Low Vision Services Provision throughout NHS Trusts in the UK.

Background/Aims: The aim of this study was to understand the picture of low vision service provision within NHS Trusts in the United Kingdom, for children and adults. Method: A survey was distributed to all members of the British and Irish Orthoptic Society (BIOS) and to all Eye Clinic Liaison Officers (ECLOs) through the Royal National Institute for the Blind (RNIB). The survey was also directly emailed to Orthoptic contacts of all 238 Trusts/Health Boards, which covered the four nations of the United Kingdom. The survey asked whether their Trust had a clinical low vision service, which professions were involved in leading and working within it, where it was based, and whether provision was offered to children, adults, or both. Results: In the United Kingdom (UK), 117 out of 238 (49%) Trusts responded. Of these responders, 94% had a level of Trust-delivered low vision service provision; 90% had services for adults; 83% had services for children; and 79% had services for both adults and children. Service accessibility for patients of all ages had regional and national variation. Conclusion: Significant variation was found in low vision service provision throughout the UK, with some regions having no NHS-delivered provision for either children, adults, or both. This calls for further research to gain a more comprehensive understanding of low vision service provision and remove inequalities in provision, access and resourcing, aiming to ensure equitable access for all.

Utilising Virtual Clinics and Orthoptists to Aid COVID-19 Service Recovery in Adult Strabismus.

Background: The Sheffield Virtual Adult Strabismus service was already well established and was put to real-time trial during the COVID-19 pandemic. We describe a multi-disciplinary adaptation to offer a safe and effective service delivery. We evaluate the efficacy of a virtual strabismus service during the pandemic to meet clinical demand, streamline patient care, balance care delivery and optimise medical input. Methods: Prospective data analysis from the virtual strabismus clinics dated from January 2015 to November 2021. All information was captured at first consultation with comprehensive specialist Orthoptic assessment and imaging; then reviewed by a strabismus consultant for clinical outcome. Management was discussed virtually with patients by the consultant. Results: Pre-COVID (January 2015-March 2020), 1,068 appointments were offered. During COVID (July 2020-November 2021), 442 appointments were offered. Clinical capacity increased to meet demand. Within two months of service re-opening, first appointment mean waiting time reduced below 18 weeks. During COVID, 24.6% of patients were listed for procedures after first visit. Face-to-face medical follow up for non-surgical cases reduced from 47.7% to 16.3%. Conclusion: Virtual strabismus services offer flexible, safe and effective ways to meet fluctuating referral patterns and maximise limited time and resources. Orthoptists are uniquely essential and highly valued keyworkers to conservatively manage non-surgical strabismus. Utilising the skillsets of Allied Health Professionals (AHPs) across the NHS is crucial to sustain ongoing clinical demand and patient care.

Conservative and Surgical Management of Unilateral and Bilateral Internuclear Ophthalmoplegia (INO)-A Retrospective Analysis.

Aim: To report the outcomes of the natural progression and ophthalmic treatment of patients reviewed in a tertiary hospital trust with unilateral or bilateral internuclear ophthalmoplegia. Method: A retrospective case note analysis was performed and 33 patients diagnosed with unilateral or bilateral internuclear ophthalmoplegia (INO) were identified. The diagnosis, aetiology, presence of diplopia, ophthalmic management options and progression were recorded and analysed. This included both conservative and surgical management. Results: The most common aetiologies of INO within this cohort were stroke/ischaemic (69.7%) and multiple sclerosis (MS) (30.3%). Unilateral INO was more prevalent than bilateral INO, with 20 cases (60.6%) compared to 13 cases (39.4%), respectively. A higher proportion of unilateral INO were attributed to stroke (90%) whilst a higher proportion of bilateral INO were attributed to MS (61.5%). The most prescribed management at primary assessment was occlusion (45.5%) and prisms (24.2%). Some patients required no orthoptic intervention (30.3%). Two patients had surgical management of strabismus secondary to bilateral INO. Conclusion: Occlusion was the most common form of management for symptomatic relief of diplopia. Patients who presented at the first visit with no symptoms were unlikely to need any orthoptic intervention. Of the two patients who went on to require surgical intervention, restoration of binocular single vision (BSV) was achieved post-operatively with the use of a Fresnel prism. However, the differences in both surgical technique and number of surgeries required make this difficult to generalise. Additional research is needed to further explore the surgical management of INO.

A DNA barcode library for mangrove gastropods and crabs of Hong Kong and the Greater Bay Area reveals an unexpected faunal diversity associated with the intertidal forests of Southern China.

