Rewarming from unwitnessed hypothermic cardiac arrest with good neurological recovery using extracorporeal membrane oxygenation.

A 26-year-old man, who was training in bad weather for a mountain ultramarathon, became hypothermic after running for 4 h. He deteriorated and was unable to continue. His running partner went for help. The man suffered an unwitnessed hypothermic cardiac arrest. The on-site management and evacuation are described and included the use of intermittent cardiopulmonary resuscitation and a mechanical device during transport. The patient was successfully resuscitated and rewarmed by Extracorporeal Membrane Oxygenation (ECMO) after more than 2 h of cardiopulmonary resuscitation. After 14 h of ECMO support and five days of ventilation, the patient subsequently made a good neurological recovery. At hospital discharge, he had normal cerebral function, and an improving peripheral polyneuropathy affecting distal limbs, with paraesthesia in both feet and reduced coordination and fine motor skills in both hands.

Cerebral visual impairment-related vision problems in primary school children: a cross-sectional survey.

AIM: To estimate how many children in mainstream primary schools have cerebral visual impairment (CVI)-related vision problems and to investigate whether some indicators might be useful as red flags, if they were associated with increased risk for these problems. METHOD: We conducted a survey of primary school children aged 5 to 11 years, using whether they were getting extra educational help and/or teacher- and parent-reported behaviour questionnaires to identify children at risk for CVI. These and a random 5% sample were assessed for CVI-related vision problems. We compared the usefulness of potential red flags using likelihood ratios. RESULTS: We received questionnaires on 2298 mainstream-educated children and examined 248 children (152 [61%] males, 96 females [39%]; mean age 8y 1mo, SD 20mo, range 5y 6mo-11y 8mo). We identified 78 out of 248 children (31.5% of those examined, 3.4% of the total sample), who had at least one CVI-related vision problem. The majority (88%) were identified by one or more red flag but none were strongly predictive. Fewer than one in five children with any CVI-related vision problem had reduced visual acuity. INTERPRETATION: Children with CVI-related vision problems were more prevalent than has been appreciated. Assessment of at-risk children may be useful so that opportunities to improve outcomes for children with CVI-related vision problems are not missed.

Cost-effectiveness of virtual reality and wet laboratory cataract surgery simulation.

PURPOSE: To evaluate the cost-effectiveness of phacoemulsification simulation training in virtual reality simulator and wet laboratory on operating theater performance. METHODS: Residents were randomized to a combination of virtual reality and wet laboratory phacoemulsification or wet laboratory phacoemulsification. A reference control group consisted of trainees who had wet laboratory training without phacoemulsification. All trainees were assessed on operating theater performance in 3 sequential cataract patients. International Council of Ophthalmology Surgical Competency Assessment Rubric-phacoemulsification (ICO OSCAR phaco) scores by 2 masked independent graders and cost data were used to determine the incremental cost-effectiveness ratio (ICER). A decision model was constructed to indicate the most cost-effective simulation training strategy based on the willingness to pay (WTP) per ICO OSCAR phaco score gained. RESULTS: Twenty-two trainees who performed phacoemulsification in 66 patients were analyzed. Trainees who had additional virtual reality simulation achieved higher mean ICO OSCAR phaco scores compared with trainees who had wet laboratory phacoemulsification and control (49.5 ± standard deviation [SD] 9.8 vs 39.0 ± 15.8 vs 32.5 ± 12.1, P < .001). Compared with the control group, ICER per ICO OSCAR phaco of wet laboratory phacoemulsification was $13,473 for capital cost and $2209 for recurring cost. Compared with wet laboratory phacoemulsification, ICER per ICO OSCAR phaco of additional virtual reality simulator training was US $23,778 for capital cost and $1879 for recurring cost. The threshold WTP values per ICO OSCAR phaco score for combined virtual reality simulator and wet laboratory phacoemulsification to be most cost-effective was $22,500 for capital cost and $1850 for recurring cost. CONCLUSIONS: Combining virtual reality simulator with wet laboratory phacoemulsification training is effective for skills transfer in the operating theater. Despite of the high capital cost of virtual reality simulator, its relatively low recurring cost is more favorable toward cost-effectiveness.

