A survey of current practices by the British Oculoplastic Surgery Society (BOPSS) and recommendations for delivering a sustainable multidisciplinary approach to thyroid eye disease in the United Kingdom

BACKGROUND: The Royal College of Physicians (RCP) and Thyroid Eye Disease Amsterdam Declaration Implementation Group (TEAMeD-5) have the common goal of improving access to high quality care for thyroid eye disease (TED). The TEAMeD-5 programme recommends all patients with moderate-to-severe TED should have access to multidisciplinary clinics (MDT)  with combined Ophthalmology and Endocrinology expertise. METHODS: The British Oculoplastic Surgery Society represents oculoplastic surgeons who usually lead TED care in the UK. A two-stage survey of the membership was conducted to ascertain current practice of existing resources. RESULTS: Seventy percent (45/65) of respondents in Survey 1 were aware of current RCP guidance, but only 49% (22/45) rated it as a good means of improving access to comprehensive TED service. Sixty percent (39/65) of respondents are working in a multidisciplinary TED clinic with co-location of ophthalmologists and endocrinologists. Care for TED appears not to be provided in a multidisciplinary context in up to 31% (20/65). Thirty five (54%) of the respondents rated their relationship with endocrinology colleagues as good. Best practice guidelines recommend routine quality of life assessments but only 6/28 (21%) of respondents use this modality in current practice. Six percent (4/65) of areas appear not to be using intravenous steroids. In many areas (25%, 16/65), second-line immunosuppression is provided in a different trust and in 8% (5/65), it appears not to be used at all. CONCLUSION: This survey is a 'snapshot' of current TED management in the UK and findings suggest scope for improvement. We recommend a framework for more robust collaboration across specialties and propose standards endorsed by multidisciplinary stakeholder societies

Assessment of Apple Watch Series 6 pulse oximetry and electrocardiograms in a pediatric population

BACKGROUND: Recent technologic advances have resulted in increased development and utilization of direct-to-consumer cardiac wearable devices with various functionality. This study aimed to assess Apple Watch Series 6 (AW6) pulse oximetry and electrocardiography (ECG) in a cohort of pediatric patients. METHODS: This single-center, prospective study enrolled pediatric patients ≥ 3kg and having an ECG and/or pulse oximetry (SpO2) as part of their planned evaluation. Exclusion criteria: 1) non-English speaking patients and 2) patients in state custody. Simultaneous tracings were obtained for SpO2 and ECG with concurrent standard pulse oximeter and 12-lead ECG. AW6 automated rhythm interpretations were compared to physician over-read and categorized as accurate, accurate with missed findings, inconclusive (automated interpretation: inconclusive ), or inaccurate. RESULTS: A total of 84 patients were enrolled over a 5-week period. 68 patients (81%) were placed into the SpO2 and ECG arm, with 16 patients (19%) placed into the SpO2 only arm. Pulse oximetry data was successfully collected in 71/84 (85%) patients and ECG data in 61/68 (90%). ΔSpO2 between modalities was 2.0±2.6% (r = 0.76). ΔRR was 43±44msec (r = 0.96), ΔPR 19±23msec (r = 0.79), ΔQRS 12±13msec (r = 0.78), and ΔQT 20±19msec (r = 0.9). The AW6 automated rhythm analysis yielded a 75% specificity and found: 1) 40/61 (65.6%) accurate , 2) 6/61 (9.8%) accurate with missed findings , 3) 14/61 (23%) inconclusive , and 4) 1/61 (1.6%) incorrect. CONCLUSION: The AW6 can accurately measure oxygen saturation when compared to hospital pulse oximeters in pediatric patients and provide good quality single lead ECGs that allow for accurate measurement of RR, PR, QRS, and QT intervals with manual interpretation. The AW6-automated rhythm interpretation algorithm has limitations for smaller pediatric patients and patients with abnormal ECGs

A single-center experience comparing first- versus second-generation insertable cardiac monitors in pediatric patients

