Efficacy and Safety outcomes of a novel model to assess new medical retina referrals in a high-volume medical retina virtual clinic

BACKGROUND

Ophthalmology outpatient attendances have significantly increased recently with rising pressure from backlogs arising from the pandemic. Medical retina digital surveillance clinics for stable follow-up appointments are well established. We present a model for assessing new referrals and evaluating clinical outcomes and long-term sustainability in a complex high-volume medical retina service.

METHODS

Suitable routine new patient referrals were identified from electronic referrals and referred to this new pathway. Structured history, visual acuities, and intraocular pressures were recorded, and widefield colour fundus and optical coherence tomography imaging were performed at a imaging hub for asynchronous consultant-led review.

RESULTS

1458 patients were invited to attend over four months, with a 13.2% did-not-attend (DNA) rate. Common diagnoses included stable diabetic retinopathy (19.9%), early age-related macular degeneration (6.7%), central serous retinopathy (8.8%), and retinal vein occlusion (6.3%). 7 patients (0.05%) required urgent same-day review. 61 (5.0%) required urgent face-to-face (F2F) assessment within two weeks. A total of 727 (59.0%) were either discharged or remained in the virtual pathway following their first visit.

CONCLUSION

This study encourages the use of a digital model that efficiently assesses suitable newly referred medical retina patients in both complex and local eye unit settings. This decreased the need for F2F clinics and resources. Further patient satisfaction surveys for digital services are currently being evaluated to guide long-term sustainability of this model.

Impaired vision in children prenatally exposed to methadone: an observational cohort study

BACKGROUND/OBJECTIVES

To examine prevalence of failed visual assessment at 8-10 years in children born to methadone-maintained opioid dependent (MMOD) mothers and relate this to known in utero substance exposure.

SUBJECTS/METHODS

Follow up of observational cohort study of methadone-exposed and comparison children matched for birthweight, gestation and postcode of residence at birth. Participants were 144 children (98 exposed, 46 comparison). Prenatal drug exposure was previously established via comprehensive maternal and neonatal toxicology. Children were invited to attend for visual assessment and casenotes were reviewed. Presence of acuity poorer than 0.2 logMAR, strabismus, nystagmus and/or impaired stereovision constituted a 'fail'. Fail rates were compared between methadone-exposed and comparison children after adjusting for known confounding variables.

RESULTS

33 children attended in person: data were also derived from casenote review for all children. After controlling for maternal reported tobacco use, methadone-exposed children were more likely to have a visual 'fail' outcome, adjusted odds ratio 2.6, 95% CI 1.1-6.2; adjusted relative risk 1.8 (95% CI 1.1-3.4). Visual 'fail' outcome rates did not differ between methadone-exposed children who had (n = 47) or had not (n = 51) received pharmacological treatment for neonatal abstinence/opioid withdrawal syndrome (NAS/NOWS); fail rate 62% vs 53% (95% CI of difference-11-27%).

CONCLUSIONS

Children born to MMOD mothers are almost twice as likely as unexposed peers to have significant visual abnormalities at primary school age. Prenatal methadone exposure should be considered in the differential diagnosis of nystagmus. Findings support visual assessment prior to school entry for children with any history of prenatal opioid exposure.

TRIAL REGISTRATION

The study was prospectively registered on ClinicalTrials.gov (NCT03603301), https://clinicaltrials.gov/ct2/show/NCT03603301 .

5 Tear proteins in premature babies at risk of retinopathy of prematurity

This feasibility study aimed to investigate the feasibility of collecting and analysing tear proteins from preterm infants at risk of retinopathy of prematurity (ROP). Additionally, we sought to identify any tear proteins which might be implicated in the pathophysiology of ROP.Eligible infants were those undergoing ROP screening without other ocular pathology. Tear samples were obtained by Schirmer's test strips coincident with routine ROP screening. Mass spectrometry was used for proteomic analysis. All participants' parents gave written, informed consent.Samples were collected from 12 infants, including two sets of twins. Gestation ranged from 25+6 to 31+1 weeks. Median postnatal age at sampling was 30.5 days (range 19 to 66). One infant developed self-limiting ROP. An adequate sample for protein analysis was obtained from each infant. 701 proteins were identified; 261 proteins identified in the majority of tear samples, including several common tear proteins, were used for analyses.Increased risk of ROP as determined by G-ROP prediction criteria was associated with an increase in lactate dehydrogenase B (LDH-B) chain protein in tears. Older, more mature infants demonstrated increased concentration of immunoglobulin complexes within their tear samples and two sets of twins in the cohort showed exceptionally similar proteomes, supporting validity of the analysis.Tear sampling by Schirmer test strips and subsequent proteomic analysis in preterm infants is feasible. A larger study is required to investigate the potential use of tear proteomics in early identification of ROP.

