The effect of sex and laterality on the phenotype of primary rhegmatogenous retinal detachment.

BACKGROUND: To assess the effect of sex and laterality on clinical features of primary rhegmatogenous retinal detachment (RRD). METHOD: This study is a retrospective analysis of data prospectively collected. We extracted data from two online datasets over a 7-year period of patients older than 16 years who had undergone surgery for primary RRD. Data on baseline characteristics were analyzed to compare males versus females, and right versus left eyes. RESULTS: Of 8133 eyes analyzed, 4342 (53.4%) were right. The overall male predominance (63.7%) was more marked in the age range 50-69 years. Men were more commonly pseudophakic and presented more frequently with baseline posterior vitreous detachment (PVD). Female sex was significantly associated with baseline myopia, retinal holes as causative retinal break, and isolated inferior RD. Men had more frequent foveal involvement, greater RRD extent, greater numbers and larger sized retinal tears including dialysis and giant retinal tears. Regarding laterality, foveal involvement, larger retinal breaks, isolated temporal RD and temporal retinal breaks were more common in right eyes, whereas left eyes were more myopic at baseline and presented more frequently with isolated nasal RD and nasal retinal breaks. CONCLUSIONS: This study confirmed the predominance of male sex and right laterality in RRD. Sex and laterality were associated with multiple presenting features of RRD including extent, break distribution, number, size and type, as well as RD distribution.

Stakeholder Perspectives of Clinical Artificial Intelligence Implementation: Systematic Review of Qualitative Evidence.

BACKGROUND: The rhetoric surrounding clinical artificial intelligence (AI) often exaggerates its effect on real-world care. Limited understanding of the factors that influence its implementation can perpetuate this. OBJECTIVE: In this qualitative systematic review, we aimed to identify key stakeholders, consolidate their perspectives on clinical AI implementation, and characterize the evidence gaps that future qualitative research should target. METHODS: Ovid-MEDLINE, EBSCO-CINAHL, ACM Digital Library, Science Citation Index-Web of Science, and Scopus were searched for primary qualitative studies on individuals' perspectives on any application of clinical AI worldwide (January 2014-April 2021). The definition of clinical AI includes both rule-based and machine learning-enabled or non-rule-based decision support tools. The language of the reports was not an exclusion criterion. Two independent reviewers performed title, abstract, and full-text screening with a third arbiter of disagreement. Two reviewers assigned the Joanna Briggs Institute 10-point checklist for qualitative research scores for each study. A single reviewer extracted free-text data relevant to clinical AI implementation, noting the stakeholders contributing to each excerpt. The best-fit framework synthesis used the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. To validate the data and improve accessibility, coauthors representing each emergent stakeholder group codeveloped summaries of the factors most relevant to their respective groups. RESULTS: The initial search yielded 4437 deduplicated articles, with 111 (2.5%) eligible for inclusion (median Joanna Briggs Institute 10-point checklist for qualitative research score, 8/10). Five distinct stakeholder groups emerged from the data: health care professionals (HCPs), patients, carers and other members of the public, developers, health care managers and leaders, and regulators or policy makers, contributing 1204 (70%), 196 (11.4%), 133 (7.7%), 129 (7.5%), and 59 (3.4%) of 1721 eligible excerpts, respectively. All stakeholder groups independently identified a breadth of implementation factors, with each producing data that were mapped between 17 and 24 of the 27 adapted Nonadoption, Abandonment, Scale-up, Spread, and Sustainability subdomains. Most of the factors that stakeholders found influential in the implementation of rule-based clinical AI also applied to non-rule-based clinical AI, with the exception of intellectual property, regulation, and sociocultural attitudes. CONCLUSIONS: Clinical AI implementation is influenced by many interdependent factors, which are in turn influenced by at least 5 distinct stakeholder groups. This implies that effective research and practice of clinical AI implementation should consider multiple stakeholder perspectives. The current underrepresentation of perspectives from stakeholders other than HCPs in the literature may limit the anticipation and management of the factors that influence successful clinical AI implementation. Future research should not only widen the representation of tools and contexts in qualitative research but also specifically investigate the perspectives of all stakeholder HCPs and emerging aspects of non-rule-based clinical AI implementation. TRIAL REGISTRATION: PROSPERO (International Prospective Register of Systematic Reviews) CRD42021256005; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256005. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/33145.

Stakeholder Perspectives on Clinical Decision Support Tools to Inform Clinical Artificial Intelligence Implementation: Protocol for a Framework Synthesis for Qualitative Evidence.

BACKGROUND: Quantitative systematic reviews have identified clinical artificial intelligence (AI)-enabled tools with adequate performance for real-world implementation. To our knowledge, no published report or protocol synthesizes the full breadth of stakeholder perspectives. The absence of such a rigorous foundation perpetuates the "AI chasm," which continues to delay patient benefit. OBJECTIVE: The aim of this research is to synthesize stakeholder perspectives of computerized clinical decision support tools in any health care setting. Synthesized findings will inform future research and the implementation of AI into health care services. METHODS: The search strategy will use MEDLINE (Ovid), Scopus, CINAHL (EBSCO), ACM Digital Library, and Science Citation Index (Web of Science). Following deduplication, title, abstract, and full text screening will be performed by 2 independent reviewers with a third topic expert arbitrating. The quality of included studies will be appraised to support interpretation. Best-fit framework synthesis will be performed, with line-by-line coding completed by 2 independent reviewers. Where appropriate, these findings will be assigned to 1 of 22 a priori themes defined by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability framework. New domains will be inductively generated for outlying findings. The placement of findings within themes will be reviewed iteratively by a study advisory group including patient and lay representatives. RESULTS: Study registration was obtained from PROSPERO (CRD42021256005) in May 2021. Final searches were executed in April, and screening is ongoing at the time of writing. Full text data analysis is due to be completed in October 2021. We anticipate that the study will be submitted for open-access publication in late 2021. CONCLUSIONS: This paper describes the protocol for a qualitative evidence synthesis aiming to define barriers and facilitators to the implementation of computerized clinical decision support tools from all relevant stakeholders. The results of this study are intended to expedite the delivery of patient benefit from AI-enabled clinical tools. TRIAL REGISTRATION: PROSPERO CRD42021256005; https://tinyurl.com/r4x3thvp. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33145.

