A retrospective study of conjunctival lesions in the Paediatric Eye Clinic over 12 years.

BACKGROUND: Paediatric conjunctival lesions are rare and diverse. Though often indolent and asymptomatic, they can in some cases be sight or life-threatening. Awareness of concerning features of conjunctival lesions is key to optimal management. We aim to provide insight into management of paediatric conjunctival lesions though a review of cases in our service in last 12 years. METHODS: We present a retrospective analysis of our population-based cohort of children with conjunctival lesions presenting to our regional service in Belfast between 2011 and 2022 inclusive. We detail three rare cases of paediatric conjunctival lesions; a congenital intrascleral cyst leading to astigmatic amblyopia, a rapidly changing salmon-pink lesion confirmed as an embryonal rhabdomyosarcoma and an unusual presentation of a chronic granuloma arising from the caruncle. RESULTS: 85 conjunctival lesions were identified in <16 year olds giving a cumulative incidence of 27 cases per 100,000 population over 12 years. Mean age at presentation was 7 years old. Most common lesions were naevi (40%), limbal dermoids (21%), conjunctival melanosis (14%), conjunctival cysts (7%) and phlycten (6%). When seen at presentation 8% of cases were immediately listed for surgery, 28% were discharged and 64% entered a phase of observation. CONCLUSION: Paediatric conjunctival lesions have potential to cause visual manifestations, whilst some may undergo malignant transformation. Anterior segment photography is crucial in monitoring change and facilitating early discharge in the absence of sinister features. Malignant transformation must be considered in changing lesions which ought to have histological diagnosis obtained to prevent potentially sight and life-threatening conditions.

Real-world evaluation of smartphone-based artificial intelligence to screen for diabetic retinopathy in Dominica: a clinical validation study.

OBJECTIVE: Several artificial intelligence (AI) systems for diabetic retinopathy screening have been validated but there is limited evidence on their performance in real-world settings. This study aimed to assess the performance of an AI software deployed within the diabetic retinopathy screening programme in Dominica. METHODS AND ANALYSIS: We conducted a prospective, cross-sectional clinical validation study. Patients with diabetes aged 18 years and above attending the diabetic retinopathy screening in primary care facilities in Dominica from 5 June to 3 July 2021 were enrolled.Grading was done at the point of care by the field grader, followed by counselling and referral to the eye clinic. Images were then graded by an AI system. Sensitivity, specificity with 95% CIs and area under the curve (AUC) were calculated for comparing the AI to field grader as gold standard. RESULTS: A total of 587 participants were screened. The AI had a sensitivity and specificity for detecting referable diabetic retinopathy of 77.5% and 91.5% compared with the grader, for all participants, including ungradable images. The AUC was 0.8455. Excluding 52 participants deemed ungradable by the grader, the AI had a sensitivity and specificity of 81.4% and 91.5%, with an AUC of 0.9648. CONCLUSION: This study provides evidence that AI has the potential to be deployed to assist a diabetic screening programme in a middle-income real-world setting and perform with reasonable accuracy compared with a specialist grader.

The oldest presenting neurenteric cyst of the spinal cord.

We describe an 81-year-old gentleman presenting with mild myelopathic symptoms in the upper limbs. Imaging showed a C1-3 intradural extramedullary lesion initially thought to be an arachnoid cyst. A C1 + 2 hemilaminectomy and partial excision was performed with histology revealing a neurenteric cyst (NC). NCs are congenital tumours that usually present within the third decade of life, they account for 1% of all spinal tumours. A literature search was conducted and we found that the age of presentation might actually be earlier than previously described. We also found that there has never before been a case described in the eighth decade of life, making this the oldest known symptomatic presentation of this rare condition.

A Case of Fulminant Listeria Rhombencephalitis with Brainstem Abscesses in a 37-Year-Old Immunocompetent Patient: From Vestibular Neuritis to Ondine's Curse.