6 Restricted diet causing irreversible visual impairment in children with autistic spectrum disorder: case series and review

Though micronutrient deficiency is recognized to cause visual system dysfunction, avoidant/restrictive food intake disorder (ARFID) has been poorly described in relation to this.Review of 18 previously published similar cases highlights the importance of identifying other micronutrient deficiencies, even when vitamin A deficiency accounts for the presenting features. We present four patients with permanent visual loss as a result of highly restricted diets due to avoidant/restrictive food intake disorder (ARFID), and with autistic spectrum disorder (ASD).The four cases reported here make a total of 22 reported cases of visual impairment due to ARFID-like restricted diets in boys with ASD. The severity of ASD varied widely across the 22 cases, but all had extremely restricted diets, in some cases tolerating only one or two food items. The most avoided food groups in children with ASD and food selectivity have been reported from the USA as vegetables, fruit, dairy and protein, with the most preferred food items being bread, chicken, cereal and yoghurt. In the 22 cases reviewed or reported here, tolerated foods tended to be predominately carbohydrate based, with dry or crunchy textures and beige or pale colouring, i.e. French fries, potato waffles, potato chips (crisps), rice, white bread, bagels, biscuits or cookies.This case series and review highlights the need for heightened vigilance for visual problems in individuals with ASD-related ARFID and early and complete assessment of micronutrient deficiency.

CD193 ( CCR3 ) expression by B cells correlates with reduced IgE production in paediatric schistosomiasis

We demonstrate that CD193, the eotaxin receptor, is highly expressed on circulating B cells in paediatric schistosomiasis mansoni. CD193 plays a role in directing granulocytes into sites of allergic-like inflammation in the mucosa, but little is known about its functional significance on human B cells. We sought to characterize CD193 expression and its relationship with S. mansoni infection. We found that CD193+ B cells increased with the intensity of schistosome infection. In addition, a significant negative association was observed between CD193 expression by B cells and IgE production. Decreased IgE levels are generally associated with susceptibility to re-infection. B cell stimulation with eotaxin-1 increased CD193 levels whereas IL-4 led to a reduction. This was supported by plasma levels of eotaxin-1 correlating with CD193 levels on B cells and other cells. In contrast, CD193 expression was induced on naive B cells with a combination of IL-10 and schistosome antigens. Whereas T cells had a modest increase in CD193 expression, only B cell CD193 appeared functionally chemotactic to eotaxin-1. Thus, CD193+ B cells, which co-express CXCR5, may be enroute to sites with allergic-like inflammation, such as gastrointestinal follicles, or even to Th2 granulomas, which develop around parasite eggs. Overall, our results suggest that schistosome infection may promote CD193 expression and suppress IgE via IL-10 and other undefined mechanisms related to B cell trafficking. This study adds to our understanding of why young children may have poor immunity. Nonetheless, praziquantel treatment was shown to reduce percentages of circulating CD193+ B cells lending hope for future vaccine efforts.

Randomized Phase 2b Study of Brimonidine Drug Delivery System Generation 2 for Geographic Atrophy in Age-related Macular Degeneration

PURPOSE

To evaluate the safety and efficacy of repeat injections of Brimonidine Drug Delivery System (Brimo DDS) Generation 2 (Gen 2) containing 400 μg brimonidine in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

DESIGN

Phase 2b, randomized, multicenter, double-masked, sham-controlled, 30-month study (BEACON).

PARTICIPANTS

Patients diagnosed with GA secondary to AMD and multifocal lesions with total area >1.25 mm² and ≤18 mm² in the study eye.

METHODS

Enrolled patients were randomized to treatment with intravitreal injections of 400-μg Brimo DDS (n=154) or sham procedure (n=156) in the study eye every 3 months from day 1 through month 21.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was change from baseline in the GA lesion area in the study eye, assessed with fundus autofluorescence imaging, at month 24. Safety measures included treatment-emergent adverse events (AEs).

RESULTS

The study was terminated early, at the time of the planned interim analysis, because of a slow GA progression rate (∼1.6 mm²/year) in the enrolled population. Least-squares mean (standard error) GA area change from baseline at month 24 (primary endpoint) was 3.24 (0.13) mm² with Brimo DDS (n=84) versus 3.48 (0.13) mm² with sham (n=91); the reduction in GA area change from baseline in the Brimo DDS group compared with the sham group was 0.25 mm² (7%) (P = 0.150). At month 30, the GA area change from baseline was 4.09 (0.15) mm² with Brimo DDS (n=49) versus 4.52 (0.15) mm² with sham (n=46), a reduction of 0.43 mm² (10%) with Brimo DDS compared with sham (P=0.033). Exploratory analysis showed numerically smaller loss over time in retinal sensitivity assessed with scotopic microperimetry with Brimo DDS compared with sham (P=0.053 at month 24). Treatment-related AEs were usually related to the injection procedure. No implant accumulation was observed.

