'Dear Doctor': a randomised controlled trial of a text message intervention to reduce burnout in trainee anaesthetists.

One in four doctors in training in the UK reports feeling 'burnt out' due to their work and similar figures are reported in other countries. This two-group non-blinded randomised controlled trial aimed to determine if a novel text message intervention could reduce burnout and increase well-being in UK trainee anaesthetists. A total of 279 trainee anaesthetists (Core Training Year 2, Specialty Training Years 3 or 4) were included. All participants received one initial message sharing support resources. The intervention group (139 trainees) received 22 fortnightly text messages over approximately 10 months. Messages drew on 11 evidence-based themes including: gratitude; social support; self-efficacy; and self-compassion. Primary outcomes were burnout (Copenhagen Burnout Inventory) and well-being (Short Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were as follows: meaning in work; professional value; sickness absence; and consideration of career break. Outcomes were measured via online surveys. Measures of factors that may have affected well-being were included post-hoc, including the impact of COVID-19 (the first UK wave of which coincided with the second half of the trial). The final survey was completed by 153 trainees (74 in the intervention and 79 in the control groups). There were no significant group differences in: burnout (ß = -1.82, 95%CI -6.54-2.91, p = 0.45); well-being (-0.52, -1.73-0.69, p = 0.40); meaning (-0.09, -0.67-0.50, p = 0.77); value (-0.01, -0.67-0.66, p = 0.99); sick days (0.88, -2.08-3.83, p = 0.56); or consideration of career break (OR = 0.44, -0.30-1.18, p = 0.24). Exploratory post-hoc analysis found the intervention was associated with reduced burnout in participants reporting personal or work-related difficulties during the trial period (-9.56, -17.35 to -1.77, p = 0.02) and in participants reporting that the COVID-19 pandemic had a big negative impact on their well-being (-10.38, -20.57 to -0.19, p = 0.05). Overall, this trial found the intervention had no impact. However, given this intervention is low cost and requires minimal time commitment from recipients, it may warrant adaptation and further evaluation.

Equatorial wrinkles in the human lens capsule.

Equatorial wrinkles, or crenations, have been previously observed around the equator in coronal images of the human ocular lens. However, wrinkles are typically not apparent when the lens is viewed from saggital directions. In the current paper, the existence and geometry of these wrinkles is shown to be consistent with a mechanical model of the isolated lens, in which the capsule is held in a state of residual tension by a spatially uniform internal pressure. The occurrence of equatorial wrinkles is therefore seen to be a mechanical consequence of the spheroidal shape of the lens capsule and an excess intralenticular pressure. New observations are made, on post mortem lenses, on the geometric arrangement of these equatorial wrinkles. These observations indicate a well-defined pattern in which wrinkles exists along meridional lines in the equatorial regions of the lens. A preliminary 'puncture test' is used to demonstrate that the residual stresses within the capsule in the equatorial region of the lens are broadly consistent with the proposed mechanical model of the lens capsule. It is suggested that the presence of equatorial wrinkles may have an influence on the mechanical performance of the capsule during the accommodation process.

Finite element modelling of radial lentotomy cuts to improve the accommodation performance of the human lens.

PURPOSE: The use of a femtosecond laser to form planes of cavitation bubbles within the ocular lens has been proposed as a potential treatment for presbyopia. The intended purpose of these planes of cavitation bubbles (referred to in this paper as 'cutting planes') is to increase the compliance of the lens, with a consequential increase in the amplitude of accommodation. The current paper describes a computational modelling study, based on three-dimensional finite element analysis, to investigate the relationship between the geometric arrangement of the cutting planes and the resulting improvement in lens accommodation performance. The study is limited to radial cutting planes. METHODS: The effectiveness of a variety of cutting plane geometries was investigated by means of modelling studies conducted on a 45-year human lens. RESULTS: The results obtained from the analyses depend on the particular modelling procedures that are employed. When the lens substance is modelled as an incompressible material, radial cutting planes are found to be ineffective. However, when a poroelastic model is employed for the lens substance, radial cuts are shown to cause an increase in the computed accommodation performance of the lens. In this case, radial cuts made in the peripheral regions of the lens have a relatively small influence on the accommodation performance of the lens; the lentotomy process is seen to be more effective when cuts are made near to the polar axis. CONCLUSIONS: When the lens substance is modelled as a poroelastic material, the computational results suggest that useful improvements in lens accommodation performance can be achieved, provided that the radial cuts are extended to the polar axis. Radial cuts are ineffective when the lens substance is modelled as an incompressible material. Significant challenges remain in developing a safe and effective surgical procedure based on this lentotomy technique.

Finite element implementation of a multiscale model of the human lens capsule.

