, compared to patients referred in from telemedicine assessment only (P < 0.05). CONCLUSION: This evaluation of CUES demonstrates a high level of primary care activity alongside a sustained reduction in EED cases. The case-mix of patients seen within EED following referral appears to be of a less benign nature than those cases seen prior to the introduction of CUES.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report.

Background Cognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions. Methods We used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four. Intervention A simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients. Results Post-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%. Conclusions Simple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Periprosthetic fractures: the next fragility fracture epidemic? A national observational study.

OBJECTIVES: Periprosthetic fractures have considerable clinical implications for patients and financial implications for healthcare systems. This study aims to determine the burden of periprosthetic fractures of the lower and upper limbs in England and identify any factors associated with differences in treatment and outcome. DESIGN: A national, observational study. SETTING: England. PARTICIPANTS: All individuals admitted to hospital with periprosthetic fractures between 1 April 2015 and 31 December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: Mortality, length of stay, change in rate of admissions. METHODS: We analysed Hospital Episode Statistics data using the International Classification of Diseases 10th Revision code M96.6 (Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate) to identify periprosthetic fractures recorded between April 2013 and December 2018. We determined the demographics, procedures performed, mortality rates and discharge destinations. Patient characteristics associated with having a procedure during the index admission were estimated using logistic regression. The annual rate of increase in admissions was estimated using Poisson regression. RESULTS: Between 1 April 2015 and 31 December 2018, there were 13 565 patients who had 18 888 admissions (89.5% emergency) with M96.6 in the primary diagnosis field. There was a 13% year-on-year increase in admissions for periprosthetic fracture in England during that period. Older people, people living in deprived areas and those with heart failure or neurological disorders were less likely to receive an operation. 14.4% of patients did not return home after hospital discharge. The overall inpatient mortality was 4.3% and total 30-day mortality was 3.3%. CONCLUSIONS: The clinical and operational burden of periprosthetic fractures is considerable and increasing rapidly. We suggest that the management of people with periprosthetic fractures should be undertaken and funded in a similar manner to that successfully employed for people sustaining hip fractures, using national standards and data collection to monitor and improve performance.

Suspected phenobarbital-induced pancytopenia in a cat.

CASE SUMMARY: A 3-year-old neutered male domestic shorthair cat developed pancytopenia 6 months after starting phenobarbital for treatment of recurrent seizures. The cat was switched from phenobarbital to levetiracetam and complete resolution of the pancytopenia was documented within 10 weeks, consistent with phenobarbital-induced pancytopenia. RELEVANCE AND NOVEL INFORMATION: While phenobarbital is frequently used as the first-line treatment for seizures in cats, phenobarbital-induced feline pancytopenia has not been documented in the veterinary literature before. Based on this case, regular monitoring of the complete blood count in cats receiving long-term phenobarbital treatment should be considered. In cases of persistent or severe haematological abnormalities, further investigations are required and treatment discontinuation may be needed in the absence of other causes of pancytopenia.

Agreement in clinical decision-making between independent prescribing optometrists and consultant ophthalmologists in an emergency eye department.

BACKGROUND: The specialty-registration of independent prescribing (IP) was introduced for optometrists in 2008, which extended their roles including into acute ophthalmic services (AOS). The present study is the first since IP's introduction to test concordance between IP optometrists and consultant ophthalmologists for diagnosis and management in AOS. METHODS: The study ran prospectively for 2 years at Manchester Royal Eye Hospital (MREH). Each participant was individually assessed by an IP optometrist and then by the reference standard of a consultant ophthalmologist; diagnosis and management were recorded on separate, masked proformas. IP optometrists were compared to the reference standard in stages. Cases of disagreement were arbitrated by an independent consultant ophthalmologist. Cases where disagreement persisted after arbitration underwent consensus-review. Agreement was measured with percentages, and where possible kappa (Κ), for: diagnosis, prescribing decision, immediate management (interventions during assessment) and onward management (review, refer or discharge). RESULTS: A total of 321 participants presented with 423 diagnoses. Agreement between all IP optometrists and the staged reference standard was as follows: 'almost perfect' for diagnosis (Κ = 0.882 ± 0.018), 'substantial' for prescribing decision (Κ = 0.745 ± 0.034) and 'almost perfect' for onward management (0.822 ± 0.032). Percentage-agreement between all IP optometrists and the staged reference standard per diagnosis was 82.0% (CI 78.1-85.4%), and per participant using stepwise weighting was 85.7% (CI 81.4-89.1%). CONCLUSIONS: Clinical decision-making in MREH's AOS by experienced and appropriately trained IP optometrists is concordant with consultant ophthalmologists. This is the first study to explore and validate IP optometrists' role in the high-risk field of AOS.

Homelessness-'It will crumble men': The views of staff and service users about facilitating the identification and support of people with an intellectual disability in homeless services.

People with an intellectual disability (ID) face significant health inequalities and barriers to accessing appropriate support, which are made worse if the person is also homeless. An important barrier is that services may not recognise that the person has ID. This qualitative study explored the views of staff members and service users about the identification and support needs of homeless people with ID and the role of an ID screening questionnaire as a way to help improve service provision. Semi-structured interviews were conducted with 16 staff members and 8 service users from homeless services in the South East of Scotland between March 2017 and 2018. Thematic analysis identified four themes: 'not diagnosed or declared', which explored the barriers to support due to the person's ID not being identified by others or disclosed by the person; 'It will crumble men', which reported on the additional challenges faced by homeless people with ID; 'disabling environment' which identified the ways in which organisations can make support difficult for people with ID to access; and 'It's not against them, it's to help them' which explored the benefits and issues associated with screening for ID in homeless services. The results identified the complex support needs likely to be experienced by many homeless people with ID and suggested a number of implications for practice. First, the screening tool was seen as having a number of benefits, if used where there is a process to provide the person with further specialist assessment and support. Second, staff members identified a need for training in relation to identifying and supporting this group of people. Third, the screening tool was seen as a way to help provide information about the prevalence and needs of people with ID, in order to inform and shape policy, service development, and delivery.