Protocol for a qualitative study to explore acceptability, barriers and facilitators of the implementation of new teleophthalmology technologies between community optometry practices and hospital eye services.

INTRODUCTION: Novel teleophthalmology technologies have the potential to reduce unnecessary and inaccurate referrals between community optometry practices and hospital eye services and as a result improve patients' access to appropriate and timely eye care. However, little is known about the acceptability and facilitators and barriers to the implementations of these technologies in real life. METHODS AND ANALYSIS: A theoretically informed, qualitative study will explore patients' and healthcare professionals' perspectives on teleophthalmology and Artificial Intelligence Decision Support System models of care. A combination of situated observations in community optometry practices and hospital eye services, semistructured qualitative interviews with patients and healthcare professionals and self-audiorecordings of healthcare professionals will be conducted. Participants will be purposively selected from 4 to 5 hospital eye services and 6-8 affiliated community optometry practices. The aim will be to recruit 30-36 patients and 30 healthcare professionals from hospital eye services and community optometry practices. All interviews will be audiorecorded, with participants' permission, and transcribed verbatim. Data from interviews, observations and self-audiorecordings will be analysed thematically and will be informed by normalisation process theory and an inductive approach. ETHICS AND DISSEMINATION: Ethical approval has been received from London-Bromley research ethics committee. Findings will be reported through academic journals and conferences in ophthalmology, health services research, management studies and human-computer interaction.

Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study-HERMES study report 1-study protocol.

INTRODUCTION: Recent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and disease management, the referral process results in unnecessary referrals from erroneous diagnoses and delays in access to appropriate treatment. A potential solution is a teleophthalmology digital referral pathway linking community optometry and HES. METHODS AND ANALYSIS: The HERMES study (Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease: a cluster randomised superiority trial with a linked diagnostic accuracy study) is a cluster randomised clinical trial for evaluating the effectiveness of a teleophthalmology referral pathway between community optometry and HES for retinal diseases. Nested within HERMES is a diagnostic accuracy study, which assesses the accuracy of an artificial intelligence (AI) decision support system (DSS) for automated diagnosis and referral recommendation. A postimplementation, observational substudy, a within-trial economic evaluation and discrete choice experiment will assess the feasibility of implementation of both digital technologies within a real-life setting. Patients with a suspicion of retinal disease, undergoing eye examination and optical coherence tomography (OCT) scans, will be recruited across 24 optometry practices in the UK. Optometry practices will be randomised to standard care or teleophthalmology. The primary outcome is the proportion of false-positive referrals (unnecessary HES visits) in the current referral pathway compared with the teleophthalmology referral pathway. OCT scans will be interpreted by the AI DSS, which provides a diagnosis and referral decision and the primary outcome for the AI diagnostic study is diagnostic accuracy of the referral decision made by the Moorfields-DeepMind AI system. Secondary outcomes relate to inappropriate referral rate, cost-effectiveness analyses and human-computer interaction (HCI) analyses. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-Bromley Research Ethics Committee (REC 20/LO/1299). Findings will be reported through academic journals in ophthalmology, health services research and HCI. TRIAL REGISTRATION NUMBER: ISRCTN18106677 (protocol V.1.1).

Ectopic spleen presenting as a slowly enlarging lung nodule in the right lower lobe following gastric pull up operation.

This is a case report of an elderly man who was investigated at our respiratory clinic for slowly enlarging right lower lobe lung nodule on the background of oesophageal cancer diagnosed more than 11 years ago with gastric pull up. CT guided biopsy confirms the diagnosis of intrathoracic ectopic spleen.

Service Evaluation of Recording Jaw Registrations for Removable Partial Dentures in NHS General Dental Practices.

AIMS: To establish the prevalence of jaw registrations being taken for removable partial dentures (RPDs) in primary dental NHS practices. METHOD: 271 RPDs made by 16 general dental practitioners across four NHS dental practices were evaluated prospectively. The number of teeth replaced, whether jaw registration was undertaken, and the number of denture adjustment appointments were recorded. Telephone interviews with dental technicians were held to establish their preferred jaw registrations material. MAIN FINDINGS: Jaw registrations were not carried out in 27% (n=72) of RPD. When jaw registration was recorded, 14% (n=28) required a further denture adjustment appointment. 64% (n=46) of dentures where jaw registration was not recorded required at least one further denture adjustment appointment. Dental technicians unanimously preferred a squash-bite wax block, with centre and canine positions marked and cast models secured with elastic bands. CONCLUSION: Overall, recording a jaw registration reduced the number of denture adjustment appointments required.

An incidental finding of an asymptomatic intraneural glomus tumor: A case report and review of the literature.

Glomus tumors are rare, soft-tissue neoplasms arising from the thermoregulatory neuromyoarterial glomus bodies. They are commonly observed in the extremities and typically present with symptoms of cold hypersensitivity, pain and localized tenderness. Intraneural glomus tumors (INGTs) are even rarer. Here we review the literature on INGT and present an unusual case of an asymptomatic INGT, found incidentally within the excision specimen of a spiradenocarcinoma that arose near the natal cleft. Interestingly, this had not been identified on magnetic resonance imaging (MRI) used to investigate the spiradenocarcinoma. Although glomus tumors are usually considered benign, malignant transformation has been reported, highlighting the need for reporting pathologists and treating clinicians to be aware of this entity.

Gangrenous cholecystitis in an asymptomatic patient found during an elective laparoscopic cholecystectomy: a case report.

INTRODUCTION: Gangrenous cholecystitis is a severe complication of acute cholecystitis. We present an unusual case of gangrenous cholecystitis which was totally asymptomatic, with normal pre-operative parameters, and was discovered incidentally during a laparoscopic cholecystectomy. We have not found any similar cases in the published literature. CASE PRESENTATION: A 79-year-old British Caucasian man presented initially with acute cholecystitis which responded to conservative management. After six weeks he was asymptomatic and had normal blood parameters. An elective laparoscopic cholecystectomy was performed and our patient was found to have a totally gangrenous gall bladder. CONCLUSION: It is important to keep a high index of suspicion for the diagnosis of gangrenous cholecystitis in order to avoid potentially serious complications.