The Role of Insulin-like Growth Factor (IGF) System in the Corneal Epithelium Homeostasis-From Limbal Epithelial Stem Cells to Therapeutic Applications

The corneal epithelium, comprising three layers of cells, represents the outermost portion of the eye and functions as a vital protective barrier while concurrently serving as a critical refractive structure. Maintaining its homeostasis involves a complex regenerative process facilitated by the functions of the lacrimal gland, tear film, and corneal nerves. Crucially, limbal epithelial stem cells located in the limbus (transitional zone between the cornea and the conjunctiva) are instrumental for the corneal epithelium integrity by replenishing and renewing cells. Re-epithelialization failure results in persistent defects, often associated with various ocular conditions including diabetic keratopathy. The insulin-like growth factor (IGF) system is a sophisticated network of insulin and other proteins essential for numerous physiological processes. This review examines its role in maintaining the corneal epithelium homeostasis, with a special focus on the interplay with corneal limbal stem cells and the potential therapeutic applications of the system components.

Time and Motion Studies to assess surgical productivity in cataract theatre lists within the National Health Service: Immediate Sequential Bilateral Cataract Surgery versus Delayed Sequential Bilateral Cataract Surgery

BACKGROUND

To compare productivity of National Health Service cataract lists performing unilateral cataract (UC) surgery vs Immediate Sequential Bilateral Cataract Surgery (ISBCS).

METHODS

Five 4-hour lists with ISBCS cases and five with UC were observed using time and motion studies (TMS). Individual tasks and timings of each staff member in theatre was recorded by two observers. All operations were performed by consultant surgeons under local anaesthesia (LA).

RESULTS

Median number of eyes operated per 4-hour list was 8 (range 6-8) in the ISBCS group and 5 (5-7) in the UC group (p = 0.028). Mean total theatre time (defined as time between the entry of the first patient and the exit of the last patient from theatre) was 177.12 (SD 73.62) minutes in the ISBCS group and 139.16 (SD 47.73) minutes in the UC group (p = 0.36). Mean time to complete two consecutive unilateral cataract surgery operations was 48.71 minutes compared to 42.23 minutes for a single ISBCS case (13.30% time saved). Based on our collected TMS data, a possible 5 consecutive ISBCS cases and 1 UC (total 11 cataract surgeries) could be performed during a four-hour theatre session, with a theatre utilisation quotient of 97.20%, contrasting to nine consecutive UC, with a theatre utilisation quotient of 90.40%.

DISCUSSION

Performing consecutive ISBCS cases under LA on routine cataract surgery lists can increase surgical efficiency. TMS are a useful way to investigate surgical productivity and test theoretical models for efficiency improvements.

Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes

PURPOSE/OBJECTIVE(S)

Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC.

MATERIALS/METHODS

In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations.

RESULTS

Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation.

CONCLUSION

Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.

Intravitreal dexamethasone to manage post endothelial keratoplasty cystoid macular oedema refractory to topical therapy

BACKGROUND/OBJECTIVES

To describe the visual and clinical outcomes of patients with post endothelial keratoplasty (EK) cystoid macular oedema (CMO) refractory to topical treatment with intravitreal sustained-release dexamethasone implant (Ozurdex).

SUBJECTS/METHODS

131 eyes from 111 patients undergoing solitary or combined EK (52 DSAEK (40.0%) and 79 DMEK (60.0%)) at Southend University Hospital between January 2020 and February 2022 with a minimum follow-up of 6 months were evaluated. Patients suspected of having CMO underwent spectral-domain macular optical coherence tomography (SD-OCT) Patients with diabetes were not included in this series.

RESULTS

CMO was identified in 5.3% (n = 7) of cases, with 2 of these patients responding to topical corticosteroid treatment. The remaining 5 patients underwent intravitreal dexamethasone implant, with 1 patient requiring repeat implant due to CMO recurrence. All presented within 2 months postoperatively. 4 out of 5 eyes treated with intravitreal dexamethasone achieved a Snellen BCVA ≤6/9.5. 1 patient had an uncontrolled rise in intraocular pressure (IOP) despite maximal medical treatment requiring an urgent PreserFlo Ab-Externo MicroShunt.

CONCLUSIONS

The use of intravitreal sustained-release dexamethasone implant in the management of post EK CMO refractory to topical therapy is effective and safe in most cases, but patients should be monitored and treated promptly for any secondary IOP response.

High Astigmatism After Conventional Diameter Deep Anterior Lamellar Keratoplasty in Keratoconus Can Be Successfully Managed With Repeat Wide Diameter Deep Anterior Lamellar Keratoplasty

PURPOSE

The aim of this study was to describe a new surgical technique to replace a conventional diameter (≤8 mm) deep anterior lamellar keratoplasty (DALK) graft with associated high astigmatism refractory to corneal-based astigmatic procedure/intolerance to contact lenses with a larger diameter (≥9 mm) DALK graft to improve best spectacle-corrected visual acuity (BSCVA).