Cost and time resourcing for ophthalmic simulation in the UK: a Royal College of Ophthalmologists' National Survey of regional Simulation Leads in 2021.

INTRODUCTION: Ophthalmic simulation is cost-effective in complication prevention. However, there is no consistent resource allocation to provide the necessary time and finance to sustain such activities. We wished to identify the current support for the regional Simulation Leads in the UK. METHODS: An online SurveyMonkey questionnaire was sent to all 26 UK ophthalmic regional Simulation Leads in February 2021 regarding current simulation activity and the degree of time and resource support available. RESULTS: There were 22 responses within 1 month (84.6% response rate). 72.7% run regular simulation induction events for new trainees. 60% run mandatory laser simulation events. 38.1% run immersive simulation (vitreous loss fire drill). 47.6% run yearly sub-specialty events. 45.5% were required to make additional work arrangements to run simulation events. 77.3% had no job plan time allocation for simulation. 59.1% dedicated >1 hr/week to simulation. 68.2% EYESI simulators were purchased via charity/endowments. 72.7% had access to dedicated dry lab simulation (40.9% wet lab). 40.9% used deanery funds to purchase initial model eyes (supplemented by charity (36.4%) and endowments (31.8%)). 65% used unspent study leave budgets for ongoing model eyes, yet 15% reported trainees purchasing their own. CONCLUSION: Nearly all ophthalmic simulation in the UK is undertaken via goodwill and personal commitment to excellence by the regional Simulation Leads. There is minimal allowance of time or finance for these vital activities, which is sporadic at best, and unsustainable. We call for the necessary investment and dedicated time allocation to permit ophthalmic simulation to be supported and maintained.

Field intubation of cardiac arrest patients: a dying art?

INTRODUCTION: The most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients. METHODS: A 4-year, observational, retrospective case review. Patients attending the Emergency Department of the Royal Infirmary of Edinburgh, Scotland, with a primary diagnosis of OHCA were identified. Patient demographics, survival to admission, airway management technique and complication rates were identified. RESULTS: Seven hundred and ninety-four cases were identified. The aetiology of cardiac arrest was medical in 95.2%, traumatic in 3.9% and unrecorded in 0.9%. Prehospital intubation was attempted in 628 patients. Prehospital intubation was successful in 573 patients. A significant complication (multiple attempts, displaced endotracheal tube or oesophageal intubation) occurred in 55 (8.8%) patients. 165 (20.8%) patients survived to hospital admission, of whom 110 had undergone prehospital intubation. 55 patients who did not undergo prehospital tracheal intubation survived to hospital admission. CONCLUSION: The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established. Prehospital tracheal intubation for OHCA is associated with significant complications and may reduce survival. The use of tracheal intubation as a routine intervention should be reconsidered. Ambulance services should consider adopting alternative strategies in airway management.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees.

OBJECTIVE: To investigate the impact of EyeSi surgical simulators on posterior capsule rupture (PCR) rates of cataract surgery performed by first and second year trainee surgeons. DESIGN: A Royal College of Ophthalmologists' National Ophthalmology Database audit study of first and second year surgeons' PCR rates over seven consecutive National Health Service (NHS) years. Participating centres were contacted to ascertain the date when their surgeons had access to an EyeSi machine and whether this was on-site or off-site. Operations were classified as before, after or no access to EyeSi. SETTING: The study took place in 29 NHS Ophthalmology Units in a secondary care setting. RESULTS: Two-hundred and sixty five first and second year trainee surgeons performed 17 831 cataract operations. 6919 (38.8%) operations were performed before access to an EyeSi, 8648 (48.5%) after access to an EyeSi and 2264 (12.7%) operations by surgeons with no access to an EyeSi. Overall, there was a 38% reduction in the first and second year surgeon's unadjusted PCR rates from 4.2% in 2009 to 2.6% in 2015 for surgeons with access to an EyeSi, and a 3% reduction from 2.9% to 2.8% for surgeons without access to an EyeSi. The overall first and second year unadjusted PCR rates for before, after and no access to EyeSi were 3.5%, 2.6% and 3.8%, respectively. The decrease in the with-access to an EyeSi group PCR rate was similar for surgeons with access to an EyeSi 'on site' or 'off site'. CONCLUSIONS: First and second year trainee surgeons' unadjusted PCR rates have decreased since 2009 which has significant benefits for patients undergoing cataract surgery. This 38% reduction in complication rates aligns with the introduction of EyeSi simulator training.

