The rapid access eye clinic's playbook: how to cut eye casualty attendance by 50.

BACKGROUND: Moorfields Eye Unit at the London Borough of Croydon sees over 47,000 outpatient attendances each year, 5894 of which attended the eye walk-in Urgent Care in the 2017- 2018 year, which has become unsustainable. METHODS: A recent audit found that referrers and patients had limited experience in managing ophthalmic conditions. If triaged according to clinical need only 22% patients attended required same-day hospital eye care. As such the service needed to be reconfigured. This was achieved through extensive collaboration with our local Clinical commissioning groups (CCG), General Practitioner (GP) body, Optometrists and host hospital at the Croydon University Hospital. The Rapid Access Clinic (RAC) was set up in November 2018 to replace the old-style walk-in pathway and provide a streamlined emergency eye care service for patients. RESULTS: RAC demonstrated an efficient and safe triage system which can improve patient flow. Since the launch date of RAC on the 1st November 2018, a 50% sustained decrease in attendances to urgent care was noted. This was achieved without impacting other eye services, by advising the referrers and redirecting referrals appropriately. At the same time the appropriateness of the attendances to our emergency clinic improved from 32% to 68%. Using a digital platform for referrals and data collection allowed up to continuously perform service evaluation. CONCLUSION: The forward-online triage and our close relationship with community enabled a safe continuation of providing emergency eye care locally. The controlled booked attendance as well as the advice and guidance system enabled us to prioritise true emergencies.

Cataract service redesign in the post-COVID-19 era.

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.

Eye care in the intensive care unit during the COVID-19 pandemic.

Ocular complications in critical care patients are common. There has been a surge in intensive care admissions following the COVID-19 outbreak. The management of COVID-19 exposes patients to a number of specific risk factors for developing ocular complications, which include non-invasive ventilation, mechanical ventilation and prone positioning. Consequently, it is likely that there will be an increase in the number of ocular complications secondary to the management of COVID-19 patients in the intensive care unit setting, and these complications could lead to permanent visual loss and blindness. Increased awareness of eye care in the intensive care unit setting is therefore vital to help prevent visual loss and maintain quality of life for patients recovering from COVID-19.

A pilot trial of serial 18F-fluorodeoxyglucose positron emission tomography in patients with medically inoperable stage I non-small-cell lung cancer treated with hypofractionated stereotactic body radiotherapy.

PURPOSE: Routine assessment was made of tumor metabolic activity as measured by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in Stage I non-small-cell lung cancer (NSCLC). This report describes PET correlates prospectively collected after stereotactic body radiotherapy (SBRT) for patients with medically inoperable NSCLC. METHODS AND MATERIALS: 14 consecutive patients with medically inoperable Stage I NSCLC were enrolled. All patients received SBRT to 60-66 Gy in three fractions. Patients underwent serial planned FDG-PET/computed tomography fusion imaging before SBRT and at 2, 26, and 52 weeks after SBRT. RESULTS: With median follow-up of 30.2 months, no patients experienced local failure. One patient developed regional failure, 1 developed distant failure, and 1 developed a second primary. The median tumor maximum standardized uptake value (SUV(max)) before SBRT was 8.70. The median SUV(max) values at 2, 26, and 52 weeks after SBRT were 6.04, 2.80, and 3.58, respectively. Patients with low pre-SBRT SUV were more likely to experience initial 2-week rises in SUV, whereas patients with high pre-SBRT SUV commonly had SUV declines 2 weeks after treatment (p = 0.036). Six of 13 patients had primary tumor SUV(max) >3.5 at 12 months after SBRT but remained without evidence of local disease failure on further follow-up. CONCLUSIONS: A substantial proportion of patients may have moderately elevated FDG-PET SUV(max) at 12 months without evidence of local failure on further follow-up. Thus, slightly elevated PET SUV(max) should not be considered a surrogate for local treatment failure. Our data do not support routine serial FDG-PET/computed tomography for follow-up of patients receiving SBRT for Stage I NSCLC.

Novel antiviral agent DTriP-22 targets RNA-dependent RNA polymerase of enterovirus 71.

Enterovirus 71 (EV71) has emerged as an important virulent neurotropic enterovirus in young children. DTriP-22 (4{4-[(2-bromo-phenyl)-(3-methyl-thiophen-2-yl)-methyl]-piperazin-1-yl}-1-pheny-1H-pyrazolo[3,4-d]pyrimidine) was found to be a novel and potent inhibitor of EV71. The molecular target of this compound was identified by analyzing DTriP-22-resistant viruses. A substitution of lysine for Arg163 in EV71 3D polymerase rendered the virus drug resistant. DTriP-22 exhibited the ability to inhibit viral replication by reducing viral RNA accumulation. The compound suppressed the accumulated levels of both positive- and negative-stranded viral RNA during virus infection. An in vitro polymerase assay indicated that DTriP-22 inhibited the poly(U) elongation activity, but not the VPg uridylylation activity, of EV71 polymerase. These findings demonstrate that the nonnucleoside analogue DTriP-22 acts as a novel inhibitor of EV71 polymerase. DTriP-22 also exhibited a broad spectrum of antiviral activity against other picornaviruses, which highlights its potential in the development of antiviral agents.

FDG-PET and stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer.

PURPOSE: To investigate the utility of positron emission tomography (PET) in patients treated with stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer (NSCLC) on prospective institutional trials. PATIENTS AND METHODS: Fifty-eight patients with medically inoperable stage I NSCLC who participated in prospective phase I and II trials of SBRT, had >or=2 years of follow-up, and received FDG-PET imaging are the focus of this evaluation. Fifty-seven of 58 patients received pre-SBRT FDG-PET to confirm stage I status. All patients received stereotactic body frame immobilization and treatment with 7-10 photon beams. SBRT total doses ranged from 24 to 72Gy in three fractions. No elective nodal irradiation was undertaken. Regular follow-up with planned CT imaging was performed on all patients. Post-SBRT FDG-PET was not mandated by protocol and was typically ordered upon concern for disease recurrence. Thirty-eight post-SBRT PET studies were performed in 28 patients at a median 17.3 months following SBRT. RESULTS: With a median follow-up of 42.5 months, the 3-year actuarial overall survival and local control for this select subset of our SBRT experience were 48.9% and 74.8%, respectively. Pre-SBRT FDG-PET SUV did not predict 3-year overall survival or local control. Fourteen of 57 patients eventually failed in nodal stations by CT and/or PET. Isolated first site of failure was nodal in 6 patients (10%). Out of 28 patients with post-SBRT PET, 4 (14%) had delayed PET imaging (22-26 months after SBRT) showing moderate hypermetabolic activity (SUV 2.5-5.07), but no evidence of local, nodal, or distant recurrence by clinical examination and conventional imaging performed 20-26 months following these concerning PET findings. CONCLUSIONS: Isolated nodal recurrence following PET-staged I NSCLC treated with SBRT is uncommon. Moderate post-SBRT PET hypermetabolic activity may persist 2 years following treatment without definite evidence of recurrence. Further study is needed to confirm these results in larger populations with longer follow-up.