METHODS

Two eyes from 2 keratoconic patients at Southend University Hospital between December 2019 and June 2021 with a minimum follow-up of 17 months were evaluated. The primary outcome of interest was Snellen BSCVA with a secondary outcome of topographic cylinder.

RESULTS

Patient 1 had undergone initial 8 mm diameter DALK, with residual keratometric astigmatism of nearly 12 diopters (D) postoperatively despite numerous astigmatic interventions, with a BSCVA of 6/60, before undergoing 9 mm diameter repeat modified DALK. After suture removal and subsequent in-the-wound blunt manual relaxing incisions, the patient had a final keratometric astigmatism of 3.5 D, manifest refraction of plano/-3.50 × 175, and a BSCVA of 6/9. Patient 2 had undergone initial 7.75 mm diameter DALK, with residual keratometric astigmatism of 10.5 D with a BSCVA of counting fingers. The patient underwent 9 mm repeat modified DALK with final residual keratometric astigmatism of 3.1 D after suture removal, manifest refraction of -1.00/-2.75 × 25, and BSCVA of 6/9.

CONCLUSIONS

Wide diameter DALK (>9 mm) is effective in the management of conventional diameter DALK (≤8 mm) associated high astigmatism in keratoconus. Creation of a peripheral posterior stromal shoulder also allows safe further titration of residual astigmatism if needed.

P-18 'No Nonsense' DMEK: Safety and efficacy of postureless DMEK with deferred post-operative review until one week

*Correspondence, Ahmad Shakeel: drshakeel333@gmail.com PURPOSE: To evaluate the clinical results of postureless (no intraoperative or postoperative posturing) Descemet's membrane endothelial keratoplasty (DMEK) with the first postoperative review conducted at one week.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

17 consecutive eyes of 17 patients requiring DMEK with PI for any cause of endothelial failure.

INTERVENTION

DMEK was performed with an intraoperative inferior PI and a near total fill of SF6 (20% concentration). After filling the anterior chamber with gas there was no intraoperative tamponade time; at the conclusion of surgery the patient was sat up in theatre and an external eye examination was performed to confirm the gas meniscus was above the PI. The patient was allowed home immediately with no instructions to posture at home and the next scheduled review occurred at day 7.

MAIN OUTCOME MEASURES

Rate of any postoperative complications, including any unplanned visits or intervention between day 0-7, graft detachment, rebubbling and primary failure rates.

RESULTS

There were zero additional or unplanned visits or interventions. No pupil block or Urrets-Zavalia syndrome occurred. No complications occurred other than partial (<1/3 DMEK surface area) detachment in the first month in 3/17 (17.6%) of which a rebubbling was performed in 2 (11.8%). Each of those required one rebubbling, after which total graft attachment was achieved. There were no cases of primary graft failure.

CONCLUSIONS

This small series highlights that DMEK surgery can be safely performed with less demands of patients in the postoperative period for hospital reviews or of posturing.

P-14 Factors associated with the disparity between manifest refractive cylinder and keratometric astigmatism in keratoconic eyes

*Correspondence, Jesse Panhtagani: jesse.panthagani@nhs.net OBJECTIVE: To investigate the factors associated with the disparity between manifest refractive cylinder (MRC) and keratometric astigmatism (KA) in keratoconic eyes to refine the refractive outcomes of toric intraocular lenses in keratoconic cataract surgery.

METHODS

A retrospective study at Southend University Hospital assessing 145 keratoconic eyes from 75 patients (57 male, 18 female, mean age 27±8.6 years), and comatic aberration of >0.3 µm (defined with Pentacam HR (Oculus, Germany) at a diameter of 6 mm). MRC power was correlated to corneal tomographic variables including higher order aberrations measured using univariate and multivariate regression analysis. Vector difference between KA and MRC was also explored, to detect tomographic variables associated with this disparity. Axis of MRC was compared and correlated to the axis of corneal coma.

RESULTS

Both KA and coma showed a significant correlation with the MRC power. The vector difference between KA and MRC is correlated to the KA, posterior keratometric astigmatism and comatic aberration. MRC axis had significant correlation to the axis of coma, with an inverse relationship between MRC axis and coma axis.

CONCLUSION

Corneal comatic aberration is a significant determinant factor of manifest refractive cylinder power and axis and is correlated with the disparity between manifest and keratometric astigmatism found in keratoconic eyes. The effect of higher order aberrations, particularly vertical coma should be considered when planning intraocular procedures for visual rehabilitation.

