Photochemical Crosslinking of Tarsal Collagen as a Treatment for Eyelid Laxity: Evaluation in Ex Vivo Human Tissue.

PURPOSE: Experimental investigation in human eyelids to confirm that exposing excised tarsal plates to ultraviolet-A radiation can induce a stiffening effect through the riboflavin-photosensitized crosslinking of tarsal collagen. METHODS: Thirteen tarsal plates excised from nonfrozen human cadavers were irradiated with ultraviolet-A rays (365 nm wavelength) at an irradiance of 75 mW/cm2 for 3 minutes, equivalent to a radiation fluence of 13.5 J/cm2, in the presence of a riboflavin derivative as a photosensitizer. The tensile stress (strength) and Young's modulus (stiffness) of both nonirradiated and irradiated specimens were measured with the BioTester 5000 in the uniaxial mode at a strain of 10% and analyzed statistically. Individual specimens excised from 2 cadavers were also examined by routine histopathologic protocols to assess the effect of radiation on the Meibomian glands and collagen organization. RESULTS: The irradiation enhanced both stiffness and strength of the human tarsal specimens, the difference between the test samples and controls being statistically significant (p < 0.0002 for n = 13). Histology indicated no damage to tarsal connective tissue or to Meibomian glands, and revealed a more compact packing of the collagen network located around the glands, which may be beneficial. The existence of collagen compaction was also supported by the reduction of samples' thickness after irradiation (p = 0.0645). CONCLUSIONS: The irradiation of tarsal tissue with ultraviolet-A light of tarsus appears to be a safe and effective method for reducing eyelid laxity in human patients.

The International Vitreoretinal B-Cell Lymphoma Registry: a protocol paper.

INTRODUCTION: Vitreoretinal lymphoma is a rare ocular cancer with high morbidity and mortality despite treatment. Diagnosis by cytopathology is often delayed, and various molecular and image-based investigations have been developed. Diverse treatments are used, but there is a limited medical evidence to differentiate their effectiveness. We designed an international registry that would collect diagnostic, treatment and outcomes data, to establish new evidence for the management of this cancer. METHODS AND ANALYSIS: The International Vitreoretinal B-Cell Lymphoma Registry will accrue data retrospectively for individuals aged 18 years or older, diagnosed with new or recurrent vitreoretinal B-cell lymphoma on or after 1 January 2020. A steering committee of subspecialised ophthalmologists identified 20 key clinical data items that describe patient demographics, tissue involvements, diagnostic testing, ocular and systemic treatments and treatment complications, and visual acuity and survival outcomes. Customised software was designed to permit collection of these data across a single baseline and multiple follow-up forms. The platform collects data without identifiers and at 3 month reporting intervals. Outcomes of the project will include: (1) descriptions of clinical presentations, and diagnostic and therapeutic preferences; (2) associations between clinical presentations, and diagnostics and treatments, and between diagnostics and treatments (assessed by ORs with 95% CIs); and (3) estimations of rates of vision loss, and progression-free and overall survival (assessed by Kaplan-Meier estimates). ETHICS AND DISSEMINATION: The registry has received Australia-wide approval by a national human research ethics committee. Sites located outside Australia are required to seek local human research ethics review. Results generated through the registry will be disseminated primarily by peer-reviewed publications that are expected to inform clinical practice, as well as educational materials.

Risk factors associated with heel pressure ulcer development in adult population: A systematic literature review.

AIMS: The main aim of this systematic literature review was to identify risk factors for development of heel pressure ulcers and quantify their effect. BACKGROUND: Pressure ulcers remain one of the key patient safety challenges across all health care settings and heels are the second most common site for developing pressure ulcers after the sacrum. DESIGN: Quantitative systematic review. METHODS: Data sources: Electronic databases were searched for studies published between 1809 to March 2020 using keywords, Medical Subject Headings, and other index terms, as well as combinations of these terms and appropriate synonyms. STUDY ELIGIBILITY CRITERIA: Previous systematic literature reviews, cohort, case control and cross-sectional studies investigating risk factors for developing heel pressure ulcers. Only articles published in English were reviewed with no restrictions on date of publication. PARTICIPANTS: patients aged 18 years and above in any care setting. Study selection, data extraction, risk of bias and quality assessment were completed by two independent reviewers. Disagreements were resolved by discussion. RESULTS: Thirteen studies met the eligibility criteria and several potential risk factors were identified. However, eligible studies were mainly moderate to low quality except for three high quality studies. CONCLUSIONS: There is a paucity of high quality evidence to identify risk factors associated with heel pressure ulcer development. Immobility, diabetes, vascular disease, impaired nutrition, perfusion issues, mechanical ventilation, surgery, and Braden subscales were identified as potential risk factors for developing heel pressure ulcers however, further well-designed studies are required to elucidate these factors. Other risk factors may also exist and require further investigation. PROSPERO ID: PROSPERO International prospective register of systematic reviews: CRD42017071459.

