Publications by authors named "Swan Kang"

20 Publications

  • Page 1 of 1

Introducing the 'Benign Eyelid Lesion Pathway': 1 year experience of synchronous tele-oculoplastics in a tertiary hospital.

Eye (Lond) 2022 Jul 4. Epub 2022 Jul 4.

Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, 162 City Rd, London, EC1V 2PD, UK.

Background: Patients with benign eyelid lesions make up a large proportion of referrals to the oculoplastic service and lend themselves well to telemedicine with assessments heavily reliant on history, observation-based examination and photographs to enable management decision-making. Our tertiary unit set up tele-oculoplastics clinics for all new patients referred for benign eyelid lesions comprising tele-consultation with antecedent patient photograph: Benign Eyelid Lesion Pathway (BELP). One year on, we describe a retrospective analysis of 974 patients looking at distinct parameters of effectiveness.

Methods: We retrospectively collected data from electronic patient records (EPR) for BELP patients from July 2020 to August 2021 (n = 974). We analysed time efficiency (referral time to treatment plan, consultation duration in minutes, average waiting times, number of patients seen per clinician and DNA rate), accessibility, safety (via video surveillance clinic) and theatre utilisation.

Results: 57.3% (n = 558) were listed for a surgical procedure direct from tele-consultation with 94.9% (n = 513) of these proceeding to surgery; 22.8% (n = 222) were discharged, 10.7% (n = 104) had further video follow-up and 6.7% (n = 65) required face-to-face follow-up. Our results showed efficient referral-to-treatment times, waiting times, consultation times and non-attendance rate. There was only a 2.57% non-attendance rate. There was no missed diagnosis of a malignancy of a presumed benign lesion.

Conclusion: Tele-oculoplastics provides a streamlined, safe, effective, and logistically convenient way to review benign eyelid lesions. With the increased waiting times for referral to biopsy of eyelid lesions, this clinic shows it is imperative to provide digital accessibility for patient assessment and booking to operating theatre.
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http://dx.doi.org/10.1038/s41433-022-02166-4DOI Listing
July 2022

Rituximab for thyroid-associated ophthalmopathy.

Cochrane Database Syst Rev 2022 06 16;6:CD009226. Epub 2022 Jun 16.

Moorfields and UCL Institute of Ophthalmology BMRC, Moorfields Eye Hospital NHS Foundation Trust, London, UK.

Background: Thyroid-associated ophthalmopathy (TAO) is the most frequent extrathyroidal manifestation of Graves' disease, affecting up to 50% of patients. It has a great impact on quality of life. Rituximab (RTX) is a human/murine chimeric monoclonal antibody that targets the CD20 receptor on B-lymphocytes. Preliminary work has shown that blocking this CD20 receptor with RTX may affect the clinical course of TAO by reducing inflammation and the degree of proptosis.  OBJECTIVES: This review update, originally published in 2013, assesses the efficacy and safety of using RTX for the treatment of TAO.

Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 2), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Science Information database (LILACS), the ISRCTN registry, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (WHO ICTRP). There were no language restrictions in the electronic search for trials. We last searched the electronic databases on 22 February 2022.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of RTX administered by intravenous infusion using any dosage regimen for the treatment of active TAO in adults, compared to placebo or glucocorticoids treatment.  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently scanned titles and abstracts, and screened full-text reports of potentially relevant studies. The outcomes of interest in this review were: clinical activity score (CAS), NOSPECS severity scale, proptosis (mm), palpebral aperture (mm), extraocular motility (degrees or diplopia rating scale), quality of life and adverse effects.