P-17 An innovative technique for practising peeling of donor descemet's membrane for descemet's membrane endothelial keratoplasty

*Correspondence, Shakeel Ahmad: drshakeel333@gmail.com PURPOSE: To evaluate the feasibility of residual corneoscleral buttons after primary surgery for practising the donor tissue preparation for Descemet's membrane endothelial keratoplasty (DMEK) by trainees and fellows.

METHODS

Fellows with zero experience in DMEK used 5 residual corneoscleral buttons after DSAEK surgery (central 8 mm graft was punched during the primary surgery), to practice donor Descemet's membrane peeling. A 9.5 mm donor punch was used for partial cutting of the residual button after staining it with brilliant blue G for 1 minute. 360° stripping of Descemet's was practised under a balanced salt solution.

RESULT

Fellow successfully peeled 360° Descemet's membrane in 3 out of 5 residual corneoscleral buttons.

CONCLUSION

Residual corneoscleral button is an excellent source to practice donor Descemet's membrane peeling for DMEK. This technique can provide cost-effective and easily available platform to the trainees and fellows for gaining skills and practising graft preparation without the fear of financial loss or surgery deferment in case of tissue loss or damage.

Selective laser trabeculoplasty for steroid-induced ocular hypertension following endothelial keratoplasty

Purpose: To examine the safety and efficacy of selective laser trabeculoplasty (SLT) in patients responding to topical steroids with elevated intraocular pressure following endothelial keratoplasty.Methods: Patients that underwent Descemet Membrane Endothelial Keratoplasty (DMEK) or Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) were offered SLT as first-line therapy if they presented with steroid response and met inclusion criteria. Patient demographics, best-corrected visual acuity (BCVA), steroid and glaucoma regimens were recorded before and after SLT.Results: Twelve eyes of 8 patients were recruited to the study. All patients demonstrated a reduction in IOP and only one patient remained on anti-glaucoma drops after SLT. The mean (±SD) reduction in IOP following SLT was 8.8 (±4.9) mmHg (p < 0.0001). BCVA remained stable and no adverse events following treatment were observed.Conclusions: SLT may be a safe and effective treatment option that reduces topical antihypertensive burden while allowing continuance of corticosteroids in steroid-responsive eyes at high risk of rejection following endothelial keratoplasty. Larger randomized studies are needed to compare SLT efficacy with topical medication in this patient group and to review any impact on graft survival and glaucoma progression.

The relationship between vitamin D status, intake and exercise performance in UK University-level athletes and healthy inactive controls

The potential ergogenic effects of vitamin D (vitD) in high performing athletes has received considerable attention in the literature and media. However, little is known about non-supplemented university athletes and students residing at a higher latitude. This study aimed to investigate the effects of vitD (biochemical status and dietary intake) on exercise performance in UK university athletes and sedentary students. A total of 34 athletes and 16 sedentary controls were studied during the spring and summer months. Serum vitD status and sunlight exposure were assessed using LC-MS/MS and dosimetry, respectively. Muscular strength of the upper and lower body was assessed using handgrip and knee extensor dynamometry (KE). Countermovement jump (CMJ) and aerobic fitness were measured using an Optojump and VO2max test, respectively. Statistical analysis was performed using paired/ independent t-tests, ANCOVA and Pearson/ Spearman correlations, depending on normality. VitD status increased significantly over the seasons, with athletes measuring higher status both in spring (51.7±20.5 vs. 37.2±18.9 nmol/L, p = 0.03) and summer (66.7±15.8 vs 55.6±18.8 nmol/L, p = 0.04) when compared to controls, respectively. Notably, 22% of the subjects recruited were vitD deficient during the spring term only (<25nmol/L, n 9). Subjects with 'insufficient' vitD status (<50nmol/L) elicited significantly lower CMJ when contrasted to the vitD 'sufficient' (>50nmol/l) group (p = 0.055) and a lower VO2 max (p = 0.05) in the spring and summer term (p = 0.05 and p = 0.01, respectively). However, an ANCOVA test showed no significant difference detected for either CMJ or VO2max following adjustments for co-variates. In conclusion, we provide novel information on the vitD status, dietary intake, physical fitness and sunlight exposure of UK young adults across two separate seasons, for which there is limited data at present.

A randomised, prospective study of 'off-the-shelf' use of toric intraocular lenses for cataract patients with pre-existing corneal astigmatism in the NHS

BACKGROUND/OBJECTIVES

To compare visual and refractive outcomes of monofocal intraocular lenses (IOLs) with limbal relaxing incisions (LRI) with 'off-the-shelf' use of toric IOLs (TIOLs), with a fixed 2-dioptre cylinder (DC) correction, for cataract patients with pre-existing corneal astigmatism in a public-sector setting.