An axisymmetric finite element implementation of a previously described structural constitutive model for the human lens capsule (Burd in Biomech Model Mechanobiol 8(3):217-231, 2009) is presented. This constitutive model is based on a hyperelastic approach in which the network of collagen IV within the capsule is represented by an irregular hexagonal planar network of hyperelastic bars, embedded in a hyperelastic matrix. The paper gives a detailed specification of the model and the periodic boundary conditions adopted for the network component. Momentum balance equations for the network are derived in variational form. These balance equations are used to develop a nonlinear solution scheme to enable the equilibrium configuration of the network to be computed. The constitutive model is implemented within a macroscopic finite element framework to give a multiscale model of the lens capsule. The possibility of capsule wrinkling is included in the formulation. To achieve this implementation, values of the first and second derivatives of the strain energy density with respect to the in-plane stretch ratios need to be computed at the local, constitutive model, level. Procedures to determine these strain energy derivatives at equilibrium configurations of the network are described. The multiscale model is calibrated against previously published experimental data on isolated inflation and uniaxial stretching of ex vivo human capsule samples. Two independent example lens capsule inflation analyses are presented.

Thermophilic enrichment of microbial communities in the presence of the ionic liquid 1-ethyl-3-methylimidazolium acetate.

AIMS: The aim of the study was to develop an approach to enrich ionic liquid tolerant micro-organisms that efficiently decompose lignocellulose in a thermophilic and high-solids environment. METHODS AND RESULTS: High-solids incubations were conducted, using compost as an inoculum source, to enrich for thermophilic communities that decompose switchgrass in the presence of the ionic liquid 1-ethyl-3-methylimidazolium acetate ([C2mim][OAc]). Ionic liquid levels were increased from 0 to 6% on a total weight basis incrementally. Successful enrichment of a community that decomposed lignocellulose at 55°C in the presence of 6% [C2mim][OAc] was achieved, when the [C2mim][OAc] level was increased stepwise from 2% to 4% to 5% to 6%. Pyrosequencing results revealed a shift in the community and a sharp decrease in richness, when thermophilic conditions were applied. CONCLUSIONS: A community tolerant to a thermophilic, high-solids environment containing 6% [C2mim][OAc] was enriched from compost. Gradually increasing [C2mim][OAc] concentrations allowed the community to adapt to [C2mim][OAc]. SIGNIFICANCE AND IMPACT OF THE STUDY: A successful approach to enrich communities that decompose lignocellulose under thermophilic high-solids conditions in the presence of elevated levels of [C2mim][OAc] has been developed. Communities yielded from this approach will provide resources for the discovery of enzymes and metabolic pathways relevant to biomass pretreatment and fuel production.

Shear modulus measurements on isolated human lens nuclei.

The use of a spinning lens test to determine ex vivo the shear modulus of 22 isolated human lens nuclei with ages ranging from 34 to 63 years is described. In this test procedure, the lens nucleus is spun about its polar axis. Images of the nucleus viewed from directions perpendicular to the polar axis are collected; these are used to quantify the deformations induced in the nucleus by the rotational motion. Data on these deformations are used to infer, by applying finite element inverse analysis, values for the shear modulus of the nucleus. The data on shear modulus obtained from this test program indicate that the nucleus stiffens very rapidly with age. These data are shown to compare well with the results of a related study (Wilde et al., 2012) in which the shear modulus of the nucleus is determined by similar spinning lens tests conducted on the entire lens substance.

Shear modulus data for the human lens determined from a spinning lens test.

The paper describes a program of mechanical testing on donated human eye bank lenses. The principal purpose of the tests was to obtain experimental data on the shear modulus of the lens for use in future computational models of the accommodation process. Testing was conducted using a procedure in which deformations are induced in the lens by spinning it about its polar axis. Shear modulus data were inferred from these observed deformations by means of a finite element inverse analysis procedure in which the spatial variation of the shear modulus within the lens is represented by an appropriate function (see Burd et al., 2011 for a detailed specification of the design of the spinning lens test rig, experimental protocols and associated data analysis procedures that were employed in the tests). Inferred data on lens shear modulus are presented for a set of twenty-nine lenses in the age range 12 years to 58 years. The lenses were tested between 47 h and 110 h from the time of death (average post-mortem time 74 h). Care was taken to exclude any lenses that had been affected by excessive post-mortem swelling, or any lenses that had suffered mechanical damage during storage, transit or the testing process. The experimental data on shear modulus indicate that, for young lenses, the cortex is stiffer than the nucleus. The shear modulus of the nucleus and cortex both increase with increasing age. The shear modulus of the nucleus increases more rapidly than the cortex with the consequence that from an age of about 45 years onwards the nucleus is stiffer than the cortex. The principal shear modulus data presented in the paper were obtained by testing at a rotational speed of 1,000 rpm. Supplementary tests were conducted at rotational speeds of 700 rpm and 1,400 rpm. The results from these supplementary tests are in good agreement with the data obtained from the principal 1,000 rpm tests. Studies on the possible effects of lens drying during the test suggested that this factor is unlikely to have led to significant errors in the experimental determination of the shear modulus. The shear modulus data presented in the paper are used to develop 'age-stiffness' models to represent the shear modulus of the lens as a function of age. These models are in a form that may be readily incorporated in a finite element model of the accommodation process. A comparison is attempted between the shear modulus data presented in the current paper and equivalent data published by previous authors. This comparison highlights various limitations and inconsistencies in the data sets.