Comparing outcomes between valve-sparing root replacement and the Bentall procedure in proximal aortic aneurysms: systematic review and meta-analysis.

In aortic root aneurysms, the challenge of a valve-sparing aortic root replacement (VSRR) procedure is to ensure durable aortic valve function without reintervention. Although the Bentall procedure defers the durability of valve function to the prosthesis, short- and long-term complications tend to be higher. The aim of this study was to compare the outcomes of VSRR and Bentall procedures in patients with aortic root aneurysms. A systematic literature review was conducted using PubMed regarding the outcomes of the Bentall procedure compared with those of VSRR from the inception of the 2 procedures until July 2018. Studies with short- and long-term comparative data were included. An initial search yielded 9517 titles. Thirty-four studies were finally included for meta-analysis (all retrospective, non-randomized), comprising 7313 patients (2944 valve-sparing and 4369 Bentall procedures) with no evidence of publication bias. Operative mortality was found to be significantly lower in the VSRR group [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37-0.70; P < 0.001] despite overall higher cardiopulmonary bypass and aortic cross-clamp times. The 5-year survival rate was also more favourable in the VSRR group (OR 1.93 95% CI 1.15-3.23; P < 0.05). Significantly lower rates of cerebral thromboembolism (OR 0.668, 95% CI 0.477-0.935; P = 0.019) and heart block (OR 0.386, 95% CI 0.195-0.767; P = 0.007) were also found after VSRR. There was no significant difference in rates of reoperation between the groups at long-term follow-up (OR 1.32, 95% CI 0.75-2.33; P = 0.336). Meta-regression of patient and operative covariates yielded no influence on the main outcomes (P > 0.05). These findings suggest that VSRR is an appropriate and potentially better treatment option for a root aneurysm when the aortic valve is repairable.

The general practice perspective on barriers to integration between primary and social care: a London, United Kingdom-based qualitative interview study.

OBJECTIVE: There is an ongoing challenge of effective integration between primary and social care in the United Kingdom; current systems have led to fragmentation of services preventing holistic patient-centred care for vulnerable populations. To improve clinical outcomes and achieve financial efficiencies, the barriers to integration need to be identified and addressed. This study aims to explore the unique perspectives of frontline staff (general practitioners and practice managers) towards these barriers to integration. DESIGN: Qualitative study using semistructured interviews and thematic analysis to obtain results. SETTING: General practices within London. PARTICIPANTS: 18 general practitioners (GPs) and 7 practice managers (PMs) based in London with experience of working with social care. RESULTS: The study identified three overarching themes where frontline staff believed problems exist: accessing social services, interprofessional relationships and infrastructure. Issues with contacting staff from other sectors creates delays in referrals for patient care and perpetuates existing logistical challenges. Likewise, professionals noted a hostile working culture between sectors that has resulted in silo working mentalities. In addition to staff being overworked as well as often inefficient multidisciplinary team meetings, poor relationships across sectors cause a diffusion of responsibility, impacting the speed with which patient requests are responded to. Furthermore, participants identified that a lack of interoperability between information systems, lack of pooled budgets and misaligned incentives between managerial staff compound the infrastructural divide between both sectors. CONCLUSION: In this study, primary care staff identify intangible barriers to integration such as poor interprofessional relationships, in addition to more well-described structural issues such as insufficient funding and difficulty accessing social care. Participants believe that educating the next generation of medical professionals may lead to the development of collaborative, instead of siloed, working cultures and that change is needed at both an interpersonal and institutional level to successfully integrate care.

Medical school teaching on interprofessional relationships between primary and social care to enhance communication and integration of care - a pilot study.

Background: A pilot study to identify if the delivery of teaching session to medical students would have the potential to enhance communication and a culture of integration between primary and social care, ultimately improving interprofessional relationships between primary and social care. Health and social care integration is a topic of great debate in the developed world and the focus of the upcoming Green Paper by the Secretary of State for Health and Social Care in the NHS. There is much uncertainty to how this should be done and is hindered by the various current barriers. The literature identifies that collaborative cultures encourage effective interprofessional relationships and that communication is vital to integration of primary and social care and should be established early in medical training. Materials and Method: The General Medical Council's Outcomes for Graduates and Imperial College School of Medicine curriculum were reviewed out to identify outcomes relating to inter-professional relationships between primary and social care. The relevant year group was surveyed to identify if the learning objective was delivered. In order to determine if delivery of a teaching session on nurturing interprofessional relationships between primary and social care would be effective, it was delivered to early clinical years to measure benefits as a pilot study. This was devised of case-based scenarios derived from learning objectives developed with experienced health care professionals. A survey was administered before and after the teaching session to determine if the students felt they had improved with respect to the learning objectives. Results: The initial survey identified the majority of students found the learning objectives were not delivered. The teaching session found a statistically significant improvement in confidence to nurture interprofessional relationships between primary and social care. Conclusion: Effective interprofessional relationships between primary and social care, improving communication and collaborative cultures, can be effectively taught in medical school, to improve integration of primary and social care.