SUBJECTS/METHODS

Seventy-seven patients (77 eyes, first treated eye) with visually significant cataract and pre-operative corneal astigmatism ≥2.00 DC were randomised to receive either 'off-the-shelf' TIOLs, with a fixed 2.00 DC cylinder correction (39 eyes), or monofocal IOLs (38 eyes) with LRIs. The concept of fixing the cylindrical correction was to minimise costs, allow a full TIOL bank to be available and eliminate the need for individual TIOL ordering. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and refraction. Astigmatic changes were evaluated using the Alpins vector method.

RESULTS

Mean UDVA improved from logMAR 0.88 (SD 0.56)[~20/150] pre-operatively to 0.18 (SD 0.19)[~20/30] post-operatively in TIOL group, versus 0.82 (SD 0.55)[~20/130] to 0.27 (SD 0.15)[~20/40] in monofocal/LRI group (P = 0.02; 95% CI: -0.17, -0.01). Mean CDVA improved from logMAR 0.40 (SD 0.26)[~20/50] to 0.01 (SD 0.12)[~20/20] in TIOL group, and 0.41 (SD 0.38)[~20/40] to 0.06 (SD 0.12)[~20/25] in LRI group (P = 0.07; 95% CI: -0.11, 0.01). Average post-operative refractive cylinder in TIOL group was 1.35 DC (SD 0.84 DC) and in LRI group 1.91 DC (SD 1.07 DC) (P = 0.01; 95% CI: -1, -0.12). Mean difference vector magnitude was 1.92 DC (SD 1.08 DC) in LRI group and 1.37 DC (SD 0.84 DC) in TIOL group (P = 0.02; 95% CI: 0.11, 0.99).

CONCLUSIONS

TIOLs with a fixed 2.00 DC correction during cataract surgery may improve UDVA, reduce post-operative cylinder and result in a more reliable astigmatic correction compared with monofocal IOLs with LRIs.

Economic modelling of immediately sequential bilateral cataract surgery (ISBCS) in the National Health Service based on possible improvements in surgical efficiency

Objective

To test a hypothesis that operating room (OR) productivity in the National Health Service (NHS) can be improved with the introduction of immediately sequential bilateral cataract surgery (ISBCS).

Methods and analysis

Previously published time and motion data of 140 unilateral cataract surgeries conducted at five different NHS locations were reanalysed to construct a hypothetical model where only ISBCS (±one unilateral case) were conducted while maintaining time durations of all key tasks previously studied. Possible time efficiency savings were calculated for the ISBCS model and percentage increases in numbers of eyes operated per 4-hour theatre session calculated. Gains in efficiency were correlated with factors from the baseline data to predict which settings could improve efficiency most by undertaking ISBCS.

Results

Based on remodelling our time and motion study (TMS) data as hypothetical ISBCS cases, we could expect a mean 16% reduction (range 9.8%–17.8%) in the time taken for two cataract operations, translating into a mean 54% improvement (range 38%–67%) in number of cases currently performed per list and an 18% improvement (range 9%–28%) even if the number of unilateral cases per list had been fully maximised. An average number of four ISBCS cases per list (range 3–6) were required to achieve sufficient time savings to allow an extra unilateral surgery to be conducted.

Conclusion

The introduction of routine ISBCS has the potential to improve the productivity of cataract surgery within the NHS, with efficiencies being possible in both high-volume and low-volume surgical models.

Risk factors for African swine fever incursion in Romanian domestic farms during 2019

African swine fever (ASF) entered Georgia in 2007 and the EU in 2014. In the EU, the virus primarily spread in wild boar (Sus scrofa) in the period from 2014-2018. However, from the summer 2018, numerous domestic pig farms in Romania were affected by ASF. In contrast to the existing knowledge on ASF transmission routes, the understanding of risk factors and the importance of different transmission routes is still limited. In the period from May to September 2019, 655 Romanian pig farms were included in a matched case-control study investigating possible risk factors for ASF incursion in commercial and backyard pig farms. The results showed that close proximity to outbreaks in domestic farms was a risk factor in commercial as well as backyard farms. Furthermore, in backyard farms, herd size, wild boar abundance around the farm, number of domestic outbreaks within 2 km around farms, short distance to wild boar cases and visits of professionals working on farms were statistically significant risk factors. Additionally, growing crops around the farm, which could potentially attract wild boar, and feeding forage from ASF affected areas to the pigs were risk factors for ASF incursion in backyard farms.