BACKGROUND: Mangroves are tropical and subtropical intertidal forests colonising sheltered coasts across the world. They host a unique faunal community, dominated by brachyuran crabs and gastropods. These invertebrates strongly contribute to the functionality of the entire forest. The reliable assessment of mangrove faunal diversity is, thus, a crucial step for efficient management and conservation plans, but it is hindered by difficulties in species identification. Here we provide a verified DNA barcode library for brachyuran crabs and gastropods inhabiting the mangroves of the Greater Bay Area, Southern China. In particular, we collected and morphologically identified 1100 specimens of mangrove associated brachyuran crabs and gastropods. The partial sequences of the mtDNA cytochrome oxidase subunit I gene were obtained from 275 specimens. Barcode sequences were then used to delineate Molecular Operational Taxonomic Units (MOTUs), employing three different delimitation methods: the automatic barcode gap discovery (ABGD) method, the general mixed Yule coalescent (GMYC) model and a Bayesian implementation of the Poisson tree processes (bPTP) model. RESULTS: By integrating DNA barcodes with morphology, we identified 44 gastropod species and 58 brachyuran species associated with Hong Kong mangroves, with five and seven new records, for gastropods and crabs, respectively, for the Greater Bay Area. The delineation of MOTUs based on barcode sequences revealed a strong congruence between morphological and molecular identification for both taxa, showing the high reliability of the barcode library. CONCLUSIONS: This study provides the first reference barcode library for mangrove-associated macrobenthic fauna in the Greater Bay Area and represents a reliable tool to management and conservation plans. Our molecular analyses resolved long lasting taxonomic misidentifications and inconsistencies and updated the knowledge on the geographical distribution of Asian mangrove associated fauna, ultimately highlighting a level of biodiversity higher than previously thought for Southern China.

A Post-Surgical Stereovision Surprise in an Adult With an Exotropia Since Infancy Previously Managed, at Two Years With Surgery.

AIM: To describe an unexpected sensory outcome in an adult male who is seeking ocular re-alignment for a psychosocially symptomatic large non-specific exotropia with suppression. The primary diagnosis was infant onset exodeviation of unclear diagnosis, was managed with bilateral strabismus surgery at two years of age, little memory of follow-up. RESULT: Measurable binocular single vision (BSV) was demonstrable following surgery at 17 years of age, albeit slowly between two weeks and six months postoperatively and subsequently enhanced. His newly acquired sub-optimal BSV led to symptomatic occupation-associated asthenopia. Following two subsequent operations over a 15-year period, he has stable, symptom-free ocular realignment within three prism diopters of orthophoria and performing tasks that require extended periods of near-vision activity. CONCLUSION: Delayed high levels of stereovision were unexpectedly achieved in an adult with infant onset exotropia with pre-operative sensory suppression that was surgically aligned to near orthophoria. The re-establishment of BSV in such a clinical scenario has to attain a level that is robust enough to meet an individual's social and occupational needs.

A retrospective study of cognitive function in doctors and dentists with suspected performance problems: an unsuspected but significant concern.

OBJECTIVE: To examine the performance assessments and cognitive function of practitioners referred to the National Clinical Assessment Service (NCAS). DESIGN: Retrospective observational study. SETTING: Practitioners referred to NCAS for performance assessment due to suspected performance problems. PARTICIPANTS: One hundred and nine practitioners over the age of 45 years referred to NCAS between 1 September 2008 and 30 June 2012. MAIN OUTCOME MEASURES: Reasons for referral of practitioners and their characteristics; details of their assessments including screening for cognition using Addenbrooke's Cognitive Examination Revised (ACE-R); outcome of the process. RESULTS: Reasons for referral included 'clinical difficulties' and 'governance or safety issues'. Eighty-seven practitioners scored above 88 on ACE-R. Twenty-two were found to have an ACE-R score of ≤88. On further assessment, 14 of these 22 practitioners were found to have cognitive impairment. The majority of all practitioners were found to be performing below the expected level of practice for someone at their grade and specialty. Of those scoring ≤88 on the screening, only seven continued in clinical practice. CONCLUSIONS: A high proportion of practitioners scoring poorly on ACE-R were found to have cognitive impairment following detailed neuropsychological testing, the youngest aged 46 years. Many were working in isolation. Nearly all practitioners scoring poorly on ACE-R were international medical graduates; reasons for this are unclear. Performance assessment results showed persisting failings in the practitioners' record keeping and in their assessment of patients. Our findings highlight the need for increased vigilance and training of responsible officers to recognise performance problems and emphasise the importance of comprehensive assessment.

Literacy and numeracy for pre-registration nursing programmes: 1. An innovative way to widen access to nursing programmes for students without formal qualifications by enabling them to give evidence of their literacy and numeracy skills.