CONCLUSIONS

Multiple intravitreal administrations of Brimo DDS (Gen 2) were well tolerated. The primary efficacy endpoint at 24 months was not met, but there was a numerical trend for reduction in GA progression at 24 months compared with sham treatment. The study was terminated early because of the lower-than-expected GA progression rate in the sham/control group.

Changes in Chinese students' academic emotions after examinations: Pride in success, shame in failure, and self-loathing in comparison

BACKGROUND

Several attempts have been made to examine students' academic emotions (AEs) in Western contexts, but less is known about how students' self-reported emotions vary over time.

AIMS

The study aimed to understand Chinese students' emotional responses to academic events and the impact of high-stakes testing on their AEs in the first year with a repeated-measures survey after the Semester 1 and Semester 2 mid-term examinations.

SAMPLES

351 first-year university students completed both surveys in an elite Chinese university, where the top 10% of first-year students were assigned to an honours programme.

METHODS

Self-reported AEs survey responses were evaluated with confirmatory factor analysis. Invariance testing between honours and ordinary students and between semesters was used to examine between-group differences across time.

RESULTS

A three-factor model of AEs (i.e., admired, shame, and self-loathing) was found in both semesters, with strong invariance between semesters. Mean scores between groups were equivalent and semester. However, self-loathing had the lowest mean (mean = 2.50; between mostly disagree and slightly agree), admired was at moderately agree (mean = 4.00), and shame was strongest at just over moderately agree (mean = 4.20).

CONCLUSIONS

This study reveals a three-factor structure of AEs and the stability of these emotions among highly successful Chinese learners. Despite being elite students, this sample of Chinese learners felt shame and pride in response to mid-term examinations.

Developing the Metacognitive Awareness of Grit Scale for a better understanding of learners of English as a foreign language

The prominent impact of metacognition on learners' academic achievement is widely discussed. Learners armed with appropriate metacognitive strategies should witness enhancement in learning performance. Similarly, the concept of grit is also valued as a crucial factor contributing to the improvement of academic achievement. Nevertheless, discussion of the relationship between metacognition and grit or their collective influence on other educational and psychological variables is limited, not to mention that an instrument measuring learners' metacognitive awareness of grit is a desideratum. Hence, by incorporating the constructs of metacognition and grit, the present research developed a measurement scale to address this need, named the Metacognitive Awareness of Grit Scale (MCAGS). The MCAGS consists of four components and initially included 48 items. It was later distributed to 859 participants for the purpose of scale validation. Confirmatory factor analysis was applied to evaluate the scale's validity and explore the factor-item relationship. A final model containing 17 items was retained. Implications and future directions were discussed.

AB0309 MEASURING THE DIFFERENCE: COMPARISON OF MEASUREMENT OF FREE INFLIXIMAB ANTI-DRUG ANTIBODIES

Background:

Infliximab (IFX) was one of the first TNF alpha inhibitors to be licenced in inflammatory arthritis and is still commonly used today. Studies have shown that approximately 50% of primary IFX responders will suffer from secondary loss of response within the first 12 months of treatment (1). The development of Anti-Drug Antibodies (ADA’s) plays a significant role in this treatment failure (2).

Monitoring of ADA’s helps identify those patients who fail to respond to treatment due to low IFX trough levels. In this scenario the presence of ADA’s can aid decision-making regarding increasing IFX dosing or switching biologic therapy to optimise treatment. (3).

Objectives:

Despite their potential importance the detection of ADAs varies widely depending on the type of assays used. The aim of this study was to determine the qualitative concordance of three commercially available ELISA kits for measurement of free ADAs to IFX on the Grifols Triturus analyser.

Methods:

150 patient samples from patients with inflammatory conditions and low IFX trough drug levels (≤0.6µg/ml) were analysed for free ADAs using Promonitor, Lisa Tracker and IDKmonitor kits on the Grifols Triturus automated ELISA analyser.

Results:

Kappa coefficient (κ) analysis indicated a moderate agreement between the Promonitor and IDKmonitor assays (κ =0.484 (95% CI, 0.357 to 0.611)) and the IDKmonitor and Lisa Tracker assays (κ = 0.485 (95% CI, 0.348-0.621)) as well as substantial agreement between the Promonitor and Lisa Tracker assays (κ =0.768 (95% CI, 0.667-0.870)). Figure 1 shows the distribution of samples identified as free ADA positive by each kit.

Figure 1.

Distribution of samples identified as free ADA positive by Promonitor, Lisa Tracker, and IDKmonitor assays. Fifty samples were considered positive by all assays. Three samples were considered positive by Promonitor and Lisa Tracker, and eight samples were considered positive by Lisa Tracker and IDKmonitor. No samples were considered positive by Promonitor and IDKmonitor. One sample was considered positive by Promonitor only, seven samples were considered positive by Lisa Tracker only, and twenty-six samples were considered positive by IDKmonitor

Conclusion:

All kits appear amenable for utilisation in a high-throughput laboratory though a true quantitative comparison between these kits was precluded by the absence of any certified reference material for free ADAs to IFX.