Endodontic Access Effect on Full Contour Zirconia and Lithium Disilicate Failure Resistance

Objectives:

To evaluate the effect of endodontic access on the failure load resistance of both adhesively and conventionally luted, full-contour monolithic yttria-stabilized zirconium dioxide (Y-TZP) and adhesively luted lithium disilicate (LD) crowns cemented on prepared teeth.

Methods and Materials:

Seventy-two human maxillary molars were prepared per respective guidelines for all-ceramic crowns with one group (n=24) restored with LD and the other (n=48) receiving Y-TZP crowns. Preparations were scanned using computer-aided design/computer-aided milling (CAD/CAM) technology, and milled crowns were sintered following manufacturer recommendations. All LD crowns and half (n=24) of the Y-TZP crowns were adhesively cemented, while the remaining Y-TZP specimens were luted using a conventional glass ionomer cement (GIC). One LD group, one Y-TZP adhesive group, and one GIC-luted group (all n=12) then received endodontic access preparations by a board-certified endodontist: the pulp chambers were restored with a dual-cure, two-step, self-etch adhesive and a dual-cure resin composite core material. The access preparations were restored using a nano-hybrid resin composite after appropriate ceramic margin surface preparation. After 24 hours, all specimens were loaded axially until failure; mean failure loads were analyzed using Mann-Whitney U test (α=0.05)

Results:

Endodontic access did not significantly reduce the failure load of adhesively luted LD or Y-TZP crowns, but Y-TZP crowns with GIC cementation demonstrated significantly less failure load.

Conclusions:

These initial findings suggest that endodontic access preparation may not significantly affect failure load resistance of adhesively luted Y-TZP and LD crowns. Definitive recommendations cannot be proposed until fatigue testing and coronal seal evaluations have been accomplished.

The use of pan-retinal photocoagulation to treat recurrent vitreous haemorrhage with neovascularisation in the context of Epstein syndrome: an MYH9-related disorder

A female patient presented with stable chronic thrombocytopaenia with large platelets, sensorineuronal deafness and renal impairment. Her treatment was refractory to intravenous immunoglobulins (IVIG) and steroids for a putative diagnosis of immune thrombocytopaenic purpura (ITP). She underwent genetic testing which revealed a MYH9 mutation in-keeping with a diagnosis of Epstein Syndrome. Subsequently to this she developed globally constricted fields on Goldmann visual field testing. MRI pituitary was unremarkable but she was diagnosed with a pituitary microprolactinoma secondary to raised prolactin in the blood responsive to carbegoline therapy. She subsequently developed retinal haemorrhages and recurrent vitreous haemorrhages due to neovascularisation. Fluorescein angiography revealed the extent of the neovascularisation and microvascular ischaemia. She underwent pan-retinal photocoagulation (PRP) to treat the ischaemic stimulus which resulted in regression of the new vessels and cessation of vitreous haemorrhages. There are no previous reported cases of microvascular retinal disease in the literature in the context of Epstein Syndrome, and this is the first report of successful treatment with PRP.

The use of finger foods in care settings: an integrative review

BACKGROUND

Reduced food intake is prevalent in people in residential and hospital care settings. Little is known about the use of finger foods (i.e. foods eaten without cutlery) with respect to increasing feeding independence and food intake. The Social Care Institute for Excellence (Malnutrition Task Force: State of the Nation, 2017) recommends the use of finger foods to enable mealtime independence and to prevent loss of dignity and embarrassment when eating in front of others. The aim of this review is to identify and evaluate the existing literature regarding the use and effectiveness of finger foods among adults in health and social care settings.

METHODS

An integrative review methodology was used. A systematic search of electronic databases for published empirical research was undertaken in October 2018. Following screening of titles and abstracts, the full texts of publications, which investigated outcomes associated with the provision of finger foods in adult care settings, were retrieved and assessed for inclusion. Two independent investigators conducted data extraction and quality assessment using Critical Appraisal Skills Programme checklists. Thematic analysis was used to summarise the findings.

RESULTS

Six studies met the inclusion criteria. Four themes were identified: Finger food menu implementation; Importance of a team approach; Effect on nutrition; and Influence on wellbeing. Study designs were poorly reported, with small sample sizes.

CONCLUSIONS

There is some evidence that the provision of finger foods may positively affect patient outcomes in long-term care settings. There is a paucity of research evaluating the use of a finger food menu in acute care settings, including economic evaluation. Future high quality trials are required.