The Nursing and Midwifery Council (NMC, 2003) removed standard entry criteria for nursing programmes and asked Higher Education Institutions (HEIs) to consider the literacy and numeracy skills of prospective students. This triggered admissions staff within a Faculty of Health to consider ways of attracting people with the right skills but not the qualifications to prove it. It is important to encourage a wide range of people into nursing to meet the demands of strategic plans and policy, as well as to ensure the nursing profession reflects the diverse client groups it serves. Removing standard entry criteria and the widening participation agenda gave an ideal opportunity to try something new. A course entitled 'Portfolio of Evidence for Entry to Level 1 Study' was developed within the Faculty of Health at Staffordshire University to enable potential nursing students without standard entry qualifications to demonstrate their skills in numeracy and literacy. This paper reports on the background to this course and its success for three student cohorts (over an 18 month period) who have completed their first year of pre-registration nursing. The methodology employed is descriptive, qualitative analysis, comparing portfolio and standard entry students' assignment results.

The anatomy, physiology and pathogenesis of a significant untoward incident.

This paper provides a structured chronology of an investigation into a significant untoward incident in an elderly care ward. Using Reason's Swiss Cheese Model, which has become one of the dominant paradigms for analysing clinical and patient safety incidents, it charts the interplay of national and local policies resulting in unsafe practice. A qualitative approach was used in this multidimensional investigation. This approach aimed to discover what actually happened in the specific and related incidents and the underlying causes. Thus, the anatomy of the incident refers to the structure of staffing, the physiology includes the process in place at the time of the incident and the pathogenesis alludes to the development of the incident. The findings report on the patients involved in the incident. The investigation also explores how strategic financial directions from the Department of Health impact on staffing levels and training. These are contextualised using the concepts of the Swiss Cheese Model to assist understanding of how and why the incident occurred. Key points emanating from a learning event are captured to aid understanding and the importance of being cognisant of the ever present risks in clinical practice. The impact of the investigation on staff and the primary care trust are also presented.

Applying network analysis to the conservation of habitat trees in urban environments: a case study from Brisbane, Australia.

In Australia more than 300 vertebrates, including 43 insectivorous bat species, depend on hollows in habitat trees for shelter with many species using a network of multiple trees as roosts. We used roost-switching data on white-striped freetail bats (Tadarida australis; Microchiroptera: Molossidae) to construct a network representation of day roosts in suburban Brisbane, Australia. Bats were caught from a communal roost tree with a roosting group of several hundred individuals and released with transmitters. Each roost used by the bats represented a node in the network, and the movements of bats between roosts formed the links between nodes. Despite differences in gender and reproductive stages, the bats exhibited the same behavior throughout three radiotelemetry periods and over 500 bat days of radio tracking: each roosted in separate roosts, switched roosts very infrequently, and associated with other bats only at the communal roost. This network resembled a scale-free network in which the distribution of the number of links from each roost followed a power law. Despite being spread over a large geographic area (> 200 km2), each roost was connected to others by less than three links. One roost (the hub or communal roost) defined the architecture of the network because it had the most links. That the network showed scale-free properties has profound implications for the management of the habitat trees of this roosting group. Scale-free networks provide high tolerance against stochastic events such as random roost removals but are susceptible to the selective removal of hub nodes. Network analysis is a useful tool for understanding the structural organization of habitat tree usage and allows the informed judgment of the relative importance of individual trees and hence the derivation of appropriate management decisions. Conservation planners and managers should emphasize the differential importance of habitat trees and think of them as being analogous to vital service centers in human societies.

Teaching evidence-based medicine to undergraduate medical students: a course integrating ethics, audit, management and clinical epidemiology.

A six-week full time course for third-year undergraduate medical students at Imperial College uniquely links evidence-based medicine (EBM) with ethics and the management of change in health services. It is mounted jointly by the Medical and Business Schools and features an experiential approach. Small teams of students use a problem-based strategy to address practical issues identified from a range of clinical placements in primary and secondary care settings. The majority of these junior clinical students achieve important objectives for learning about teamwork, critical appraisal, applied ethics and health care organisations. Their work often influences the care received by patients in the host clinical units. We discuss the strengths of the course in relation to other accounts of programmes in EBM. We give examples of recurring experiences from successive cohorts and discuss assessment issues and how our multi-phasic evaluation informs evolution of the course and the potential for future developments.

Using a modified nominal group technique as a curriculum evaluation tool.

The modified nominal group technique (NGT) is a useful and practical course evaluation tool that complements existing methods such as evaluation forms, surveys, pretests and posttests, focus groups, and interviews. The NGT's unique contribution to the evaluation process is the semi-quantitative, rank-ordered feedback data obtained on learners' perceptions of a course's strengths and weaknesses. In this paper, we demonstrate through a worked example how to use a modified NGT as a course evaluation tool in medical education.