Using knowledge discovery through data mining to gain intelligence from routinely collected incident reporting in an acute English hospital.

PURPOSE: Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. DESIGN/METHODOLOGY/APPROACH: Incident reporting data recorded in one NHS acute Trust was mined for insight (n = 133,893 April 2005-July 2016 across 201 fields, 26,912,493 items). An a priori dataset was overlaid consisting of staffing, vital signs, and national safety indicators such as falls. Analysis was primarily nonlinear statistical approaches using Mathematica V11. FINDINGS: The organization developed a deeper understanding of the use of incident reporting systems both in terms of usability and possible reflection of culture. Signals emerged which focused areas of improvement or risk. An example of this is a deeper understanding of the timing and staffing levels associated with falls. Insight into the nature and grading of reporting was also gained. PRACTICAL IMPLICATIONS: Healthcare incident reporting data is underused and with a small amount of analysis can provide real insight and application to patient safety. ORIGINALITY/VALUE: This study shows that insight can be gained by mining incident reporting datasets, particularly when integrated with other routinely collected data.

An observational study on the rate of reporting of adverse event on healthcare staff in a mental health setting: An application of Poisson expectation maximisation analysis on nurse staffing data.

Evidence highlights the intrinsic link between nurse staffing and expertise, and outcomes for service users of healthcare, and that workforce retention is linked to the clinical and organisational experiences of employees. However, this understanding is less well established in mental health. This study comprises a retrospective observational study carried out on routinely collected data from a large mental healthcare provider. Two databases comprising nurse staffing levels and adverse events were modelled using latent variable methods to account for the presence of multiple underlying behaviours. The analysis reveals a strong dependence of the rate of adverse events on the location and perceived clinical demand of the wards, and a reduction in adverse events where registered nurses exceed 'clinically required levels'. In the first study of its kind, these findings present significant implications for nursing workforce policy and present an opportunity to not only improve safety but potentially impact nurse retention.

Nursing pay by gender distribution in the UK - does the Glass Escalator still exist?

AIMS AND OBJECTIVES/BACKGROUND: Nursing is a predominantly female profession. This is reflected in the demographic of nursing around the world. Some authors have noted that despite being a gendered profession men are still advantaged in terms of pay and opportunity. The aim of this study was to examine if the so called glass escalator in which men are advantaged in female professionals still exists. DESIGN AND METHOD: Descriptive statistics of the routinely collected national workforce datasets from across the UK central repositories and mining of a bespoke data set that has been curated which focuses on the activity of specialist advanced practice clinical nurses. RESULTS: Even in a gendered occupation such as nursing the advantage of men in terms of pay is apparent with men being over-represented at senior Bands compared to their overall proportion in the UK nursing population. From the bespoke dataset there also seem to be an advantage in term of faster attainment of higher grades from the point of registration. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Reward and remuneration are essential to the workforce. This work reveals a gender differential towards men in higher paid nursing work. The drivers for this are complex and further work is required to determine the factors associated with career progression with men in nursing, and the rate limiting factors with the female workforce.

Variation in job titles within the nursing workforce.

AIMS AND OBJECTIVES/BACKGROUND: The work of specialist nursing has been under scrutiny for many years in the UK due to a perception that it is not cost-effective. A common issue is the lack of consistency of job titles, which causes confusion to the public, employing organisations, colleagues and commissioners of services. Lack of consistency has implications for the wider perception of advanced specialist practice in the worldwide community and the workforce more generally. This study aims to understand the variation in job titles in the UK population. METHODS: A pre-existing data set of accrued studies into the work of nurses working in specialisms was mined for insight (N = 17,960). This study used knowledge discovery through data and descriptive statistics to perform secondary analysis. RESULTS: Mining these data revealed 595 job titles in use in 17,960 specialist posts once the specialism had been removed. The most commonly used titles were Clinical Nurse Specialist, Nurse Specialist/Specialist Nurse, Advanced Nurse Practitioner and Nurse Practitioner. There were three other primary groupings. These were variants with a specialist or technical prefix of suffix, for example Nurse Endoscopist, variants of seniority such as trainee, senior nurse for [specialism] or variants of function such as Nurse Prescriber. The clustering was driven primarily by pay band. A total of 323 posts were recorded as holding titles such as Advanced Nurse Practitioner or Specialist Nurse who were not registered with the Nursing & Midwifery Council. RELEVANCE TO CLINICAL PRACTICE: In this data set, there is a large array of titles, which appear to have little relationship with other factors like education. This is confusing to the public, employers and those commissioning services. It also demonstrates that the previous assumptions by Council for Healthcare Regulatory Excellence that advanced practice labels are associated with career progression are unsound and should be addressed by the regulator.