We present a rare case of Listeria monocytogenes (LM) rhombencephalitis with the formation of multifocal abscesses in a young immunocompetent patient. His initial symptoms of dizziness, headache, and feeling generally unwell were put down to a coincidental coinfection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The unfortunate rapid progression to trigeminal, hypoglossal, vagal, facial, and abducens nuclei palsies, and then an acquired central hypoventilation syndrome, known as Ondine's curse, required a prolonged intensive care unit (ICU) stay, and prolonged mechanical ventilation. As they continued to deteriorate despite targeted antibiotic treatment, surgical drainage of the abscesses was seen as the only meaningful available treatment option left to contain the disease. Postoperatively, the patient's strength rapidly improved as well as the severity of the cranial nerve palsies. After prolonged rehabilitation, at 3 months of follow-up, the patient was weaned off mechanical ventilation, independently mobile, and was left with only minor residual neurologic deficits. This case highlights a number of interesting findings only touched upon in current literature including the route of entry of LM into the central nervous system, the rare entity of acquired central hypoventilation syndrome, and finally the use of surgical intervention in cerebral LM infections.

Assessing the quality of consent in elective hip and knee arthroplasty: Do modern orthopaedic surgeons make the cut?

INTRODUCTION: Improper consent is a failure of clinical care and also a major cause of litigation within health care authorities. 4% of surgical negligence claims are attributed to improper consenting in the NHS, with an average settlement fee of approximately £40,000 per claim. Improving quality of consenting therefore not only improves patient care but could also reduce healthcare cost. METHOD: A retrospective analysis of 100 elective hip and knee arthroplasties at a district general hospital in the South of England. Clinic letters and consent forms were reviewed, using the British Orthopaedic Association (BOA) consent proforma as a comparison standard. Quality of consent was reviewed based upon inclusion of BOA suggested risks. RESULTS: 40% of hip arthroplasty clinic letters and 20% of knee arthroplasty clinic letters did not include a risk discussion. Common risks on consent forms when compared to BOA standards were 84.8% compliant in knees and 88.8% in hips. Less common risks on consent forms were 100% compliant in knees and 96% in hips. Rare risks on consent forms were 74.8% compliant in knees and 57.7% in hips. Notably blood clots and infection were consented for in almost all patients. Risk of death meanwhile, was only consented for 62% of the time, across both procedures. CONCLUSION: Standard of consenting in this audit falls short of BOA standards. Improvement is needed to improve patient care and avoid medical litigation. An integrated electronic form linking consent process of both outpatient and pre-operative review could be a beneficial intervention.

Comparison of chest X-ray interpretation by Emergency Department clinicians and radiologists in suspected COVID-19 infection: a retrospective cohort study.

OBJECTIVES: We describe the inter-rater agreement between Emergency Department (ED) clinicians and reporting radiologists in the interpretation of chest X-rays (CXRs) in patients presenting to ED with suspected COVID-19. METHODS: We undertook a retrospective cohort study of patients with suspected COVID-19. We compared ED clinicians' and radiologists' interpretation of the CXRs according to British Society of Thoracic Imaging (BSTI) guidelines, using the area under the receiver operator curve (ROC area). RESULTS: CXRs of 152 cases with suspected COVID-19 infection were included. Sensitivity and specificity for 'classic' COVID-19 CXR findings reported by ED clinician was 84 and 83%, respectively, with a ROC area of 0.84 (95%CI 0.77 to 0.90). Accuracy improved with ED clinicians' experience, with ROC areas of 0.73 (95%CI 0.45 to 1.00), 0.81 (95%CI 0.73 to 0.89), 1.00 (95%CI 1.00 to 1.00) and 0.90 (95%CI 0.70 to 1.00) for foundation year doctors, senior house officers, higher speciality trainees and ED consultants, respectively (p < 0.001). CONCLUSIONS: ED clinicians demonstrated moderate inter-rater agreement with reporting radiologists according to the BSTI COVID-19 classifications. The improvement in accuracy with ED clinician experience suggests training of junior ED clinicians in the interpretation of COVID-19 related CXRs might be beneficial. Large-scale survey studies might be useful in the further evaluation of this topic. ADVANCES IN KNOWLEDGE: This is the first study to examine inter-rater agreement between ED clinicians and radiologists in regards to COVID-19 CXR interpretation.Further service configurations such as 24-hr hot reporting of CXRs can be guided by these data, as well as an ongoing, nationwide follow-up study.

Spontaneous pneumomediastinum secondary to hyperemesis gravidarum: A case report and principles of recognition and management.