Main Results: We identified two studies that met the inclusion criteria in this updated review. Across both studies, the mean age of participants was 55 years and 77% were women. RTX compared to intravenous methylprednisolone (IVMP) One study, conducted in Italy, compared RTX (n = 15 after one participant withdrew) with IVMP (n = 16) for active TAO (CAS ≥ 3 out of 7 or 4 out of 10). We judged this study to be at low risk of bias in most domains, but it was stopped early because of disease reactivation in the comparator group (5/16 participants). This study provided low-certainty evidence that RTX may result in CAS improvement at 24 weeks compared to IVMP (15/15 versus 12/16 improved by ≥ 2 points; risk ratio (RR) 1.32, 95% confidence interval (CI) 0.98 to 1.78). Only very low-certainty evidence was available for the other outcomes: NOSPECS improvement by 2 or more classes (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); proptosis improvement by 2 mm or more (0/15 versus 1/16; RR 0.35, 95% CI 0.02 to 8.08); palpebral aperture improvement by 3 mm or more (2/15 versus 0/16; RR 5.31, 95% CI 0.28 to 102.38); motility improvement by 1 class or more (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); and improvement on the Graves' ophthalmopathy QoL scale by at least 6 points for "functioning" (5/14 versus 8/13; RR 0.58, 95% CI 0.25 to 1.32), and "appearance" (9/14 versus 6/13; RR 1.39, 95% CI 0.69 to 2.82). Adverse events were more common in the RTX group (RR 1.39, 95% CI 0.90 to 2.13; low-certainty evidence). Minor adverse effects (mild infusion reactions) were observed in most people receiving RTX at first infusion. Two participants experienced a major infusion reaction, likely cytokine release syndrome. RTX compared to placebo One study, conducted in the USA, enrolled 25 participants with active TAO (CAS ≥ 4 out of 7), comparing RTX (13 participants) to placebo. We judged this study to be at low risk of bias in most domains, but it was stopped early due to recruitment issues. It provided very low-certainty evidence on the following outcomes at 24 weeks: CAS improvement by 2 or more points (4/13 RTX versus 3/12 placebo; RR 1.23, 95% CI 0.34 to 4.40); NOSPECS improvement by 2 or more classes (2/13 versus 2/12; RR 0.92, 95% CI 0.15 to 5.56); proptosis improvement by 2 mm or more (2/13 versus 4/12; RR 0.46, 95% CI 0.10 to 2.08); palpebral aperture median change (0 mm in RTX group, in both eyes separately, versus -0.5 mm and 0.5 mm in placebo group right and left eye, respectively); motility median diplopia score (3 versus 2.5); SF-12 physical component median score (45.9 versus 40.3) and mental component median score (52.8 versus 46.1). More participants in the RTX group experienced adverse effects (8/13 versus 3/12; RR 2.46, 95% CI 0.84 to 7.18).  AUTHORS' CONCLUSIONS: There is currently insufficient evidence to support the use of RTX in people with TAO. Future studies investigating RTX in people with active TAO may need to be multi-centre in order to recruit enough participants to make an adequate judgement on the efficacy and safety of this novel therapy.
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http://dx.doi.org/10.1002/14651858.CD009226.pub3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202994PMC
June 2022

Digital Transformation in Ophthalmic Clinical Care During the COVID-19 Pandemic.

Asia Pac J Ophthalmol (Phila) 2021 Jul-Aug 01;10(4):381-387

Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, United Kingdom.

Abstract: COVID-19 has placed unprecedented pressure on health systems globally, whereas simultaneously stimulating unprecedented levels of transformation. Here, we review digital adoption that has taken place during the pandemic to drive improvements in ophthalmic clinical care, with a specific focus on out-of-hospital triage and services, clinical assessment, patient management, and use of electronic health records. We show that although there have been some successes, shortcomings in technology infrastructure prepandemic became only more apparent and consequential as COVID-19 progressed. Through our review, we emphasize the need for clinicians to better grasp and harness key technology trends such as telecommunications and artificial intelligence, so that they can effectively and safely shape clinical practice using these tools going forward.
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http://dx.doi.org/10.1097/APO.0000000000000407DOI Listing
September 2021

Impact and Challenges of Integrating Artificial Intelligence and Telemedicine into Clinical Ophthalmology.

Asia Pac J Ophthalmol (Phila) 2021 May-Jun 01;10(3):317-327

NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.

Abstract: Aging populations and worsening burden of chronic, treatable disease is increasingly creating a global shortfall in ophthalmic care provision. Remote and automated systems carry the promise to expand the scale and potential of health care interventions, and reduce strain on health care services through safe, personalized, efficient, and cost-effective services. However, significant challenges remain. Forward planning in service design is paramount to safeguard patient safety, trust in digital services, data privacy, medico-legal implications, and digital exclusion. We explore the impact and challenges facing patients and clinicians in integrating AI and telemedicine into ophthalmic care-and how these may influence its direction.
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http://dx.doi.org/10.1097/APO.0000000000000406DOI Listing
October 2021

Telemedicine in oculoplastic and adnexal surgery: clinicians' perspectives in the UK.

Br J Ophthalmol 2021 Apr 28. Epub 2021 Apr 28.

Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.

Background/aims: The COVID-19 has facilitated a paradigm shift in the sphere of ophthalmic telemedicine: its utility is no longer limited to providing care to remote regions, rather it is expeditiously being adopted as the new standard of care. The aim of our paper is to explore the current attitudes of oculoplastic surgeons towards telemedicine and its utility in the present landscape and its prospects in the future.

Methods: A 39-item questionnaire was distributed to consultant oculoplastic surgeons practising across the UK and anonymised responses were collected and analysed.