Livestock Health and Food Chain Risk Assessment

The EUFORA fellowship programme ‘Livestock Health and Food Chain Risk Assessment’ was proposed by the Animal and Plant Health Agency (APHA), a British governmental institution responsible for safeguarding animal and plant health in the UK. The working programme, which was organised into four different modules, covered a wide range of aspects related to risk assessment including identification of emerging risks, risk prioritisation methods, scanning surveillance, food production exposure assessment and import risk assessment of animal and human infectious diseases. Over the course of the year, the Fellow had the opportunity to work for international projects with experts in these disciplines. This allowed for significant opportunities to ‘learn‐by‐doing’ the methods and the techniques that are employed to assess animal health and food safety risks. Moreover, he consolidated his knowledge by attending several training courses and academic lessons, submitting scientific papers to peer‐reviewed journals and conferences, giving presentations and using modelling software.

Linear Coefficient of Thermal Expansion Evaluation of Glass Ionomer and Resin-Modified Glass Ionomer Restorative Materials

OBJECTIVE

The purpose of this evaluation was to evaluate the linear coefficient of thermal expansion (LCTE) of 12 conventional glass ionomer (GIC) and four resin-modified glass ionomer (RMGI) restorative materials.

METHODS

GIC and RMGI specimens (2 mm × 5 mm × 5 mm) were fabricated (n=12) following manufacturer instructions and were placed in 0.2M phosphate-buffered saline and stored at 37°C and 98% humidity for one week. Specimens had LCTE determined with a thermomechanical analysis (TMA) unit using a 15°C-50°C heating cycle as well as a 50°C-15°C cooling cycle at a 5°C/min rate, using a 3-mm ball-point probe under 0.02 N probe pressure with all specimens kept saturated with PBS using a specially designed quartz container. Each specimen was tested three times, with the mean representing the specimen LCTE. Mean results between specimen heating and cooling were compared with paired Wilcoxon sign rank test, while results between materials were compared with Kruskal-Wallis/Dunn's ( α=0.05).

RESULTS

GIC LCTE ranged from approximately 5°C to 20°C ppm °K^-1, while the RMGI LCTE ranged from approximately 25°C to 47°C ppm °K^-1. With some exception, the LCTE during cooling displayed a greater trend.

SIGNIFICANCE

Under moisture conditions similar to the oral cavity, GIC materials overall had LCTE values closer to that reported for tooth structure. RMGI materials displayed higher values, which was thought to be related to the amount of resin in the matrix. A generally greater LCTE trend with cooling for all materials was noted, but the small magnitude of the difference is presently thought to be of minor clinical significance.

Effect of Endocrown Pulp Chamber Extension Depth on Molar Fracture Resistance

PURPOSE

The purpose of this study was to evaluate the effect of endocrown pulp chamber extension on mandibular molar fracture resistance.

METHODS AND MATERIALS

A total of 36 recently extracted mandibular third molars of approximate equal size were sectioned at the facial lingual height of contour followed by endodontic access into the pulp chamber. The specimens were then randomly divided into three groups (n=12) and pulpal and root canal contents removed. Pulp chamber floors were established at 2, 3, and 4 mm from the occlusal table using a three-step etch-and-rinse adhesive and a flowable resin composite. The prepared specimens were then embedded in auto-polymerizing denture base resin with surface area available for adhesive bonding determined using a digital recording microscope. Specimens were restored using a standardized template with a chairside computer-aided design/computer-aided manufacturing unit with the endocrown milled from a lithium disilicate glass-ceramic material. Restoration parameters of occlusal table anatomy and thickness were standardized with the only parameter difference being the pulp chamber extension depth. The endocrown restorations were luted with a self-adhesive resin luting agent and tested to failure after 24 hours on a universal testing machine, with force applied to the facial cusps at a 45° angle to the long axis of the tooth. The failure load was converted into stress for each specimen using the available surface area for bonding. Mean failure load and stress among the three groups was first subjected to the Shapiro-Wilk and Bartlett tests and then analyzed with an analysis of variance with the Tukey post hoc test at a 95% confidence level (p=0.05).

RESULTS

The 2- and 4-mm chamber extension groups demonstrated the highest fracture resistance stress, with the 3-mm group similar to the 2-mm group. The 3- and 4-mm chamber extension group specimens demonstrated nearly universal catastrophic tooth fracture, whereas half the 2-mm chamber extension group displayed nonrestorable root fractures.

CONCLUSIONS

Under the conditions of this study, mandibular molars restored with the endocrown technique with 2- and 4-mm pulp chamber extensions displayed greater tooth fracture resistance force as well as stress. All groups demonstrated a high number of catastrophic fractures, but these results may not be clinically significant because the fracture force results are higher than normal reported values of masticatory function.