Pneumomediastinum is the presence of aberrant air in the mediastinum and is most commonly caused by oesophageal or alveolar rupture. Hyperemesis gravidarum is persistent nausea and vomiting before the 20th week of pregnancy and can increase intra-thoracic pressure, precipitating pneumomediastinum. A 22-year-old patient presented with hyperemesis gravidarum in the 6th week of pregnancy. During her hospital admission, she developed chest pain, and imaging showed pneumomediastinum. Endoscopy excluded oesophageal perforation, a diagnosis of spontaneous pneumomediastinum was made, and her symptoms improved with conservative management. This case demonstrates how oesophageal perforation and spontaneous mediastinum can present in similar fashion. Oesophageal perforation has high morbidity and mortality and it is vital to identify it early. It is therefore important that clinicians are aware of pneumomediastinum as a potential complication of hyperemesis gravidarum and exclude oesophageal perforation in these individuals.

Increasing genetic variability in oilseed rape (Brassica napus) - Genotypes and phenotypes of oilseed rape transformed by wild type Agrobacterium rhizogenes.

Brassica napus (oilseed rape) is a major oil crop worldwide. Due to the short domestication period of oilseed rape the genetic variability is limited compared to other crops. Transfer of rol and aux genes from Agrobacterium rhizogenes is used in horticulture to increase genetic variability. In the current study, we explore transformation by A. rhizogenes as a biotechnological approach in breeding for more branched and shorter oilseed rape. In the 2nd generation of transformed oilseed rape, branch numbers increased significantly by 49% from 7.7 ±â€¯0.4 to 11.5 ±â€¯1.9 when comparing rol+/aux+ plants with WT. Simultaneously, the apical height of plants was reduced by 25% from 81.3 ±â€¯1.9 cm to 62.4 ±â€¯6.7 cm in rol+/aux+ plants at the onset of flowering. Reproductive parameters affecting yield as seed size and number were negatively affected in rol+/aux+ plants. Interestingly, oil composition was changed in rol+/aux+ seeds. Oleic acid (ω9) contents were reduced by more than 3% whereas α-linolenic acid (ω6) increased by more than 25% in mature seeds. To obtain shorter and more branched breeding material of oilseed rape we suggest crossing plants with the rol+/aux+ genotype back into the parental breeding line. This could reduce the negative impact of rol+/aux+ on yield.

The impact of education on the knowledge and documentation of Driving and Vehicle Licensing Agency (DVLA) driving restrictions by doctors.

Many hospitals are still setting up acute stroke thrombolysis services, often delayed by fears over workload. However, there are few data on how many patients require urgent assessment before one is treated. We prospectively studied all referrals to the 24-hour stroke thrombolysis service, February 2009 - January 2010, in Southampton General Hospital. 128 patients were referred to the thrombolysis team and 20 received thrombolysis. The most common reasons for treatment exclusion were: stroke severity (37%), time from onset (26%) or CT findings (15%). Approximately six patients required urgent assessment by the thrombolysis team for every one treated. These data are crucial to inform service planning.

Near infra-red spectroscopy and arterial oxygen extraction at altitude.

The ratio of oxygenated to total haemoglobin (Hb), or rSO2, obtained by near infrared spectroscopy (NIRS), includes both arterial and venous blood of the region examined. The relationship of arterial oxygen extraction, E, and saturation, SaO2, to rSO2 can be expressed, for normally functioning tissue, as E = 1.39 (1 - rSO2/SaO2). Cerebral E, at rest, is constant at lower altitudes but is reduced at 5000 m. This corresponds to constant values of E for SaO2 values above 90% (approximately). E declines linearly for lower SaO2 values, either including measurement at high altitude or at sea level with a reduced inspiratory oxygen concentration. In addition to measurements of brain NIRS resting oxygen extraction of liver, muscle and kidney have also been calculated from NIRS measurements made, on normal inspired air, at sea level and after acute ascent to 2400 m and 5050 m. At 5050 m E was reduced for all four regions but at 2400 m was the same as at sea level for brain, liver and muscle; for the kidney E was elevated at 2400 m. Cerebral oxygen extraction was calculated for rest and the full range of exercise. It was constant at sea level for the lower levels of exercise and, if the calculated extraction value assumptions still hold at lower SaO2 values, reduced for the higher work rates at intermediate altitudes. The present study confirms constancy of oxygen extraction and hence the ratio of oxygen delivery to oxygen consumption (1/E), within physiological limits, and appears to show where those limits lay and, to some extent, show how matters change beyond ordinary physiological limits.