Results: The COVID-19 pandemic has allowed rapid implementation of telemedicine services in oculoplastic departments across the UK with 86.6% of the respondents incorporating telemedicine into the routine clinical practice. Clinicians reported a statistically significant increase in utility of telemedicine, confidence in using telemedicine and quality of infrastructure available to employ telemedicine following the COVID-19 outbreak. The greatest utility of telemedicine is in triaging, postoperative assessment and eyelid lesion assessment. Main barriers to implementation of telemedicine included difficulties in conducting clinical examinations, lack of administrative support and poor access to digital technologies for patients. Overall, most clinicians were satisfied with the impact of telemedicine services and almost all experts foresee themselves continuing to use telemedicine in the future.

Conclusions: Telemedicine has become an integral part of the oculoplastic service delivery since the COVID-19 pandemic its use is likely to continue. Further development of digital infrastructure and improvement of clinical examination capabilities are required to enable its wider adoption.
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http://dx.doi.org/10.1136/bjophthalmol-2020-318696DOI Listing
April 2021

Recurrent epiphora after dacryocystorhinostomy surgery: Structural abnormalities identified with dacryocystography and long term outcomes of revision surgery : Success rates of further surgery following failed dacryocystorhinostomy surgery.

BMC Ophthalmol 2021 Mar 5;21(1):117. Epub 2021 Mar 5.

Moorfields Eye Hospital NHS Trust, 162 City Road, London, EC1V2PD, UK.

Background: To investigate the aetiopathology of recurrent epiphora or stickiness after dacryocystorhinostomy (DCR) surgery, identifiable on dacryocystography (DCG), and to assess the success rates of secondary corrective surgeries.

Methods: Consecutive post-DCR DCG images from patients with recurrent symptoms were reviewed between 2012 and 2015.

Results: One hundred fifty-nine eyes of 137 patients were evaluated. Fifty-eight DCGs showed normal postoperative findings, 4 an upper/lower canalicular block, 13 a common canalicular block, 31 a completely closed anastomosis, 50 a narrow anastomosis, and 3 an anastomosis draining into a nasal sinus. The most successful corrective procedures for each failure category were: Lester Jones Tube (LJT) for a normal post-operative DCG (17/18 success), Sisler trephination with tubes for upper/lower canalicular block (1/2 success), redo-DCR with tube for common canalicular blockage (5/6 success), redo-DCR +/- tube for completely closed anastomosis (12/16 success), LJT followed by redo-DCR +/- tube for narrow surgical anastomosis (1/1 and 17/27 success respectively), and redo-external-DCR with tube for anastomosis into a nasal sinus (1/1 success). Redo-DCR was ineffective in patients who had good post-DCR anatomical patency (22% success).

Conclusion: This is the first study to report success rates of redo-DCR surgery according to anatomical findings confirmed by DCG. The outcome flow diagram help clinicians recommend procedures that are most likely to be successful for their patient's specific anatomical abnormality. It also provides a visual tool for the shared decision-making process. Notably, symptomatic patients with a normal DCG post DCR are unlikely to benefit from redo-DCR, with a LJT being the recommended next step.
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http://dx.doi.org/10.1186/s12886-021-01869-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934262PMC
March 2021

Accuracy of periocular lesion assessment using telemedicine.

BMJ Health Care Inform 2021 Jan;28(1)

Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK.

Objectives: To assess the agreement in diagnosis and management plans reached between clinicians reviewing eyelid lesions remotely and in face-to-face clinics.

Methods: In this single-centre observational case series, data were prospectively collected on 50 consecutive adults referred with eyelid lesions suitable to be seen by a nurse. A proforma was completed to gather salient information. A nurse specialist saw patients in face-to-face clinics and collected information using the proforma, devising a diagnosis and management plan. Photographs of the eyelid lesions were taken by a medical photographer. A subsequent remote review was completed by an oculoplastic consultant using the proforma information and photographs in the absence of the patient. The diagnosis and management plan constructed by the nurse specialist were compared with those reached by the consultant.

Results: Complete data were available for 44 consecutive cases. There was an overall 91% agreement (40 cases out of 44) between the diagnoses reached by the nurse specialist, and the remote reviewer; kappa coefficient 0.88 (95% CI 0.76 to 0.99). There was an overall 82% agreement (36 out of 44 cases) in the management plans devised by the nurse-led clinic and remote reviewer; kappa coefficient 0.74 (95% CI 0.58 to 0.90). The average time taken for a remote reviewer to reach a diagnosis and management plan was 1 min and 20 s.