TiO2 nanoparticles can selectively bind CXCL8 impacting on neutrophil chemotaxis

The interaction between TiO₂ nanoparticles (NPs) and inflammatory cytokines, including CXCL8, a clinically relevant pro-inflammatory chemokine was investigated. TiO₂ is present in tissues adjacent to failing implanted Ti (titanium) devices. TiO₂ NPs were shown to bind to CXCL8 in vitro, causing perturbation of quantification of CXCL8 by ELISA, in both simple and complex protein panels, in a dose-dependent manner. Binding between TiO₂ NPs and CXCL8 was demonstrated by protein gel electrophoresis. TiO₂ NPs were also shown to inactivate the chemoattractant property of CXCL8 in a dose-dependent manner, suggesting that the binding between TiO₂ NPs and CXCL8 is likely to be clinically relevant. The results of this study disputed the applicability of detection of CXCL8 by ELISA in systems where TiO₂ NPs were present. Clinically, the disruption of chemotaxis of neutrophils in response to CXCL8 in the presence of TiO₂ might mean a hampered immune response to inflammation in tissues containing TiO₂ NPs.

What is Comprehensive Geriatric Assessment (CGA)? An umbrella review

Background

Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most.

Objectives

our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA.

Methods

we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources.

Results

we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported.

Conclusions

we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

Leaving foster or residential care: a participatory study of care leavers' experiences of health and social care transitions

BACKGROUND

Young people in residential or foster care experience multiple transitions around their 18^th birthday without the long term and consistent support from their family of origin that most of their peers can expect. We report a mixed methods qualitative study of transitions across health and social care services for children leaving care, providing narratives of what young people described as positive, and what they and professionals think might be improved.

METHODS

Data were collected in participatory meetings and individual interviews between young people and researchers (n = 24) and individual interviews with practitioners (n = 11). In addition to discussion and interview techniques, we used pictorial and other participatory methods. Interviews were coded by three members of the team and differences resolved with a fourth. Our analysis draws on thematic and framework approaches.

RESULTS

Health was rarely at the top of any young person's agenda, although gaps in health care and exceptional care were both described. Housing, financial support and education took priority. Young people and professionals alike emphasized the importance of workers prepared to go the extra mile; of young people being able to contact professionals; and professionals being able to contact one another.

CONCLUSIONS

Policy and practice aspirations for care leavers recommend gradual change but transfer rather than transition continues to be described by care leavers. Our data support the need for transition as a long-term process, with children and young people having early opportunities to prepare for citizenship.

Urgent request on avian influenza

Highly pathogenic avian influenza (HPAI) H5N8 is currently causing an epizootic in Europe, infecting many poultry holdings as well as captive and wild bird species in more than 10 countries. Given the clear clinical manifestation, passive surveillance is considered the most effective means of detecting infected wild and domestic birds. Testing samples from new species and non‐previously reported areas is key to determine the geographic spread of HPAIV H5N8 2016 in wild birds. Testing limited numbers of dead wild birds in previously reported areas is useful when it is relevant to know whether the virus is still present in the area or not, e.g. before restrictive measures in poultry are to be lifted. To prevent introduction of HPAIV from wild birds into poultry, strict biosecurity implemented and maintained by the poultry farmers is the most important measure. Providing holding‐specific biosecurity guidance is strongly recommended as it is expected to have a high impact on the achieved biosecurity level of the holding. This is preferably done during peace time to increase preparedness for future outbreaks. The location and size of control and in particular monitoring areas for poultry associated with positive wild bird findings are best based on knowledge of the wider habitat and flight distance of the affected wild bird species. It is recommended to increase awareness among poultry farmers in these established areas in order to enhance passive surveillance and to implement enhanced biosecurity measures including poultry confinement. There is no scientific evidence suggesting a different effectiveness of the protection measures on the introduction into poultry holdings and subsequent spread of HPAIV when applied to H5N8, H5N1 or other notifiable HPAI viruses.

This publication is linked to the following EFSA Supporting Publications article: http://onlinelibrary.wiley.com/doi/10.2903/sp.efsa.2016.EN-1142/full

Premolar Axial Wall Height Effect on CAD/CAM Crown Retention

OBJECTIVE

To evaluate the significance of reduced axial wall height on retention of adhesively luted, all-ceramic, lithium disilicate premolar computer-aided design/computer-aided manufacturing (CAD/CAM) crowns based on preparations with a near ideal total occlusal convergence of 10°.

METHODS

Forty-eight recently extracted premolars were randomly divided into four groups (n=12). Each group received all-ceramic CAD/CAM crown preparations featuring axial wall heights of 0, 1, 2, and 3 mm, respectively, all with a 10° total occlusal convergence. Scanned preparations were fitted with lithium disilicate all-ceramic crowns that were luted with a self-etching resin cement. Specimens were tested to failure at a 45° angle to the tooth long axis with failure load converted to megapascals (MPa) based on the measured bonding surface area. Mean data were analyzed using analysis of variance/Tukey's post hoc test (α=0.05).