Although broad qualitative agreement was found between the three kits, they should not be used interchangeably for patient management.

Further research is required to estimate the impact of free ADAs on efficiency of IFX treatment and patient management.

References:

[1]Quistrebert J, Hässler S, Bachelet D et al.Incidence and risk factors for adalimumab and infliximab anti-drug antibodies in rheumatoid arthritis: A European retrospective multicohort analysis. Seminars in Arthritis and Rheumatism Volume 48, Issue 6, June 2019, Pages 967-975 2.

[2]Moots RJ, Xavier RM, Mok CC, Rahman MU, Tsai W-C, Al-Maini MH, et al. (2017)The impact of anti-drug antibodies on drug concentrations and clinical outcomes in rheumatoid arthritis patients treated with adalimumab, etanercept, or infliximab: Results from a multinational, real-world clinical practice, non-interventional study. PLoS ONE 12(4): e0175207.https://doi.org/10.1371/journal.pone.0175207

[3]Smolen JS, Landewé R, Bijlsma J, et al.EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:2016 update.Annals of the Rheumatic Diseases 2017;76:960-977.

Disclosure of Interests:

Rhona Hamilton: None declared, Stephanie Shields: None declared, Andrew McGucken: None declared, Jonathan MacDonald: None declared, Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Allan Dunlop: None declared, Elaine Gribben: None declared, Peter Galloway: None declared

Heroin Adulterated with the Novel Synthetic Cannabinoid, 5F-MDMB-PINACA: A Case Series

Introduction

Heroin can be adulterated with various substances that may or may not have pharmacological effects. Here we report a case series of 8 patients who presented to the emergency department after overdose with intravenous heroin preparation adulterated with the synthetic cannabinoid methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (5F-MDMB-PINACA).

Case Series

Except for one patient, all of them presented with a typical initial opioid toxidrome consisting of central nervous system and respiratory depression along with pinpoint pupils. Naloxone was given to them, triggering severe agitation and combative behavior along with overlapping features of anticholinergic and sympathomimetic toxidrome. All patients required multiple doses of benzodiazepines. Three were successfully treated with physostigmine.

Discussion

5F-MDMB-PINACA is a synthetic cannabinoid that was added to heroin in samples obtained from patients reported in this case series. Patients demonstrated significant agitation after receiving naloxone for opioid toxidrome, presumably because of the removal of the depressant effect of opioids, which unmasked the excitatory effects of the synthetic cannabinoids. Three patients required physostigmine along with the benzodiazepines for control of their agitation, urine retention and abnormal vitals, suggesting the possibility of an anticholinergic toxidrome to have developed in these patients.

Conclusion

Heroin contaminated with 5F-MDMB-PINACA exhibits variable severities of anticholinergic effects, some on presentation and others only after opiate antagonism.

An Unusual Case of Carbon Monoxide Poisoning from Formic and Sulfuric Acid Mixture

Formic acid, when combined with sulfuric acid, gets dehydrated to form carbon monoxide (CO). A 27-year-old female was found unconscious inside a car, next to a container with a mixture of sulfuric acid and formic acid. Concentrations of up to 400 parts per million of CO were measured inside the car post ventilation. Serum carboxyhemoglobin level was 15% after receiving 100% oxygen for two hours. The patient received hyperbaric oxygen therapy after which she was extubated with normal mental status. On follow-up after three months, she demonstrated neurocognitive abnormalities suggestive of delayed neurological sequelae from CO exposure.

Australia's contribution to the free abdominoplasty flap in breast reconstruction

N/a

Genome-scale evaluation of core one-carbon metabolism in gammaproteobacterial methanotrophs grown on methane and methanol

Methylotuvimicrobium alcaliphilum 20Z is a promising platform strain for bioconversion of one-carbon (C1) substrates into value-added products. To carry out robust metabolic engineering with methylotrophic bacteria and to implement C1 conversion machinery in non-native hosts, systems-level evaluation and understanding of central C1 metabolism in methanotrophs under various conditions is pivotal but yet elusive. In this study, a genome-scale integrated approach was used to provide in-depth knowledge on the metabolic pathways of M. alcaliphilum 20Z grown on methane and methanol. Systems assessment of core carbon metabolism indicated the methanol assimilation pathway is mostly coupled with the efficient Embden-Meyerhof-Parnas (EMP) pathway along with the serine cycle. In addition, an incomplete TCA cycle operated in M. alcaliphilum 20Z on methanol, which might only supply precursors for de novo synthesis but not reducing powers. Instead, it appears that the direct formaldehyde oxidation pathway supply energy for the whole metabolic system. Additionally, a comparative transcriptomic analysis in multiple gammaproteobacterial methanotrophs also revealed the transcriptional responses of central metabolism on carbon substrate change. These findings provided a systems-level understanding of carbon metabolism and new opportunities for strain design to produce relevant products from different C1-feedstocks.