An improved spinning lens test to determine the stiffness of the human lens.

It is widely accepted that age-related changes in lens stiffness are significant for the development of presbyopia. However, precise details on the relative importance of age-related changes in the stiffness of the lens, in comparison with other potential mechanisms for the development of presbyopia, have not yet been established. One contributing factor to this uncertainty is the paucity and variability of experimental data on lens stiffness. The available published data generally indicate that stiffness varies spatially within the lens and that stiffness parameters tend to increase with age. However, considerable differences exist between these published data sets, both qualitatively and quantitatively. The current paper describes new and improved methods, based on the spinning lens approach pioneered by Fisher, R.F. (1971) 'The elastic constants of the human lens', Journal of Physiology, 212, 147-180, to make measurements on the stiffness of the human lens. These new procedures have been developed in an attempt to eliminate, or at least substantially reduce, various systematic errors in Fisher's original experiment. An improved test rig has been constructed and a new modelling procedure for determining lens stiffness parameters from observations made during the test has been devised. The experiment involves mounting a human lens on a vertical rotor so that the lens spins on its optical axis (typically at 1000 rpm). An automatic imaging system is used to capture the outline of the lens, while it is rotating, at pre-determined angular orientations. These images are used to quantify the deformations developed in the lens as a consequence of the centripetal forces induced by the rotation. Lens stiffness is inferred using axisymmetric finite element inverse analysis in which a nearly-incompressible neo-Hookean constitutive model is used to represent the mechanics of the lens. A numerical optimisation procedure is used to determine the stiffness parameters that provide a best fit between the finite element model and the experimental data. Sample results are presented for a human lens of age 33 years.

Can reliable values of Young's modulus be deduced from Fisher's (1971) spinning lens measurements?

The current textbook view of the causes of presbyopia rests very largely on a series of experiments reported by R.F. Fisher some three decades ago, and in particular on the values of lens Young's modulus inferred from the deformation caused by spinning excised lenses about their optical axis (Fisher 1971) We studied the extent to which inferred values of Young's modulus are influenced by assumptions inherent in the mathematical procedures used by Fisher to interpret the test and we investigated several alternative interpretation methods. The results suggest that modelling assumptions inherent in Fisher's original method may have led to systematic errors in the determination of the Young's modulus of the cortex and nucleus. Fisher's conclusion that the cortex is stiffer than the nucleus, particularly in middle age, may be an artefact associated with these systematic errors. Moreover, none of the models we explored are able to account for Fisher's claim that the removal of the capsule has only a modest effect on the deformations induced in the spinning lens.

Modelling the mechanics of accommodation and presbyopia.

Finite element methods have been used to compute the expected relationship between changes in ciliary body diameter and the change in refractive power implied by the change in geometry of the human ocular lens, using values for the material properties and initial geometry taken from the literature (notably the slit lamp photography of Brown (1973) and the studies by Fisher (1969) of the lens material properties). The results show that if the non-linearity associated with the changing geometry is taken into account the lens does not respond to ciliary body stretch by an increase in power [as recently claimed by Schachar et al. (1993), but in the conventional way with a decrease in power. The models show a decrease in the amplitude of accommodation between the age of 29 and 45 years (using Brown's data, 1973), but using Brown's data for the 11-year-old eye leads to the paradoxical conclusion that accommodation amplitude in this eye would have been small. In the process of carrying out the modelling, we have examined the consistency of the published measurements and also the validity of the mathematical methods used in interpreting them, and this analysis suggests that further work is needed before one can be confident that the assumptions about geometry and material properties on which the modelling is based are sound.

Numerical modelling of the accommodating lens.

Data on geometric and material properties of the human lens derived from various published sources are used to construct axisymmetric, large displacement, finite element models of the accommodating lens of subjects aged 11, 29 and 45 years. The nucleus, cortex, capsule and zonule are modelled as linearly elastic materials. The numerical model of the 45-year lens is found to be significantly less effective in accommodating than the 29-year lens, suggesting that the modelling procedure is capable of capturing at least some of the features of presbyopia. The model of the 11-year lens shows some anomalous behaviour, and reasons for this are explored.

Mechanics of accommodation of the human eye.

The classical Helmholtz theory of accommodation has, over the years, not gone unchallenged and most recently has been opposed by Schachar at al. (1993) (Annals of Ophthalmology, 25 (1) 5-9) who suggest that increasing the zonular tension increases rather than decreases the power of the lens. This view is supported by a numerical analysis of the lens based on a linearised form of the governing equations. We propose in this paper an alternative numerical model in which the geometric non-linear behaviour of the lens is explicitly included. Our results differ from those of Schachar et al. (1993) and are consistent with the classical Helmholtz mechanism.