Developing a national 'low risk' febrile neutropenia framework for use in children and young people's cancer care.

PURPOSE: A Delphi study was undertaken to develop a framework guidance that would rationalise and standardise the care of children with febrile neutropenia (FNP) across the UK. METHODS: A mailed Delphi survey was undertaken with health professionals working in children's cancer units. The survey employed two rounds of feedback on 22 practice statements drawn from a systematic review of clinical evidence. Consensus was assumed for any statement where 80+ % of respondents indicated that they "agreed" or "strongly agreed". RESULTS: Consensus was reached on 21 of the 22 practice statements in round 1 that were categorised into six areas: definition of fever and neutropenia, initial management and choice of antibiotic, defining low-risk patients, strategy in low-risk patients and alternative approaches. Consensus could not be reached on whether patients needed to be afebrile to be suitable for discharge and the required length of outpatient antibiotic treatment. CONCLUSIONS: A Delphi survey allowed the successful development of a national framework for identification and management of children with FNP. The use of an existing well-functioning professional network was key in this project's success.

Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort.

OBJECTIVES: To reassess the definition of a large macular hole, factors predicting hole closure and post-surgery visual recovery. DESIGN: Database study of 1483 primary macular hole operations. Eligible operations were primary MH operations treated with a vitrectomy and a gas or air tamponade. Excluded were eyes with a history of retinal detachment, high myopia, previous vitrectomy or trauma. RESULTS: A higher proportion of operations were performed in eyes from females (71.1%) who were 'on average' younger (p < 0.001), with slightly larger holes (p < 0.001) than male patients. Sulfur hexafluoride gas was generally used for smaller holes (p < 0.001). From 1253 operations with a known surgical outcome, successful hole closure was achieved in 1199 (96%) and influenced by smaller holes and complete ILM peeling (p < 0.001), but not post-surgery positioning (p = 0.072). A minimum linear diameter of ~500 µm marked the threshold where the success rate started to decline. From the 1056 successfully closed operations eligible for visual outcome analysis, visual success (defined as visual acuity of 0.30 or better logMAR) was achieved in 488 (46.2%) eyes. At the multivariate level, the factors predicting visual success were better pre-operative VA, smaller hole size, shorter duration of symptoms and the absence of AMD. CONCLUSIONS: Females undergoing primary macular hole surgery tend to be younger and have larger holes than male patients. The definition of a large hole should be changed to around 500 µm, and patients should be operated on early to help achieve a good post-operative VA.

Dirty hands: bacteria of faecal origin on commuters' hands.

Although many studies have investigated bacteria on the hands of health-care workers and caregivers, few have looked at microbiological contamination on the hands of the general adult public. This study investigated faecal bacteria on the hands of commuters in five UK cities. Of the 404 people sampled 28% were found to have bacteria of faecal origin on their hands. A breakdown by city showed that the proportion of people with contaminated hands increased the further north the city of investigation (P<0.001), an effect which was due in large part to a significant trend in men but not in women. Bus users were more contaminated than train users. The results of this exploratory study indicate that hand hygiene practices in the UK may be inadequate and that faecal indicator bacteria on hands may be used to monitor the effect of hand-washing promotion campaigns.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery. Report 5: Clinical outcome and risk factors for posterior capsule rupture and visual acuity loss following cataract surgery in patients aged 90 years and older.

BACKGROUND: Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes. PURPOSE: To report cataract surgery outcomes and risk indicators for patients aged 90 years and older. METHODS: Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome. RESULTS: 25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA. CONCLUSIONS: Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery: report 2, relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture.

PURPOSE: To describe the relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture rates in patients undergoing cataract surgery.DesignThe Royal College of Ophthalmologists' National Ophthalmology Database (NOD) study. METHODS: Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Data parameters included: demographics, biometry, ocular copathology, visual acuity measurements, and surgical complications including posterior capsule rupture, or vitreous loss or both (PCR). RESULTS: Consultant surgeons performed a higher proportion of operations on eyes whose axial length were at the extremes. Glaucoma and age related macular degeneration were more common in eyes with shorter axial lengths, whilst previous vitrectomy was associated with longer axial lengths. Eyes with brunescent or white cataracts or amblyopia were more common at both axial length extremes. Preoperative visual acuities were similar for eyes with axial length measurements up to approximately 28 mm and worse for eyes with longer axial length measurements. PCR rates showed little change with axial length (overall mean 1.95%, 95% CI: 1.89 to 2.01%), except for a borderline increase in eyes with axial length <20.0 mm where rates were 3.6% (95% CI: 2.0 to 6.3%). The likelihood of PCR in eyes with axial length <20.0 mm was 1.88 times higher than those of ≥20.0 mm (P=0.0373). CONCLUSION: Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications.