Rapid, label-free genetic detection of enteropathogens in stool without genetic isolation or amplification

Current genetic detection methods require gene isolation, gene amplification and detection with a fluorescent-tagged probe. They typically require sophisticated equipment and expensive fluorescent probes, rendering them not widely available for rapid acute infection diagnoses at the point of care to ensure timely treatment of the diseases. Here we report a rapid genetic detection method that can detect the bacterial gene directly from patient stools using a piezoelectric plate sensor (PEPS) in conjunction with a continuous flow system with two temperature zones. With stools spiked with sodium dodecyl sulfate (SDS) in situ bacteria lysing and DNA denaturation occurred in the high-temperature zone whereas in situ specific detection of the denatured DNA by the PEPS occurred in the lower-temperature zone. The outcome was a rapid genetic detection method that directly detected bacterial genes from stool in < 40 min without the need of gene isolation, gene amplification, or expensive fluorescent tag but with polymerase chain reaction (PCR) sensitivity. In 40 blinded patient stools, it detected the toxin B gene of Clostridium difficile with 95% sensitivity and 95% specificity. The all-electrical, label-free nature of the detection further supports its potential as a low-cost genetic test that can be used at the point of care.

The Prostate Cancer Rehabilitation Clinic: a biopsychosocial clinic for sexual dysfunction after radical prostatectomy

Purpose

The most prevalent intervention for localized prostate cancer (pca) is radical prostatectomy (rp), which has a 10-year relative survival rate of more than 90%. The improved survival rate has led to a focus on reducing the burden of treatment-related morbidity and improving the patient and partner survivorship experience. Post-rp sexual dysfunction (sdf) has received significant attention, given its substantial effect on patient and partner health-related quality of life. Accordingly, there is a need for sdf treatment to be a fundamental component of pca survivorship programming.

Methods

Most research about the treatment of post-rp sdf involves biomedical interventions for erectile dysfunction (ed). Although findings support the effectiveness of pro-erectile agents and devices, most patients discontinue use of such aids within 1 year after their rp. Because side effects of pro-erectile treatment have proved to be inadequate in explaining the gap between efficacy and ongoing use, current research focuses on a biopsychosocial perspective of ed. Unfortunately, there is a dearth of literature describing the components of a biopsychosocial program designed for the post-rp population and their partners.

Results

In this paper, we detail the development of the Prostate Cancer Rehabilitation Clinic (pcrc), which emphasizes multidisciplinary intervention teams, active participation by the partner, and a broad-spectrum medical, psychological, and interpersonal approach.

Conclusions

The goal of the pcrc is to help patients and their partners achieve optimal sexual health and couple intimacy after rp, and to help design cost-effective and beneficial rehabilitation programs.

Rare Earth Elements Alter Redox Balance in Methylomicrobium alcaliphilum 20ZR

Background: Rare Earth Elements (REEs) control methanol utilization in both methane- and methanol-utilizing microbes. It has been established that the addition of REEs leads to the transcriptional repression of MxaFI-MeDH [a two-subunit methanol dehydrogenase (MeDH), calcium-dependent] and the activation of XoxF-MeDH (a one-subunit MeDH, lanthanum-dependent). Both enzymes are pyrroquinoline quinone-dependent alcohol dehydrogenases and show significant homology; however, they display different kinetic properties and substrate specificities. This study investigates the impact of the MxaFI to XoxF switch on the behavior of metabolic networks at a global scale.

Results: In this study we investigated the steady-state growth of Methylomicrobium alcaliphilum 20Z^R in media containing calcium (Ca) or lanthanum (La, a REE element). We found that cells supplemented with La show a higher growth rate compared to Ca-cultures; however, the efficiency of carbon conversion, estimated as biomass yield, is higher in cells grown with Ca. Three complementary global-omics approaches–RNA-seq transcriptomics, proteomics, and metabolomics–were applied to investigate the mechanisms of improved growth vs. carbon conversion. Cells grown with La showed the transcriptional activation of the xoxF gene, a homolog of the formaldehyde-activating enzyme (fae2), a putative transporter, genes for hemin-transport proteins, and nitrate reductase. In contrast, genes for mxaFI and associated cytochrome (mxaG) expression were downregulated. Proteomic profiling suggested additional adjustments of the metabolic network at the protein level, including carbon assimilation pathways, electron transport systems, and the tricarboxylic acid (TCA) cycle. Discord between gene expression and protein abundance changes points toward the possibility of post-transcriptional control of the related systems including key enzymes of the TCA cycle and a set of electron-transport carriers. Metabolomic data followed proteomics and showed the reduction of the ribulose-monophosphate (RuMP) pathway intermediates and the increase of the TCA cycle metabolites.