RESULTS

Lithium disilicate crowns adhesively luted on preparations with 0 axial wall height demonstrated significantly less failure resistance compared with the crowns luted on preparations with axial wall heights of 1 to 3 mm. There was no failure stress difference between preparations with 1 to 3 mm axial wall height.

CONCLUSIONS

Under conditions of this study, adhesively luted lithium disilicate bicuspid crowns with a total occlusal convergence of 10° demonstrated similar failure resistance independent of axial wall height of 1 to 3 mm. This study provides some evidence that adhesion combined with an ideal total occlusal convergence may compensate for reduced axial wall height.

Living with Heart Failure; Patient and Carer Perspectives

Patients with heart failure have multiple readmissions to hospital, a poor prognosis and varying quality of life. This paper explores how patients with heart failure and their family carers cope with daily life. 36 patients and 20 family caregivers were interviewed in five centres in the UK. Analysis showed that living with heart failure can be frightening, restrictive and distressing for both patients and their family carers. Patients found most difficulty coping with functional limitation and adapting to living with heart failure, but also reported particular problems due to side effects of medications, co-morbidities and a lack of psychosocial support and rehabilitation services. Those with less socio-economic resources found it harder to cope. Patients from minority ethnic groups held different beliefs about the illness and its treatment, and some had profound problems communicating with health and social care professionals that made managing the disease even more difficult. Caring for a person with heart failure often has a considerable impact on the psychological and physical health of family caregivers. Psychosocial support and rehabilitation services provided at diagnosis and after an acute episode would enable families to better manage living with this syndrome.

Socioeconomic deprivation independently predicts painful diabetic neuropathy in type 2 diabetes

OBJECTIVE

Painful peripheral neuropathy in people with type 2 diabetes is a disabling complication. We explored associations of this condition with socioeconomic deprivation.

RESEARCH DESIGN AND METHODS

The Townsend index of socioeconomic deprivation was examined in the pseudonymised GP records of 15388 (44.1% female) individuals with type 2 diabetes in the Cheshire county of England, and related to prevalence of drug treated painful diabetic neuropathy. We also analysed prescription trends with respect to pharmacotherapy for neuropathy pain relief.

RESULTS

Treatment for neuropathic pain was initiated in 3 266 (21.2%) of patients. Those on treatment were older [68.2 (95% CI 67.8-68.7) vs. 66.6 (66.4-66.8) years] than those not on treatment. There was no difference in HbA1c (7%, 55 mmol/mol).There were significant differences between the groups for the Townsend deprivation index, with a greater proportion (30.6% vs. 22.8% of patients with treated neuropathic pain) having a score of ≥1 (Χ(2)=83.9, p<0.0001).Multivariate logistic regression analyses indicated that each unit increment in the Townsend index was associated with an 6% increased odds of requiring neuropathic pain treatment [odds ratio (95%CI) 1.06 (1.05-1.08), p<0.0001] independent of 5 year age band, BMI, gender, systolic BP, eGFR, HbA1C and total cholesterol.

CONCLUSIONS

In this study using pseudonymised clinical records, a higher level of socioeconomic deprivation seemingly may predispose to severe neuropathic pain in diabetes requiring pharmacological intervention. Targeted allocation of healthcare resources to this group may offer clinical benefits.

'Did not attends' in children 0-10: a scoping review

Patients who do not attend ('DNA') health appointments have been identified as a service problem incurring significant costs to the NHS. In order to explore the causes, effects and costs of child DNAs, we carried out a scoping study to map the literature and identify gaps in the research. Given the breadth of issues underpinning DNAs, a scoping study, including research studies, audits, policy documents and conference abstracts, was the most useful way to map the field. To foster public and patient participation, we sought advice from parents participating in the National Children's Bureau's Family Research Advisory Group. From a pool of 1997 items, we found few UK studies with non-attendance of 0-10 year olds as a primary focus, though many more incidentally reported DNA rates. Overall, four topics predominated: the conceptualization of DNAs; the correlates of non-attendance; initiatives to reduce non-attendance; and the relationship between non-attendance and safeguarding. The Family Research Advisory Group identified broadly similar issues, but with a stronger emphasis on communication and practical matters. While there may be circumstances where failing to attend appointments makes little or no difference to a child (or even benefits them) it is likely that there are children whose health or well-being are compromised as a result of failing to attend appointments. Both 'over' and 'under'-attendance can be a source of anxiety to health professionals. Areas where further work is needed include robust evaluation of the effectiveness, cost-effectiveness and maintenance of measures to reduce DNAs and a better understanding of the relationship of safeguarding to non-attendance.