AIMS: To describe the outcomes of cataract surgery in the United Kingdom. METHODS: Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Outcome measures included intraoperative and postoperative complication rates, and preoperative and postoperative visual acuities. RESULTS: Median age at first eye surgery was 77.1 years, 36.9% cases had ocular co-pathology and 41.0% patients underwent cataract surgery on both eyes. Preoperative visual acuity was 0.30 logMAR or better in 32.0% first eyes and 47.7% second eyes. Postoperative best-measured visual acuity was 0.00 and 0.30 logMAR or better in 50.8 and 94.6% eyes without ocular co-pathology, and 32.5 and 79.9% in eyes with co-pathology. For eyes without co-pathology, postoperative uncorrected distance visual acuity was 0.00 and 0.30 logMAR or better in 27.3 and 80.9% eyes. Posterior capsule rupture or vitreous loss or both occurred in 1.95% cases, and was associated with a 42 times higher risk of retinal detachment surgery within 3 months and an eight times higher risk of endophthalmitis. CONCLUSION: These results provide updated data for the benchmarking of cataract surgery. Visual outcomes, and the rate of posterior capsule rupture or vitreous loss or both appear stable over the past decade.

The relationship between tick (Amblyomma hebraeum) infestation and immunity to heartwater (Cowdria ruminantium infection) in calves in Zimbabwe.

The occurrence of endemic stability for heartwater (Cowdria ruminantium infection) is a controversial issue, because the means by which young cattle and other neonatal ruminants become infected and acquire immunity to the disease have never been adequately explained. We conducted a study in a heartwater-endemic area in southeastern Zimbabwe to investigate the relationships between calf immunity to C. ruminatium, infestations of the tick vector Amblyomma hebraeum and dam, colostral and calf antibody titres to C. ruminantium. Two groups of cows (tick-infested and acaricide-treated) were artificially inseminated and then monitored through pregnancy and lactation by means of tick counts and serum antibody titres. The calves born to the cows in each treatment group were similarly monitored from birth until after weaning, when they were challenged with a heartwater stabilate (Ball-3 vaccine). Colostrum was collected from the cows on the days that the calves were born. Serum and colostrum samples were screened for Cowdria-specific antibodies using an indirect fluorescent antibody test. The cows and calves in the acaricide-treated group remained essentially tick-free for the duration of the study. The cows in the tick-infested group were continuously infested with A. hebraeum, but their calves only became infested between 12 and 31 weeks after birth. Cowdria-specific antibodies were detected in the sera of the cows and calves and in the colostrum of both treatment groups, but the titres were consistently higher in the tick-infested group than in the acaricide-treated group. Antibodies, probably of maternal origin since the precolostral serum titres were negative, were present in the calves of both groups for at least 8 weeks after birth. Between Weeks 24 and 52 postpartum, the antibody titres of the tick-infested group of calves were significantly correlated with the numbers of A. hebraeum present on the animals. The antibody titres of the calves in the acaricide-treated group increased considerably following challenge with heartwater stabilate, 60 weeks after birth. No clinical heartwater was detected in either group of calves following inoculation of stabilate, and it was concluded that the calves in both groups were immune to the disease. In the acaricide-treated group, immunity did not correlate with exposure to tick-transmitted infections. Hence, we concluded that the calves in both groups had probably been infected by vertical transmission around the time of birth. Such early infections are likely to have been controlled by maternal antibodies or by an unidentified immune mechanism.(ABSTRACT TRUNCATED AT 400 WORDS)

Demonstration of vertical transmission of Cowdria ruminantium, the causative agent of heartwater, from cows to their calves.

One of the most important questions about the epidemiology of heartwater in the field is how Cowdria ruminatium is transmitted within vertebrate host populations. In this study vertical transmission of C. ruminantium from cows to their calves was demonstrated. Twelve mixed-breed calves, born to dams living in a heartwater-endemic area of Zimbabwe, were tested post-natally for the presence of C. ruminantium. Vertical transmission was demonstrated to occur under natural field conditions using tests in which uninfected laboratory-reared Amblyomma ticks were fed on neonatal calves and subsequently either fed on, or inoculated into, susceptible small ruminants or tested by a polymerase chain reaction (PCR) assay. Prior to natural Amblyomma tick infestation, C. ruminantium infection in 5 of the 12 calves was confirmed by tick transmission to small ruminants and 11 of the 12 calves tested positive based on PCR analysis of ticks fed on them. The role of colostral cells, as one mode of infection, was demonstrated by the transmission of C. ruminantium to three out of five goats inoculated intravenously with viable colostral cells collected from dams living in a heartwater-endemic area. The significance of vertical transmission is presented in relation to the epidemiology and control of heartwater.