Insertable cardiac monitors (ICMs) have undergone advancements in size and functionality over the past decade, resulting in the introduction of small, easily insertable devices capable of long-term remote monitoring. We define first-generation ICMs as implantable cardiac monitoring devices that require an incision and surgical creation of a subcutaneous pocket and second-generation ICMs as devices implanted using a custom-made tool for subcutaneous insertion, respectively. The aim of this study was to understand the differences between first- and second-generation pediatric ICM implants, implant indications, and time to diagnosis. We performed a retrospective, single-center chart review of patients who underwent ICM implantation from 2009-2019, spanning a 5-year course of first-generation ICM implantations and 5-year course of second-generation ICM implantations. Demographic data, past medical history, implant indication, and time to diagnosis were obtained. A total of 208 patients were identified over the 10-year time period, including 38 (18%) who underwent implantation with a first-generation device and 170 (82%) who underwent implantation with a second-generation device. Implant indications for first-generation ICMs included syncope (71%), palpitations (16%), inherited arrhythmia syndrome (IAS) management (5%), and premature ventricular contractions/ventricular tachycardia (VT) (8%); implant indications for second-generation ICMs included syncope (48%), palpitations (19%), IAS management (40%), premature ventricular contractions/VT (11%), atrial fibrillation (2%), tachycardia (3%), and heart block (0.5%). The average time to diagnosis was 38 weeks for patients with first-generation devices and 55 weeks for those with second-generation devices. With innovations in ICM technologies, there are expanding indications for ICM implantation in pediatric patients for long-term monitoring, specifically regarding the management of IAS patients

Early preclinical experience of a mixed reality ultrasound system with active GUIDance for NEedle-based interventions: The GUIDE study

BACKGROUND: Use of ultrasound (US) to facilitate vascular access has increased compared to landmark-based procedures despite ergonomic challenges and need for extrapolation of 2-dimensional images to understand needle position. The MantUS™ system (Sentiar, Inc.,) uses a mixed reality (MxR) interface to display US images and integrate real-time needle tracking. OBJECTIVE: The purpose of this prospective preclinical study was to evaluate the feasibility and usability of MantUS in a simulated environment. METHODS: Participants were recruited from pediatric cardiology and critical care. Access was obtained in 2 vascular access training models: a femoral access model and a head and neck model for a total of 4 vascular access sites under 2 conditions-conventional US and MantUS. Participants were randomized for order of completion. Videos were obtained, and quality of access including time required, repositions, number of attempts, and angle of approach were quantified. RESULTS: Use of MantUS resulted in an overall reduction in number of needle repositions ( CONCLUSION: Use of MantUS improved vascular access among all comers, including the quality of access. This improvement was even more notable in the vascular variant (RFV). MantUS readily benefited users by providing improved spatial understanding. Further development of MantUS will focus on improving user interface and experience, with larger clinical usage and in-human studies

Cryoablation: how to improve results in atrioventricular nodal reentrant tachycardia ablation?

Ablation for atrioventricular nodal reentry tachycardia is very effective, with a potential for damage to the normal conduction system. Cryoablation is an alternative, as it allows cryomapping, which permits assessment of slow pathway elimination at innocent freezing temperatures, avoiding permanent damage to the normal conduction system. It is associated with shorter radiation times and the absence of heart block in all published data. We discuss in this overview different approaches of cryoenergy delivery (focusing on spot catheter ablation), and how lesion formation is influenced by catheter tip size, application duration, and freezing rate. Some advantages of cryoenergy are explained. Whether these features also apply for an approach with a cryoballoon, e.g. for atrial fibrillation is unclear

Trust and contextual engagement with the PEPPER system: The qualitative findings of a clinical feasibility study

Background and aims. PEPPER (Patient Empowerment through Predictive PERsonalised decision support) is an EU-funded research project which aims to improve self-management of type 1 diabetes (T1D). The system comprises an AI insulin bolus recommender, coupled with a safety system. The aim of the qualitative arm of this clinical feasibility study was to examine the context of participants’ interaction with the PEPPER system and identify incidents where bolus recommendations were trusted and accepted. Methods. This was a multicentre (UK and Spain) non-randomised open-labelled 6-week pilot study. Thirteen adults with T1D participated in weekly telephone interviews to explore the context of their interactions and responses to PEPPER. Data was thematically analysed through conceptual frameworks for engagement with healthcare digital behaviour change interventions. Results. Participants reported their key interactions as responding to PEPPER bolus recommendations, inputting carbohydrate values, interpreting continuous glucose monitoring (CGM) values through visualization of personal data and dealing with safety alarms. Two themes were associated with trust and engagement with the system; ‘feeling monitored’ and ‘feeling in control’. The incidents where participants trusted PEPPER also enhanced personal expertise of T1D through insights provided by the safety system such as low glucose basal insulin for pump users. Benefits were balanced against technical challenges of the system, which were used to improve the PEPPER application and enhance user experience. Conclusion. Some participants suggested that even access to PEPPER for a temporary period could positively influence self-management strategies. Contextual interviewing is a valuable tool in mobile application development for diabetes decision support systems

