Salman Waqar

Cost implications, deprivation and geodemographic segmentation analysis of non-attenders (DNA) in an established diabetic retinopathy screening programme.

AIM To ascertain the relationship between socioeconomic status and non attendance alongside the role of geodemographic analysis in identifying reasons for non attendance. To also ascertain the financial implications of non attendance on the service. METHODS Retrospective analysis of DNA patients between April 2009 and March 2010. Cost to the service was calculated based on Devon Primary Care Trust tariffs. Deprivation Analysis was based on the Indices of Multiple Deprivation 2007 for England. Geodemographic analysis was done using a commercially available software (MOSAIC Public Sector, Experian Information Solutions Inc.). RESULTS 22,651 patients were invited for screening with 20,514 screened and 2137 (9.4%) DNAs. Of these, 1757 (82.2%) were DNA 1s while 380 (17.7%) were DNA 2s. Mean age of screened patients was 68 (SD ±14.2), DNA 1s was 62 (SD ±17.3) and DNA 2s was 57 (SD ±18.7).1269 (59%) of DNAs were males and 868 (41%) were females. Cost to the service as calculated by lost earnings from missed appointments came to £78,259. Deprivation analysis showed increasing non attendance rates with increasing deprivation. Geodemographic segmentation analysis revealed that the lowest DNA rates were seen in successful professionals and active retired communities and the highest rates were seen in areas of social housing. CONCLUSIONS The study demonstrates an association between non attendance and socioeconomic deprivation. The use of geodemographic analysis programmes can help identify groups that do not respond to traditional postal reminders. More focused and customised strategies can then be developed for these groups to eliminate nonattendance.

Effect of distraction on simulated anterior segment surgical performance

PURPOSE: To determine the effect of distraction on anterior segment surgical performance using a virtual reality simulator in expert and novice surgeons. SETTING: Horizon Suite Simulation Centre, South Devon Foundation NHS Trust, Devon, England. DESIGN: Cohort study. METHODS: Expert and novice ophthalmic surgeons completed a standardized and validated surgical task 10 times on a virtual reality simulator (EyeSi). They then completed a cognitive task (arithmetic questions), after which they completed 10 attempts on the simulator module while also completing the cognitive task. RESULTS: For experts (n = 7), the distracting cognitive task had no statistically significant effect on operating scores. The rate of correctly answered questions decreased from 12.3 per minute ± 2.1 (SD) while single tasking to 8.6 ± 3.1 per minute while dual tasking (P=.018). For novices (n = 14), the distracting cognitive task had no effect on any operating score except a small reduction in the penalty odometer score. The rate of correctly answered questions decreased from 11.5 ± 4.1 per minute while single tasking to 7.0 ± 3.2 per minute while dual tasking (P=.001). CONCLUSION: A distractive cognitive task reduced the ability of novice surgeons and expert surgeons to deal with that cognitive task, although their simulated surgical performance was not overtly compromised. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Safety of nondominant-hand ophthalmic surgery

PURPOSE: To establish the safety of nondominant‐hand simulated intraocular surgery. SETTING: Horizon Suite Simulation Centre, South Devon Foundation NHS Trust, Devon, United Kingdom. DESIGN: Cohort study. METHODS: Physicians with no previous ophthalmic surgical experience completed an introductory program on the EyeSi ophthalmic surgical simulator to eliminate the learning curve. They then completed the validated level‐4 forceps module 4 times with their dominant hand and then 4 times with their nondominant hand. Simulator total score, odometer movement, corneal injury, lens injury, and total time were recorded. Acuity (Snellen near) and stereoacuity (Frisby) were also recorded. RESULTS: All 30 physicians showed good acuity (6/6 and N6 or better) and stereopsis (mean 35 seconds of arc). The total score was lower (mean 60.8 versus 65.6; P=.019), operating times were longer (mean 71.6 versus 70.0; P=.026), and lens injury was greater (mean 0.93 versus 0.79, P=.021) when operating with the nondominant hand than with operating with the dominant hand. Those with higher scores with the dominant hand had higher scores with their nondominant hand. CONCLUSIONS: Simulated nondominant‐hand ophthalmic surgery resulted in less efficient, less safe, and slower surgery. This observation was more marked in those with less skill with their dominant hand. This has practical implications for trainee and trainer if 1 surgeon is left handed and 1 right handed. It also suggests that a higher degree of competence with the dominant hand is required before performing nondominant‐hand surgery. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Can virtual reality simulation help to determine the importance of stereopsis in intraocular surgery