Conclusion: Cells exposed to REEs display higher rates of growth but have lower carbon conversion efficiency compared to cells supplemented with Ca. The most plausible explanation for these physiological changes is an increased conversion of methanol into formate by XoxF-MeDH, which further stimulates methane oxidation but limits both the supply of reducing power and flux of formaldehyde into the RuMP pathway.

Dark-adapted red flash ERGs in healthy adults

Purpose

The x-wave of the dark-adapted (DA) ERG to a red flash reflects DA cone function. This exploratory study of healthy adults aimed to investigate changes in the DA red ERG with flash strength and during dark adaptation to optimise visualisation and therefore quantification of the x-wave.

Methods

The effect of altering red flash strength was investigated in four subjects by recording ERGs after 20 min dark adaptation to red flashes (0.2–2.0 cd s m⁻²) using skin electrodes and natural pupils. The effect of dark adaptation duration was investigated in 16 subjects during 20 min in the dark, by recording DA 1.5 red ERGs at 1, 2, 3, 4, 5, 10, 15 and 20 min.

Results

For a dark adaption period of 20 min, the x-wave was more clearly visualised to weaker (< 0.6 cd s m⁻²) red flash strengths: to stronger flashes it became obscured by the b-wave. For red flashes of 1.5 cd s m⁻², the x-wave was most prominent in ERGs recorded after 1–5 min of dark adaptation: with longer dark adaptation, it was subsumed into the b-wave’s rising edge.

Conclusions

This small study suggests that x-wave visibility in healthy subjects after 20 min dark adaptation is improved by using flashes weaker than around 0.6 cd s m⁻²; for flash strengths of 1.5 cd s m⁻², x-wave visibility is enhanced by recording after only around 5 min of dark adaptation. No evidence was found that interim red flash ERGs affect the dark-adapted state of the normal retina.

Single centre audit of early impact of inclusion of the three vessel and trachea view in obstetric screening

Detection rates of congenital cardiac malformations have traditionally remained low. The NHS Fetal Anomaly Screening Programme (FASP) aims to increase these detection rates for various reasons, including influencing perinatal management and aiding parental decision making. The inclusion of the three vessel view and trachea (3VT) view in 2015 aimed to improve detection rates of arch abnormalities in particular. This study evaluated the early impact of the new initiative at one NHS Trust. Departmental screen-positive rates were compared for a full year before and after implementation. Referrals to, and opinions of, the foetal medicine unit (FMU) were assessed; as were undetected congenital heart defects for the two time periods. Compared with the pre-implementation (pre-3VT) period, the number of completed anomaly scans performed after implementation (post-3VT) increased by 3% and the number of FMU referrals increased by 625%. Departmental screen-positive rates for cardiac abnormalities increased from 40% (pre-3VT) to 91% (post-3VT). Over half (52%) of the FMU referrals were made due to a suspected abnormal 3VT view. Early evaluation of 3VT implementation at this NHS Trust indicates that it has been a success. Departmental screen-positive rates for congenital cardiac malformations have risen. However, this performance has come at a cost: Some abnormalities now being detected, such as loose vascular ring and PLSVC, are frequently asymptomatic and likely to be clinically insignificant. The implementation of 3VT achieves the aims of FASP but may begin to exceed what is expected from a low risk population screening programme.

Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines

Low intensity transcranial electrical stimulation (TES) in humans, encompassing transcranial direct current (tDCS), transcutaneous spinal Direct Current Stimulation (tsDCS), transcranial alternating current (tACS), and transcranial random noise (tRNS) stimulation or their combinations, appears to be safe. No serious adverse events (SAEs) have been reported so far in over 18,000 sessions administered to healthy subjects, neurological and psychiatric patients, as summarized here. Moderate adverse events (AEs), as defined by the necessity to intervene, are rare, and include skin burns with tDCS due to suboptimal electrode-skin contact. Very rarely mania or hypomania was induced in patients with depression (11 documented cases), yet a causal relationship is difficult to prove because of the low incidence rate and limited numbers of subjects in controlled trials. Mild AEs (MAEs) include headache and fatigue following stimulation as well as prickling and burning sensations occurring during tDCS at peak-to-baseline intensities of 1-2mA and during tACS at higher peak-to-peak intensities above 2mA. The prevalence of published AEs is different in studies specifically assessing AEs vs. those not assessing them, being higher in the former. AEs are frequently reported by individuals receiving placebo stimulation. The profile of AEs in terms of frequency, magnitude and type is comparable in healthy and clinical populations, and this is also the case for more vulnerable populations, such as children, elderly persons, or pregnant women. Combined interventions (e.g., co-application of drugs, electrophysiological measurements, neuroimaging) were not associated with further safety issues. Safety is established for low-intensity 'conventional' TES defined as <4mA, up to 60min duration per day. Animal studies and modeling evidence indicate that brain injury could occur at predicted current densities in the brain of 6.3-13A/m2 that are over an order of magnitude above those produced by tDCS in humans. Using AC stimulation fewer AEs were reported compared to DC. In specific paradigms with amplitudes of up to 10mA, frequencies in the kHz range appear to be safe. In this paper we provide structured interviews and recommend their use in future controlled studies, in particular when trying to extend the parameters applied. We also discuss recent regulatory issues, reporting practices and ethical issues. These recommendations achieved consensus in a meeting, which took place in Göttingen, Germany, on September 6-7, 2016 and were refined thereafter by email correspondence.