Treatment outcomes for amblyopia using PEDIG amblyopia protocols: a retrospective study of 877 cases.

BACKGROUND: The landmark Pediatric Eye Disease Investigators Group (PEDIG) Amblyopia Treatment Studies (ATS) 2A and 2B concluded that 6 hours of occlusion were as efficacious as full-time occlusion in treating severe amblyopia and that 2 hours occlusion were as effective as 6 in treating moderate amblyopia. We present the first retrospective study of real-world outcomes of amblyopia treatment using PEDIG amblyopia protocols in 877 patients treated at a single center. METHODS: Electronic patient records were reviewed retrospectively to identify children meeting ATS2A (severe amblyopia) and ATS2B (moderate amblyopia) inclusion criteria who presented at the Gloucestershire Eye Unit from 2013 to 2017. Clinical data for each patient were entered during routine clinical care. Severely amblyopic children were prescribed 6 hours occlusion daily, and moderately amblyopic children 2 hours, after 12 weeks refractive adaptation. RESULTS: A total of 288 children were in the ATS2A group and 589 in the ATS2B group. Of the severely amblyopic eyes, 40% achieved best-corrected visual acuity better than 0.4 logMAR at 32 weeks, increasing to 55% at 48 weeks; of the moderately amblyopic eyes, 71% achieved best-corrected visual acuity better than 0.3 logMAR at 32 weeks. The mean number of lines of visual improvement was 4.2 for severely amblyopic eyes and 2.1 for moderately amblyopic eyes. CONCLUSIONS: This is the largest reported series of amblyopia treated according to PEDIG protocols. The study population achieved outcomes comparable to those demonstrated by the PEDIG studies. This audit represents a "real-world" benchmark for treatment outcomes in clinical practice.

Epidemiology and location of primary retrieval missions in a Scottish aeromedical service.

INTRODUCTION: Prehospital critical care teams comprising an appropriately trained physician and paramedic or nurse have been associated with improved outcomes in selected trauma patients. These teams are a scarce and expensive resource, especially when delivered by rotary air assets. The optimal tasking of prehospital critical care teams is therefore vital and remains a subject of debate. Emergency Medical Retrieval Service (EMRS) provides a prehospital critical care response team to incidents over a large area of Scotland either by air or by road. METHODS: A convenience sample of consecutive EMRS missions covering a period of 18 months from May 2013 to January 2015 was taken. These missions were matched with the ambulance service information on geographical location of the incident. In order to assess the appropriateness of tasking, interventions undertaken on each mission were analysed and divided into two subcategories: 'critical care interventions' and 'advanced medical interventions'. A tasking was deemed appropriate if it included either category of intervention or if a patient was pronounced life extinct at the scene. RESULTS: A total of 1279 primary missions were undertaken during the study period. Of these, 493 primary missions met the inclusion criteria and generated complete location data. The median distance to scene was calculated as 5.6 miles for land responses and 34.2 miles for air responses. Overall, critical care interventions were performed on 17% (84/493) of patients. A further 21% (102/493) of patients had an advanced medical intervention. Including those patients for whom life was pronounced extinct on scene by the EMRS team, a total of 42% (206/493) taskings were appropriate. DISCUSSION: Overall, our data show a wide geographical spread of tasking for our service, which is in keeping with other suburban/rural models of prehospital care. Tasking accuracy is also comparable to the accuracy shown by other similar services.

Emergency department at the cutting edge.