Aim To establish the effect of acute loss of stereopsis on simulated intraocular surgical performance. Methods This study was performed using the EYESi ophthalmic surgical simulator. Thirty junior doctors with no previous ophthalmic surgical experience were enrolled and distance visual acuity (Snellen), near visual acuity and stereoacuity (Frisby) were recorded. All participants completed a standard introductory programme on the forceps module to eliminate the learning curve. They then undertook four attempts of level 4 forceps module binocularly and another four monocularly to simulate an acute loss of stereopsis. Total score, odometer movement, corneal area injured, lens area injured and total time taken were recorded. Results Mean age was 31 years (SD±9). None had amblyopia, with all demonstrating distance visual acuity of 6/6 or better and N6 for near. Mean stereopsis was 35 s of arc (SD±18). Average total score decreased from 60 while operating binocularly to 47 monocularly (p<0.05). Average corneal area injured increased from 0.95 mm2 to 2.30 mm2 (p<0.05), average lens area injured increased from 1.76 mm2 to 3.53 mm2 (p<0.05) and average time taken increased from 69.6 s to 77.4 s (p<0.05). Conclusion The importance of stereopsis for intraocular surgery is difficult to establish in a live theatre setting without compromising patient safety. Virtual reality simulators provide a safe alternative. This study demonstrates a statistically significant decrease in simulated intraocular surgical performance with acute loss of stereopsis in potential ophthalmic training applicants. Caution is recommend in using these results to advocate stereopsis testing as a screening tool in interviews because some participants performed well despite an absence of stereopsis.

Exacerbation of psoriasis with β-blocker therapy

A 54-year-old man with a 20-year history of erythrodermic psoriasis underwent coronary artery bypass graft surgery. The patient had no prior history of β-blocker use. He was given the β-blocker bisoprolol postoperatively to treat atrial fibrillation. Within 72 hours after beginning therapy with

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a relatively rare but important cause of acute coronary syndrome. The diagnosis is often made at autopsy. Risk factors include the peripartum period, oral contraceptive use, and atherosclerotic disease. SCAD must be considered every time a healthy young patient presents with an onset of acute myocardial ischemic syndrome. A timely diagnosis and intervention are mandatory as SCAD can cause sudden death. We describe two cases of SCAD, both treated successfully with emergency coronary artery bypass grafting using left internal mammary and radial arteries in the first case and the left internal mammary artery only for the second case.

Bilateral coronary ostial disease following mediastinal irradiation: a case report

IntroductionOstial coronary artery disease is rare with a reported incidence of 0.07 to 0.25% in all patients undergoing angiography. It has a strong association with previous mediastinal irradiation, which induces specific histological changes distinct from atherosclerotic lesions. The radiation also affects the myocardium and surrounding structures, which can alter the surgical approach.Case presentationWe present a case of a 62-year-old female who developed bilateral ostial coronary artery stenosis 32 years following therapeutic radiotherapy for Hodgkins disease. She underwent successful coronary artery bypass surgery using a combination of arterial and venous conduits. Postoperatively she developed a clinical picture of diastolic impairment not detected pre-operatively. She was managed appropriately and made a successful recovery.ConclusionsThis case highlights the cardiac pathology associated with mediastinal irradiation, which should be suspected during surgical assessment, especially in long-term survivors. It heightens the surgeons awareness so a more thorough evaluation of coronary anatomy, ventricular function and potential conduits is made prior to surgery.

Night blindness in primary biliary cirrhosis

A 58-year-old woman was referred by her optician because of decreased clarity of vision in both eyes with poor night vision. Her medical history included late-stage primary biliary cirrhosis. Her visual acuity was 6/6 in both eyes and ocular examination was unremarkable. An electroretinogram showed

Simple technique of talc delivery for video-assisted talc pleurodesis

It has been proven that talc is the sclerosant of choice for pleurodesis, especially for malignant effusions. Uniform talc deposition on the visceral pleura is often difficult, resulting in clump deposition with the use of an atomizer or bladder syringe delivery apparatus. We have devised a simple sterile apparatus that allows the operator to retain full control over the talc delivery rate and coat the lung uniformly under direct vision using a pressurized system.