Understanding the distribution of A&E attendances and hospital admissions for the case managed population: A single case cross sectional study.

AIM: To describe the characteristics of case-managed patients presenting at accident and emergency (A & E) and to explore the distribution of their attendances and admissions. BACKGROUND: Recently, the UK Government announced extended-hours primary care provision in an effort to reduce the growing utilization of A & E. No evidence is available to understand the use of acute services by this high-risk patient group. METHOD: A cross-sectional design utilising routinely collected anonymsed A & E attendance and hospital admission data from 2010 to 2015. RESULTS: The case-managed population is typically 70years and older and most often arrive at A & E via emergency services and during the night (00:00-08:59). A large proportion are subsequently admitted having a statistically significant A & E conversion rate. No variables were predictive of admission. CONCLUSION: The high level of A&E conversion could indicate case-managed patients are presenting appropriately with acute clinical need. However, inadequate provision in primary-care could drive decisions for admitting vulnerable patients.

Mining routinely collected acute data to reveal non-linear relationships between nurse staffing levels and outcomes.

OBJECTIVES: Nursing is a safety critical activity but not easily quantified. This makes the building of predictive staffing models a challenge. The aim of this study was to determine if relationships between registered and non-registered nurse staffing levels and clinical outcomes could be discovered through the mining of routinely collected clinical data. The secondary aim was to examine the feasibility and develop the use of 'big data' techniques commonly used in industry for this area of healthcare and examine future uses. SETTING: The data were obtained from 1 large acute National Health Service hospital trust in England. Routinely collected physiological, signs and symptom data from a clinical database were extracted, imported and mined alongside a bespoke staffing and outcomes database using Mathmatica V.10. The physiological data consisted of 120 million patient entries over 6 years, the bespoke database consisted of 9 years of daily data on staffing levels and safety factors such as falls. PRIMARY AND SECONDARY OUTCOMES: To discover patterns in these data or non-linear relationships that would contribute to modelling. To examine feasibility of this technique in this field. RESULTS: After mining, 40 correlations (p<0.00005) emerged between safety factors, physiological data (such as the presence or absence of nausea) and staffing factors. Several inter-related factors demonstrated step changes where registered nurse availability appeared to relate to physiological parameters or outcomes such as falls and the management of symptoms. Data extraction proved challenging as some commercial databases were not built for extraction of the massive data sets they contain. CONCLUSIONS: The relationship between staffing and outcomes appears to exist. It appears to be non-linear but calculable and a data-driven model appears possible. These findings could be used to build an initial mathematical model for acute staffing which could be further tested.

A framework for advanced clinical practice.

The NHS needs a skilled, knowledgeable workforce of advanced clinical practitioners, who require multidisciplinary approach to their postgraduate development. To meet these demands we set up a regional programme to help clinical practitioners move into these new and demanding roles. As a result, health professionals who want to progress their career and advance their practice have an opportunity in the West Midlands to qualify as advanced clinical practitioners.

COMPARE and Pediatric Heart Network Investigator trials: Losartan finally validated in humans with Marfan, but much work remains!