Mechanochemical ablation for symptomatic great saphenous vein reflux: A two-year follow-up

Background Several studies have shown comparable early efficacy of mechanochemical ablation to endothermal techniques. The goal of this report was to show if early efficacy is maintained at 24 months. Methods This was a two-year analysis on the efficacy of mechanochemical ablation in patients with symptomatic C2 or more advanced chronic venous disease. Patients with reflux in the great saphenous vein involving the sapheno-femoral junction and no previous venous interventions were included. Demographic information, clinical, and procedural data were collected. The occlusion rate of treated veins was assessed with duplex ultrasound. Patient clinical improvement was assessed by Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class and venous clinical severity score. Results Of the initial 126 patients, there were 65 patients with 24 month follow-up. Of these 65 patients, 70% were female, with a mean age of 70 ± 14 years and an average body mass index (BMI) of BMI of 30.5 ± 6. The mean great saphenous vein diameter in the upper thigh was 7.6 mm and the mean treatment length was 39 cm. Adjunctive treatment of the varicosities was performed in 14% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, 95% at 12 months, and 92% at 24 months. There was one patient with complete and four with partial recanalization ranging from 7 to 12 cm (mean length 9 cm). There was significant improvement in CEAP and venous clinical severity score (P < .001) for all time intervals. Conclusion Early high occlusion rate with mechanochemical ablation is associated with significant clinical improvement which is maintained at 24 months, making it a very good option for the treatment of great saphenous vein incompetence.

Clinical Characteristics and Outcomes of Late Relapse in Stage I Testicular Seminoma

AIMS

To identify the characteristics and outcomes associated with late relapse in stage I seminoma.

MATERIALS AND METHODS

A retrospective review was carried out of all patients with stage I seminoma managed at our institution between 1981 and 2011. Data were obtained from a prospectively maintained database. Late relapse was defined as tumour recurrence > 2 years after orchiectomy.

RESULTS

Overall, 1060 stage I seminoma patients were managed with active surveillance (n=766) or adjuvant radiotherapy (n=294). At a median follow-up of 10.6 years (range 1.2-30), 142 patients relapsed at a median (range) of 14 (3-129) months; 128 on active surveillance and 14 after adjuvant radiotherapy. The late relapse rate for the active surveillance and adjuvant radiotherapy groups was 4% and 1%, respectively. There was no specific clinicopathological factor associated with late relapse. Isolated para-aortic node(s) was the most common relapse site in active surveillance patients either in late (88%) or early relapse (82%). Among the active surveillance group, no patients with late relapse subsequently developed a second relapse after either salvage radiotherapy (n=25) or chemotherapy (n=6), whereas in early relapse patients a second relapse was reported in seven (10%) of 72 patients treated with salvage radiotherapy and one (4%) of 23 patients who received chemotherapy; all second relapses were subsequently salvaged with chemotherapy. No patient in the adjuvant radiotherapy group developed a second relapse after salvage chemotherapy (n=10) or inguinal radiotherapy/surgery (n=4). Of seven deaths, only one was related to seminoma. Among active surveillance patients, the 10 year overall survival for late and early relapse groups were 100% and 96% (P = 0.2), whereas the 10 year cancer-specific survival rates were 100% and 99% (P = 0.3), respectively.

CONCLUSIONS

In stage I seminoma, the extent and pattern of late relapse is similar to that for early relapse. For active surveillance patients, selective use of salvage radiotherapy/chemotherapy for relapse results in excellent outcomes regardless of the timing of relapse, whereas salvage radiotherapy for late relapse seems to be associated with a minimal risk of second relapse.