OBJECTIVE: This paper reviews the experience of penetrating chest trauma over a 3-year period in one UK emergency department. METHODS: A retrospective review was performed of patients assessed in the emergency department resuscitation room between 1 January 2002 and 31 December 2005. Patients with penetrating chest trauma, either isolated or in combination with other injuries, were included. A Medline search was performed using the terms 'chest', 'trauma' and 'penetrating'. RESULTS: A total of 120 patients presented with penetrating chest trauma. Ninety-two percent were male. Ninety-six percent (115) of the patients survived to hospital discharge. Seventy-eight percent of the patients presented at night (20.00 and 8.00 h). A single wound accounted for 52% (63) of patients, multiple wounds 43% (52) with 2% (two) gun-shot wounds and 3% (three) impalings. The mean prehospital time of patients in cardiac arrest was 42 min with a mean on-scene time of 24 min. The mean prehospital time for patients undergoing formal emergency surgery was 39 min with a mean on-scene time of 16 min. Twenty-three patients required one or more tube thoracostomies to be performed in the emergency department and six underwent emergency department thoracotomy. Sixteen patients required immediate formal emergency surgery for haemorrhage control. CONCLUSION: Penetrating chest trauma contributes significantly to our trauma workload with a high proportion of patients sustaining life-threatening injuries requiring immediate intervention. Significant prehospital delays occur. Overall mortality of 4.2% is comparable with that of a major American case series. Further education and protocol development is required to ensure that prehospital and emergency department management of these patients reflects the latest evidence-based guidelines.

Ocular presentation of pediatric Miller-Fisher syndrome.

The authors describe a case of Miller-Fisher syndrome in a child who presented to the ophthalmology department with bilateral abducens nerve palsies. Miller-Fisher syndrome is an important differential diagnosis in any case of bilateral sixth nerve palsies but should only be definitively diagnosed once tumors, infections, and other neurological diseases have been conclusively ruled out.

Molecular origin of two polysaccharides of Campylobacter jejuni 81116.

The nature of the polysaccharide molecules of the human enteric pathogen Campylobacter jejuni has been the subject of debate. Previously, C. jejuni 81116 was shown to contain two different polysaccharides, one acidic (polysaccharide A) and the other neutral (polysaccharide B), occurring in a 3 : 1 ratio, respectively. The aim of this study was to determine the molecular origin of these polysaccharides. Using a combination of centrifugation, gel permeation chromatography, chemical assays, and (1)H-NMR analysis, polysaccharide B was shown to be derived from lipopolysaccharide and polysaccharide A from capsular polysaccharide. Thus, C. jejuni 81116 produces both lipopolysaccharide-like molecules and capsular polysaccharide.

Role of Helicobacter pylori rfaJ genes (HP0159 and HP1416) in lipopolysaccharide synthesis.

The genome of Helicobacter pylori 26695 has been sequenced and the lipopolysaccharide (LPS) O sidechain of this strain has been shown to express both Lewis x and Lewis y units. To determine the role of HP0159 and HP1416, genes recognized as rfaJ homologs and implicated in LPS synthesis, isogenic mutants of H. pylori 26695 were generated. The LPS of mutant 26695::HP0159Kan did not express either Lewis epitope as detected by immunoblotting, whereas the control strain and 26695::HP1416Kan produced both epitopes. Structural analysis of the LPS of the mutants showed that HP0159 encodes an alpha(1,2/3)-glucosyltransferase whereas HP1416 encodes an alpha(1,2/4)-glucosyltransferase.

Structures of two polysaccharides of Campylobacter jejuni 81116.

Campylobacter jejuni 81116 has been extensively investigated in studies on genes associated with the synthesis of Campylobacter lipopoly/lipooligosaccharides (LPS/LOS). Despite these investigations, data on the chemical structure of polysaccharides from C. jejuni 81116 have been absent. The present study was undertaken to fill that void. Biomass was grown in large quantities on agar medium, harvested and extracted by hot phenol-water extraction. Subsequently, extracts were treated by DNase, RNase and proteinase K to remove contaminants. After mild acid treatment, followed by preparative gel-permeation and anion-exchange chromatography, fractions were isolated and studied by 1H and 13C NMR spectroscopy, including 2D COSY, TOCSY, 1H,(13)C HMQC and HMBC experiments. These advanced investigations revealed the occurrence of two different polysaccharides in the approximate ratio of 3:1, each having a tetrasaccharide repeating unit. Polysaccharide A contained glucose, glucuronic acid and mannose, and is O-acetylated. Polysaccharide B contained glucose, galactose and N-acetylglucosamine. Importantly, polysaccharide A is acidic, whereas polysaccharide B is neutral. [carbohydrate structure: see text]

Algal esterase activity as a biomeasure of environmental degradation in a freshwater creek.