Sotrovimab versus usual care in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Background: Sotrovimab is a neutralising monoclonal antibody targeting the SARS-CoV-2 spike protein. We aimed to evaluate the efficacy and safety of sotrovimab in the RECOVERY trial, an investigator-initiated, individually randomised, controlled, open-label, adaptive platform trial testing treatments for patients admitted to hospital with COVID-19. Methods: Patients admitted with COVID-19 pneumonia to 107 UK hospitals were randomly assigned (1:1) to either usual care alone or usual care plus a single 1 g infusion of sotrovimab, using web-based unstratified randomisation. Participants were eligible if they were aged at least 18 years, or aged 12–17 years if weighing at least 40kg, and had confirmed COVID-19 pneumonia with no medical history that would put them at significant risk if they participated in the trial. Participants were retrospectively categorised as having a high antigen level if baseline serum SARS-CoV-2 nucleocapsid antigen was above the median concentration (the prespecified primary efficacy population), otherwise they were categorised as having a low antigen level. The primary outcome was 28-day mortality assessed by intention to treat. Safety outcomes were assessed among all participants, regardless of antigen level. Recruitment closed on March 31, 2024, when funding ended. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936). Findings: From Jan 4, 2022, to March 19, 2024, 1723 patients were enrolled in the RECOVERY sotrovimab comparison. Of these, 828 (48%) were assigned to usual care plus sotrovimab and 895 (52%) were assigned to usual care only. Mean patient age was 70·7 years (SD 14·8) and 1033 (60%) were male. 720 (42%) patients were classified as having a high antigen level, 717 (42%) as having a low antigen level, and 286 (17%) had unknown antigen status. 1389 (81%) patients were vaccinated, 1179 (82%) of 1438 patients with known serostatus had anti-spike antibodies at randomisation, and 1021 (>99%) of 1026 patients with sequenced samples were infected with omicron variants. Among patients with a high antigen level, 82 (23%) of 355 assigned to sotrovimab versus 106 (29%) of 365 assigned usual care died within 28 days (rate ratio 0·75, 95% CI 0·56–0·99; p=0·046). In an analysis of all randomly assigned patients (regardless of antigen status), 177 (21%) of 828 patients assigned to sotrovimab versus 201 (22%) of 895 assigned to usual care died within 28 days (0·95, 0·77–1·16; p=0·60). Infusion reactions were recorded in 12 (2%) of 781 patients receiving sotrovimab. We found no difference between groups in any other safety outcome. Interpretation: In patients admitted to hospital with COVID-19 pneumonia, sotrovimab was associated with reduced mortality in the primary analysis population who had a high serum SARS-CoV-2 antigen concentration at baseline, but not in the overall population. Treatment options for patients admitted to hospital are limited, and mortality in those receiving current standard of care was high. The emergence of high-level resistance to sotrovimab among subsequent SARS-CoV-2 variants restricts its current usefulness, but these results indicate that targeted neutralising antibody therapy could potentially still benefit some patients admitted to hospital who are at high risk of death in an era of widespread vaccination and omicron infection. Funding: UK Research and Innovation (Medical Research Council) and National Institute for Health and Care Research

An Experimental Study on Ternary Blended Fibre Reinforced concrete with Basalt Fibre and Steel Fibre

Abstract Concrete is a popular building material because of its great compressive strength, durability, and availability of sub-components. The strain at fracture and tensile strength of normal concrete are extremely poor. Simple concrete usually contains multiple micro-cracks and fails due to a lack of tensile strength under continuous loading conditions. Concrete is strengthened with fibres to increase tensile and flexure strength. Fibre-reinforced concrete’s primary function is to monitor cracking and thus provide some post-cracking ductility. The aim is to compare the performance of fibres on the mechanical properties of M30 grade concrete and to find the optimal fibre concentration. Fibres are added by 0.5%, 1%, 1.5% and 2% in concrete. Ternary blended concrete was considered in the study. Cement is partially replaced by GGBS with 30% and Dolomite powder 10% respectively. The study took in to account the replacement to reduce the CO2 emission while also conserving natural resources. Total 8 mixes are prepared with fibre proportions. Different concrete specimens such as cubes, cylinders and beams are prepared with different proportions of fibres. Prepared concrete specimens were tested at 3, 7&amp; 28days. The inclusion of fibres resulted in significant improvements in compression, flexure, and split tensile strength in experimental test results.</jats:p