A landmark study by Habashi et al(1) in 2006 documented for the first time both the prevention and reversal of structural changes in the aorta associated with Marfan syndrome, via pharmacological means. This study, carried out in a rat model, concluded that such results were due to an inhibitor effect by the drug losartan on TGB-ß1 (Figure 1). Habashi's paper prompted some physicians, in the absence of human trials, to begin the clinical off-label use of losartan on Marfan patients, arguing that this was justified due to the drug's excellent safety profile. This has caused some controversy. Two significant randomized human trials of losartan in Marfan patients have since been conducted, which contribute different but valuable elements to the debate; the COMPARE trial demonstrated a significantly lower increase in aortic root diameter among study subjects receiving losartan compared with a placebo group after 3 years, although no significant differences were observed in aortic diameter beyond the root itself. A more recently concluded trial by Lacro et al(2) from the Paediatric Heart Network, comparing losartan with atenolol (and no placebo group), appeared to show no comparative benefit with respect to the rate of aortic dilatation over three years among the losartan users compared with study patients given atenolol, with both groups of patients experiencing a similar decrease in the rate of dilatation over the 3 year follow-up. Both studies suggest a positive impact of losartan on aortic dilation in humans with Marfan, but they also highlight a number of important questions that remain unanswered. Further trials are clearly needed in order to assess optimal dosing and to guide timing of therapy, and also to further assess the potential and comparative effectiveness of both losartan and ß-blockers, individually and in combination, as therapeutic treatments for aortic protection of different groups of patients with Marfan syndrome.

Radiation in medicine: Origins, risks and aspirations.

The use of radiation in medicine is now pervasive and routine. From their crude beginnings 100 years ago, diagnostic radiology, nuclear medicine and radiation therapy have all evolved into advanced techniques, and are regarded as essential tools across all branches and specialties of medicine. The inherent properties of ionizing radiation provide many benefits, but can also cause potential harm. Its use within medical practice thus involves an informed judgment regarding the risk/benefit ratio. This judgment requires not only medical knowledge, but also an understanding of radiation itself. This work provides a global perspective on radiation risks, exposure and mitigation strategies.

Alcohol use and discounting of delayed and probabilistic gain and loss.

OBJECTIVE: Little is known about the relationship between alcohol and discounting of loss, one of procrastinative behaviors. This study examined the relationship between the frequency of alcohol use and discounting delayed and probabilistic gain and loss, which is of interest in neuroeconomics of addiction. METHODS: Thirty-three subjects conducted tasks of delay and probability discounting of gain and loss. Their alcohol use was also assessed. RESULTS: The frequency of alcohol use was significantly correlated with the degree to which delayed monetary losses were discounted. CONCLUSIONS: Frequent use of alcohol may associate with an increased degree of procrastination. Further, the degrees of delay discounting of loss could be a predictor of a frequent alcohol intake.

Cultural differences in cognition: Rosetta Phase I.

Cultural differences in cognition are important during multinational commercial, military, and humanitarian operations. The Rosetta Project addresses definition and measurement of key cognitive dimensions. Six potential diagnostic measures related to Analytic-Holistic reasoning were assessed: the Exclusion Task, the Attribution Complexity Scale, the Syllogism Task, Categorization, the Framed Line Test, and the Facial Expression Task. 379 participants' ages ranged from 17 to 24 years (M = 19.8, SD = 1.4). 64.6% were women; Eastern Asian groups (Japan, Korea, and Taiwan) were assumed to have Holistic reasoning tendencies, and those from a Western group (USA) were assumed to have Analytic tendencies. Participants were recruited from subject pools in psychology using the procedures of each university. Results on the Exclusion and Categorization Tasks confirmed hypothesized differences in Analytic-Holistic reasoning. The Attribution Complex-ity Scale and the Facial Expression Task identified important differences among the four groups. Outcomes on the final two tasks were confounded by unrelated group differences, making comparisons difficult. Building on this exploratory study, Rosetta Phase II will include additional groups and cognitive tasks. Measures of complex cognition are also incorporated to link findings to the naturalistic contexts.

How to keep score of acuity and dependency.

This article describes how the introduction of an acuity and dependency tool at University Hospitals Coventry and Warwickshire NHS Trust has provided nurses with a structure for gathering evidence about patient care levels, and discusses how this information is shared throughout the trust to improve patient outcomes and safety.

[Effect of contextual factors on patterns of eye-movement: comparing sensitivity to background information between Japanese and Westerners].

Recent cross-cultural research suggests that East Asians are more likely than their Western counterparts to be sensitive to contextual information. In this experimental research study, we presented a blinking circle situated at the center of the computer screen for 30s. Both Japanese and Western participants were alternately engaged in two different tasks: (a) A single target circle, and (b) a target circle with four surrounding circles. In either case, they were asked to focus only on the target circle while ignoring the surrounding information. The results indicated that, even though the Japanese attempted to focus on the center circle, they failed to focus only on the center circle. Their number of fixations and variances from the center to each fixation points were significantly larger than found with the Westerners. This effect was stronger when four circles surrounded the target circle compared to a single circle. These findings suggest that cultural influences on basic psychological processes may be very deep.