This study investigated the potential for using algal esterase activity of Microcystis aeruginosa and Selenastrum capricornutum as a rapid measure of the biological effects of acid mine drainage (AMD) in a South Australian stream (Australia) also affected by sewage pollution and dry-land salinity. Algal bioassays were based on the non-fluorescent substrate, fluorescein diacetate (FDA) which is metabolised by esterases to the fluorescent product, fluorescein. Esterase activity was interpreted as the mean rate of conversion of FDA to fluorescein and expressed as a percentage of the rate achieved by control algae (%FDAC). Flow cytometry was used to measure the fluorescence of individual algal cells, enabling differentiation of three esterase activity states (low=S(1), normal and stimulated) and calculation of the percentage of algal cells in each activity state relative to that found for control algae (e.g. %S(1)). Algal esterase activity responded rapidly to AMD-affected water but also to increased conductivity (associated with dry-land salinity) and nutrient concentrations (associated with sewage). Exposure to AMD-affected water for 1 h reduced %FDAC by 30-70%, and increased %S(1) by 60-90%, a depression of esterase activity that was maintained over 24 h. A similar depression of esterase activity occurred in both algae exposed to comparatively high-conductivity water (ca. 20 mS cm(-1)) for 1 h but the algae recovered from this 'shock' within 24 h. The %FDAC of S. capricornutum increased from 66 to 158% of control values after a 24 h exposure to nutrient-enriched water sampled downstream from a sewage treatment plant, despite the fact that the alga was grown in nutrient-sufficient culture. The combination of cyanobacterial (M. aeruginosa) and green (S. capricornutum) algal cultures with exposure times of 1 and 24 h was successful in distinguishing between the three types of pollution. Correlation of esterase activity measures with water quality parameters indicated that the clearest and least equivocal biological measure of AMD for the study area was the %S(1) for M. aeruginosa after a 24 h exposure. The use of the flow cytometer to define a low esterase activity state was therefore successful in clarifying the response to AMD-affected water. The study demonstrates the successful application of algal esterase activity bioassays, in combination with flow cytometry, to rapidly assess the toxicity of AMD-affected waters and to differentiate this response from the effects of other pollutants (increased nutrients and conductivity).

Radiotherapy in thyroid eye disease: the effect on the field of binocular single vision.

PURPOSE: Thyroid eye disease (TED) can be a functionally disabling condition if ocular muscle involvement causes diplopia. The extraocular muscle restriction creates a reduced or eccentric field of binocular single vision (BSV). Orbital radiotherapy is now widely used in the treatment of TED, and although it has been reported as improving ocular motility, there have been few quantitative studies of the effect of treatment on ocular motor function. METHODS: Retrospective case note review of patients undergoing orbital radiotherapy for TED between 1992-1998 identified 79 case records. A total of 27 patients had diplopia in primary position or a significantly reduced binocular field before undergoing radiotherapy. The fields of BSV were analyzed pretreatment and at 3, 12, and 24 months after therapy to assess any improvement in function. We used the field of BSV as an outcome measure because it can be quantified and is a good indicator of functional ability. RESULTS: None of the 12 patients with double vision in primary position pretreatment regained a central binocular field with radiotherapy alone. Of the 15 patients with a central but reduced binocular field, 8 (53%) remained unchanged with treatment. In 4 patients (26.6%), there was an improvement in the field, while in 3 (20%) the field deteriorated. In all, 12 patients (44%) went on to require strabismus surgery. CONCLUSIONS: Orbital radiotherapy alone is ineffective in treating restrictive thyroid myopathy and improving binocular function.