Colostrum from dams living in a heartwater-endemic area influences calfhood immunity to Cowdria ruminantium.

Two studies were carried out to determine whether colostrum from dams living in a heartwater-endemic area has an influence on calfhood immunity to Cowdria ruminantium infection. The initial study was conducted using Friesian calves originating from a heartwater-free herd. Experimental groups consisted of calves receiving colostrum from dams living in a heartwater-endemic area and known to be exposed to C. ruminantium (as determined by the indirect fluorescent antibody test) and calves receiving colostrum from dams located in a heartwater-free area. All calves were challenged at 3 days of age with a homologous C. ruminantium blood stabilate originating from the same area as the endemic colostrum. A significant difference in both the intensity of clinical reactions and percentage of fatal heartwater cases was noted between the two groups of calves. Three of the five calves receiving the colostrum free of C. ruminantium-specific antibodies succumbed to challenge, whereas none of the five calves receiving the colostrum from the heartwater-endemic area showed any clinical reactions. A second similar study was carried out using 12 mixed breed calves born in a heartwater-endemic area of Zimbabwe. The results from this study supported the findings of the first. The significant role of colostrum in calfhood immunity to C. ruminantium infection is discussed in relation to the epidemiology and control of heartwater.

A novel bile duct cannulation method with tail cuff exteriorization allowing continuous intravenous infusion and enterohepatic recirculation in the unrestrained rat.

A variety of bile duct cannulation methods have been used in the study of biliary excretion in the rat. We now report the validation and use of one such method. In this method, the common bile duct and duodenum were cannulated, the free ends of the cannulae tunnelled through the abdominal wall, passed through a trochar and exteriorized at the ventral aspect of the tail. A purpose-designed stainless steel tail cuff was then attached, to protect the cannulae from the rat. The cannulae were passed through the top of a metabolism cage and attached to a dual swivel that allows the rat freedom of movement within the metabolism cage. Where necessary an additional cannula could be placed in the femoral vein to allow infusion of test material or blood sampling. The results demonstrate that the method is robust and that its use allows a reliable correlation between surgically prepared and intact animals, as physiological parameters are allowed to return to normal prior to inclusion of the animals in the study. The technique allows the animals a great deal of freedom and, as such, is considered to minimize stress associated with the procedure. This fact is reflected in the reliability and reproducibility of the data obtained over the wide range of studies that have been conducted using this method. This method has been in use for over 4 years at Inveresk and this paper describes the authors' experience with the method to date.

United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery: report 1; case mix, complications, and cataract.

AIM: To report the vitreoretinal (VR) surgical case mix in the United Kingdom, the intraoperative complication rate of pars plana vitrectomy (PPV), and the incidence of post-vitrectomy cataract extraction. METHODS: Participating hospitals prospectively collected ophthalmic data using a single electronic medical record system, with automatic extraction of anonymised data to a national database. This study included the subset of 11618 VR operations undertaken on 9619 eyes, of 8741 patients, over 8 years, from 27 sites. Surgical data included the indication for surgery, all procedure elements, and whether or not an intraoperative complication occurred. Post-vitrectomy cataract data were also analysed. The main outcome measures were a description of the indications for surgery, intraoperative PPV complication rate, and percentage of eyes undergoing post-vitrectomy cataract surgery (PVCS). RESULTS: The most common indications for VR intervention were retinal breaks and rhegmatogenous retinal detachment (48.5%), macular hole (9.8%), epiretinal membrane (9.6%), and diabetic eye disease (7.3%). Overall, 7.8% of PPVs had at least one intraoperative complication-the most common were iatrogenic retinal breaks (3.2%), and lens touch (1.2-1.6% of phakic eyes). PVCS occurred in 50.2, 68.7, and 74.0% of eyes at 1, 2, and 3 years, respectively. CONCLUSION: VR surgery is undertaken for a wide range of conditions, but a small number of diagnoses encompass the majority of cases. Intraoperative PPV complications are not uncommon, and post-vitrectomy cataract is to be expected in most phakic eyes.

Which visual acuity measurements define high-quality care for patients with neovascular age-related macular degeneration treated with ranibizumab?