Photometric Compliance of Tablet Screens and Retro-Illuminated Acuity Charts As Visual Acuity Measurement Devices

Mobile technology is increasingly used to measure visual acuity. Standards for chart-based acuity tests specify photometric requirements for luminance, optotype contrast and luminance uniformity. Manufacturers provide some photometric data but little is known about tablet performance for visual acuity testing. This study photometrically characterised seven tablet computers (iPad, Apple inc.) and three ETDRS (Early Treatment Diabetic Retinopathy Study) visual acuity charts with room lights on and off, and compared findings with visual acuity measurement standards. Tablet screen luminance and contrast were measured using nine points across a black and white checkerboard test screen at five arbitrary brightness levels. ETDRS optotypes and adjacent white background luminance and contrast were measured. All seven tablets (room lights off) exceeded the most stringent requirement for mean luminance (≥ 120 cd/m2) providing the nominal brightness setting was above 50%. All exceeded contrast requirement (Weber ≥ 90%) regardless of brightness setting, and five were marginally below the required luminance uniformity threshold (Lmin/Lmax ≥ 80%). Re-assessing three tablets with room lights on made little difference to mean luminance or contrast, and improved luminance uniformity to exceed the threshold. The three EDTRS charts (room lights off) had adequate mean luminance (≥ 120 cd/m2) and Weber contrast (≥ 90%), but all three charts failed to meet the luminance uniformity standard (Lmin/Lmax ≥ 80%). Two charts were operating beyond manufacturer's recommended lamp replacement schedule. With room lights on, chart mean luminance and Weber contrast increased, but two charts still had inadequate luminance uniformity. Tablet computers showed less inter-device variability, higher contrast, and better luminance uniformity than charts in both lights-on and lights-off environments, providing brightness setting was >50%. Overall, iPad tablets matched or marginally out-performed ETDRS charts in terms of photometric compliance with high contrast acuity standards.

Mechanochemical ablation for symptomatic great saphenous vein reflux: A two-year follow-up

Background Several studies have shown comparable early efficacy of mechanochemical ablation to endothermal techniques. The goal of this report was to show if early efficacy is maintained at 24 months. Methods This was a two-year analysis on the efficacy of mechanochemical ablation in patients with symptomatic C2 or more advanced chronic venous disease. Patients with reflux in the great saphenous vein involving the sapheno-femoral junction and no previous venous interventions were included. Demographic information, clinical, and procedural data were collected. The occlusion rate of treated veins was assessed with duplex ultrasound. Patient clinical improvement was assessed by Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class and venous clinical severity score. Results Of the initial 126 patients, there were 65 patients with 24 month follow-up. Of these 65 patients, 70% were female, with a mean age of 70 ± 14 years and an average body mass index (BMI) of BMI of 30.5 ± 6. The mean great saphenous vein diameter in the upper thigh was 7.6 mm and the mean treatment length was 39 cm. Adjunctive treatment of the varicosities was performed in 14% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, 95% at 12 months, and 92% at 24 months. There was one patient with complete and four with partial recanalization ranging from 7 to 12 cm (mean length 9 cm). There was significant improvement in CEAP and venous clinical severity score (P < .001) for all time intervals. Conclusion Early high occlusion rate with mechanochemical ablation is associated with significant clinical improvement which is maintained at 24 months, making it a very good option for the treatment of great saphenous vein incompetence.

Draft genomes of gammaproteobacterial methanotrophs isolated from terrestrial ecosystems

Genome sequences of Methylobacter luteus, Methylobacter whittenburyi, Methylosarcina fibrata, Methylomicrobium agile, and Methylovulum miyakonense were generated. The strains represent aerobic methanotrophs typically isolated from various terrestrial ecosystems.

Multi-centre variability of ISCEV standard ERGs in two normal adults

BACKGROUND

The reproducibility of an individual's full-field ERG between centres has not previously been investigated.

METHODS

ERGs were recorded using both silver thread and skin electrodes from the same two normal adult subjects at 15 UK centres using routine, local protocols and a highly standardised, 'ISCEV-specified' protocol matching the values specified in the ISCEV standard; where the ISCEV standard allows options, a single value was chosen.

RESULTS

Inter-ocular differences were small, and amplitudes were smaller for skin than silver thread electrodes. No centre produced outlying data points, and ERGs across all 15 centres were remarkably similar. Amplitude variability was less for local protocols (using LED flashes) than for the ISCEV-specified protocol using xenon flashes (22 vs. 24 %, p = 0.01), but peak time variability was less for the ISCEV-specified protocol (6.1 vs. 7.4 %, p = 0.001). Only the DA 0.01 ERG correlated with photometric variability. The bifidity of the DA 3 a-wave doubled its peak time variability compared with the DA 10 a-wave.

CONCLUSIONS

Inter-centre amplitude variability was typically within clinically significant thresholds, suggesting that inter-centre variability with suitable standardisation may not add more to total variability than inter-subject variability. Variability improvements gained by the tighter specifications of the ISCEV-specified protocol were possibly more than lost due to imprecisions of xenon flashtubes. Peak time variability was far lower than amplitude variability, corresponding with acceptable variability of biochemical assays. These results represent a vindication of the existence of an ERG standard and suggest that further standardisation would lend itself to greater reproducibility of ERGs worldwide.