An evidence-based approach to the routine use of optical coherence tomography

Optical coherence tomography is an imaging technology that has revolutionised the detection, assessment and management of ocular disease. It is now a mainstream technology in clinical practice and is performed by non-specialised personnel in some settings. This article provides a clinical perspective on the implications of that movement and describes best practice using multimodal imaging and an evidence-based approach. Practical, illustrative guides on the interpretation of optical coherence tomography are provided for three major diseases of the ocular fundus, in which optical coherence tomography is often crucial to management: age-related macular degeneration, diabetic retinopathy and glaucoma. Topics discussed include: cross-sectional and longitudinal signs in ocular disease, so-called ‘red-green’ disease whereby clinicians rely on machine/statistical comparisons for diagnosis in managing treatment-naïve patients, and the utility of optical coherence tomography angiography and machine learning

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: A multimethod study

Objectives The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme. Design Multimethod: survey and retrospective review of referral forms. Setting Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia. Participants Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed. Results Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases. Conclusions This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes

A new early cognitive screening measure to detect cognitive side-effects of electroconvulsive therapy?

Cognitive side-effects from electroconvulsive therapy (ECT) can be distressing for patients and early detection may have an important role in guiding treatment decisions over the ECT course. This prospective study examined the utility of an early cognitive screening battery for predicting cognitive side-effects which develop later in the ECT course. The screening battery, together with the Mini Mental Status Examination (MMSE), was administered to 123 patients at baseline and after 3 ECT treatments. A more detailed cognitive battery was administered at baseline, after six treatments (post ECT 6) and after the last ECT treatment (post treatment) to assess cognitive side-effects across several domains: global cognition, anterograde memory, executive function, speed and concentration, and retrograde memory. Multivariate analyses examined the predictive utility of change on items from the screening battery for later cognitive changes at post ECT 6 and post treatment. Results showed that changes on a combination of items from the screening battery were predictive of later cognitive changes at post treatment, particularly for anterograde memory ( p<0.01), after controlling for patient and treatment factors. Change on the MMSE predicted cognitive changes at post ECT 6 but not at post treatment. A scoring method for the new screening battery was tested for discriminative ability in a sub-sample of patients. This study provides preliminary evidence that a simple and easy-to-administer measure may potentially be used to help guide clinical treatment decisions to optimise efficacy and cognitive outcomes. Further development of this measure and validation in a more representative ECT clinical population is required. © 2013 Elsevier Ltd

Visualisation of peripheral retinal degenerations and anomalies with ocular imaging

Purpose: Certain peripheral retinal degenerations pose a significant risk to vision and require prompt detection and management. Other historically “benign” peripheral lesions are being recognised as clinically significant due to their associations with ocular and systemic disorders. Assessment and documentation of these entities however can be difficult due to challenges in visualisation of the peripheral retina. This review addresses this by providing a series of clinical examples of these entities visualised with a variety of ocular imaging technologies. Methods: A literature search was performed in Embase, Medline, and Google Scholar. We identified and analysed all papers referring to peripheral retinal degenerations and the peripheral retina, as well as reference lists of retrieved articles until August 2019. Results: Using ocular imaging technologies including ultra-widefield imaging and peripheral optical coherence tomography, we comprehensively describe current evidence and knowledge of a number of peripheral retinal degenerations and anomalies including microcystoid, pavingstone, lattice, snail track, snowflake and reticular pigmentary degenerations, peripheral drusen, white without pressure, retinal holes and vitreoretinal tufts. A summary of these entities is also provided as a short and easily interpretable chairside guide to facilitate the translation of this evidence base into clinical practice. Conclusion: While ocular technologies are useful in visualising peripheral retinal degenerations, the current evidence is fragmented throughout the literature and there is a paucity of information on imaging of “benign” peripheral lesions. This review facilitates a multimodal imaging approach to evaluating peripheral lesions

Nation and/or Homeland: Identity in 19th-Century Music and Literature between Central and Mediterranean Europe

The aim of this book is to focus on the development of national awareness elaborated around a series of different case studies, in which the terms nation, homeland and people have been applied. This Romantic lexicon identifies similar but various conceptions of the national idea in some countries dominated by Italian, German and Slavic cultures, and in some groups or minorities such as the Jews and the Vlachs in Central and Mediterranean Europe. In order to clarify the cultural framework, the authors explore the construction of identity through folk tunes, poetry inspired by popular culture, and opera in which the national myths or heroes appear. In the self-making tradition, the national traits are sustained by the process of embodiment of any regional utterance, and also by disregarding the \u201cother\u201d, in particular the minorities. The symbols of the nation, as an achievement of the power that flourishes from the sense of belonging, are defined \u201cper differentiam\u201d. Theoretical perspectives are shaped by the new approaches to this topic, taking into consideration the artistic issues as socio-historical events and subsequently evaluating them in their aesthetic quality

Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: A randomised controlled proof-of-concept trial

Background Reduction of the pulse width has been reported to improve ECT outcomes with unilateral ECT (similar efficacy, fewer cognitive side effects), but has been minimally studied for bitemporal ECT. The only study comparing brief and ultrabrief pulse bitemporal ECT found reduced efficacy for bitemporal ultrabrief compared to bitemporal brief pulse stimulation. This randomised controlled trial (RCT) aimed to test if ultrabrief pulse bitemporal ECT results in fewer cognitive side effects than brief pulse bitemporal ECT, when given at doses adjusted with the aim of achieving comparable efficacy.Methods Thirty-six participants were randomly assigned to receive ultrabrief (at 3 times seizure threshold) or brief (at 1.5 times seizure threshold) pulse bitemporal ECT given 3 times a week in a double-blind, controlled proof-of-concept trial. Blinded raters assessed mood and cognitive functioning over the ECT course.Results Efficacy and cognitive outcomes did not differ significantly between the two treatment groups over the ECT course. The ultrabrief pulse group performed better on a test of visual memory assessed acutely after an ECT treatment.Conclusions This study suggests there may be a small cognitive advantage in giving bitemporal ECT with an ultrabrief pulse when dosage is increased to match the efficacy of brief pulse bitemporal ECT, but the study was underpowered to fully examine this issue. Clinical Trials Registration: www.clinicaltrials.gov, NCT00870805