PURPOSE: The purpose of this study is to define which visual acuity (VA) measurements are the best indicators of high-quality care for patients receiving intravitreal ranibizumab for neovascular age-related macular degeneration (nAMD). METHODS: Analysis of prospectively collected data recorded within an electronic medical record system on treatment-naive, first-eligible eyes with nAMD, treated with ranibizumab using an as-needed treatment regimen with a minimum follow-up of 1 year. Data collection included the following: age, gender, laterality, type of nAMD, VA, central 1 mm OCT retinal thickness, number of intravitreal injections, and number of follow-up assessments. RESULTS: Data were available on the first-treated eye from 406 patients with at least 1 year follow-up; of these, 198 had data at 2 years. The mean baseline VA of 54.4 Early Treatment Diabetic Retinopathy Study letters improved to 58.5 letters at 12 months and to 56.8 letters at 24 months. The mean VA changes from baseline to 1 year were +6.5, +7.5, +1.7, and -1.5 letters, respectively, for baseline VA categories of 23-35, 36-55, 56-70, and >70 letters. Change in mean VA from the end of the loading phase to year 1 ranged from -2.9 to +1.4 letters for the different baseline VA categories. The mean number of injections were similar across baseline VA categories ranging from 5.7 to 6.0 injections in year 1 and from 3.3 to 3.8 in year 2. CONCLUSIONS: This large, real-world series demonstrates that mean change in VA is largely a function of selection criteria and baseline VA. The quality of a service is therefore better judged by actual VA outcomes and maintenance of vision after the loading phase.

United Kingdom National Ophthalmology Database Study: Diabetic Retinopathy; Report 1: prevalence of centre-involving diabetic macular oedema and other grades of maculopathy and retinopathy in hospital eye services.

AIMS: To report estimates of the prevalence of diabetic retinopathy (DR) and maculopathy grades for a large cohort of patients managed by the UK hospital eye service (HES). METHODS: Anonymised data were extracted from 30 UK NHS hospital trusts using a single ophthalmic electronic medical record (EMR) for the period from April 2000 to November 2010 to create the National Ophthalmology Database (NOD). From 2007, the EMR facilitated capture of a nationally agreed-upon standardised data set (DR Structured Assessment) relating to the presence or absence of clinical signs of DR and maculopathy. An algorithm in the software automatically calculated the Early Treatment of Diabetic Retinopathy Study grades of retinopathy and maculopathy. RESULTS: Between 2007 and 2010, 307,538 patients had data on the NOD, with 76,127 (24.8%) patients having been recorded as having diabetes. The proportion of patients with diabetes who had a structured assessment increased from 50.7% (2007) to 86.8% (2010). In each NHS year, 12.6-20.6% of eyes with structured assessments had no DR; 59.6-67.3% had non-proliferative DR; and 18.3-20.9% had active or regressed proliferative DR. Clinically significant macular oedema was present in 15.8-18.1% of eyes, and in 8.7-10.0% of eyes, this involved the central macula. CONCLUSION: This study provides contemporary estimates of the prevalence of retinopathy and maculopathy grades in a large cohort of patients with diabetes managed by the UK HES. Centre-involving diabetic macular oedema, potentially amenable to anti-VEGF therapy, is present in the eyes of almost 10% of these patients. This information is useful for clinicians, health-care economists, and commissioners involved in planning and delivering diabetic eye services.

Effects of tick infestation and tick-borne disease infections (heartwater, anaplasmosis and babesiosis) on the lactation and weight gain of Mashona cattle in south-eastern Zimbabwe.

The effects of ticks and tick-borne disease infections on the lactation and weight gain of Mashona cattle were studied at Mbizi Quarantine Station in the south-eastern lowveld of Zimbabwe. Twenty-nine Mashona cows were allocated to 2 balanced groups and kept in separate paddocks at a stocking rate of one animal per 8 ha. One group received regular acaricide treatment to control bont (Amblyomma hebraeum) and other ticks. The other group was left untreated. The cows were artificially inseminated. The acaricide-treated cows and calves were essentially tick free throughout the experiment, while the untreated cows and calves were continuously tick infested. There was a drought-related decline in tick infestations in the second year of the experiment. Antibodies to Cowdria ruminantium, Babesia bigemina and Anaplasma marginale were detected in cows and calves from both groups, though the untreated group had significantly higher titres to C. ruminantium (P < 0.001). The total, measured amount of milk suckled by untreated calves was significantly more than treated calves (273 kg vs. 241 kg, P < or = 0.05). By interpolating between the twice weekly measurements, it was calculated that over the entire lactation untreated calves suckled an average of 935 kg/hd vs. 837 kg/hd for the treated group. There were no statistical differences in the weights of the 2 groups of calves at birth, weaning, 180 and 210 days post partum (P < 0.05). For cows, there were no statistically significant differences in gestation periods (288 vs. 279 days), reconception rates or weight patterns over time (P < 0.05). The results show that intensive acaricide treatment in areas of Zimbabwe where heartwater is enzootically stable is uneconomical. The maintenance of enzootic stability for tick-borne diseases through minimal tick control is clearly a more economic and practical control option.