Conclusions: This study evaluated the feasibility of assessing eyelid lesions using asynchronous telemedicine. There was overall a high rate of concordance in the diagnosis reached, and management devised between the clinic and remote review.
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http://dx.doi.org/10.1136/bmjhci-2020-100287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831705PMC
January 2021

An Artificial Intelligence Approach to the Assessment of Abnormal Lid Position.

Plast Reconstr Surg Glob Open 2020 Oct 27;8(10):e3089. Epub 2020 Oct 27.

Microsoft, London, United Kingdom.

New artificial intelligence (AI) approaches to facial analysis show promise in the clinical evaluation of abnormal lid position. This could allow more naturalistic, quantitative, and automated assessment of lid position. The aim of this article was to determine whether OpenFace, an AI approach to real-time facial landmarking and analysis, can extract clinically useful measurements from images of patients before and after ptosis correction. Manual and AI-automated approaches to vertical palpebral aperture measurement of 128 eyes in pre- and postoperative full-face images of ptosis patients were compared in this study. Agreement in interpupillary distance to vertical palpebral aperture ratio between clinicians and an AI-based system was assessed. Image quality varied highly with interpupillary distance defined by a mean of 143.4 pixels (min = 60, max = 328, SD = 80.3 pixels). A Bland-Altman analysis suggests a good agreement between manual and AI analysis of vertical palpebral aperture (94.4% of measurements falling within 2 SDs of the mean). Correlation between the 2 methods yielded a Pearson's r(126) = 0.87 ( < 0.01) and r = 0.76. This feasibility study suggests that existing, open-source approaches to facial analysis can be applied to the clinical assessment of patients with abnormal lid position. The approach could be extended to further quantify clinical assessment of oculoplastic conditions.
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http://dx.doi.org/10.1097/GOX.0000000000003089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647646PMC
October 2020

Oculoplastic video-based telemedicine consultations: Covid-19 and beyond.

Eye (Lond) 2020 Jul 12;34(7):1193-1195. Epub 2020 May 12.

Adnexal Service, Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.

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http://dx.doi.org/10.1038/s41433-020-0953-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216849PMC
July 2020

Pulsating lid: a rare presentation of sinus pericranii.

Can J Ophthalmol 2020 06 31;55(3):e100-e104. Epub 2019 Dec 31.

Moorfields Eye Hospital, London, England; The St John Ophthalmic Association, London, UK.

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http://dx.doi.org/10.1016/j.jcjo.2019.09.007DOI Listing
June 2020

Eye clinic liaison officers service in the United Kingdom.

Int J Health Plann Manage 2020 Mar 14;35(2):506-519. Epub 2019 Nov 14.

Eye Treatment Centre, Barts Health, Whipps Cross University Hospital, London, UK.

Background: To investigate the role of eye clinic liaison officers (ECLOs) in the United Kingdom and analyse patients' demographics and services provided.

Methods: This is a retrospective observational study. Data were collected from the Royal National Institute of Blind People for ECLOs in Wales, Scotland, Northern Ireland and England for the first quarter of 2015. Statistical analysis was performed using chi-square and t test as appropriate.

Results: Trusts with ECLOs support vary greatly in the UK regions. Only one-third of NHS trusts in England have an ECLO service. Over 4000 patients were assessed. The majority of patients were of White ethnic background (94%), lived alone (37%), had no carers (58%) and were in their 80s (29.5%). The principal ocular conditions causing sight loss and certification were age-related macular degeneration (41.6%) and glaucoma (18.1%). Approximately 70% of patients are first seen at 13 to 18 months from diagnosis.

Conclusions: ECLO services vary in the UK regions. England has the lowest ECLO availability per trust and the majority of those assessed were of White British origin with AMD. There are significant delays from diagnosis to the first visit indicating the need for improved services. Further studies are necessary to develop the evidence base for the expansion and funding of ECLO services.
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http://dx.doi.org/10.1002/hpm.2938DOI Listing
March 2020

Ocular amyloid: adnexal and systemic involvement.

Orbit 2020 Feb 2;39(1):13-17. Epub 2019 Oct 2.

Moorfields Eye Hospital, NHS Foundation Trust, London, UK.

: To investigate the natural history of ocular adnexal and orbital amyloidosis.: In a retrospective, non-comparative case series, the clinical records of patients with biopsy-proven ocular, adnexal, and orbital amyloidosis managed at our institution between 1980 and 2016 were evaluated.: Forty-one patients (29 female; 71%) were identified. The mean interval from presentation to diagnosis was 24 months (median 12 months, range 1-84 months). Whilst most patients presented with a conjunctival mass (34/41; 83%) or ptosis (15/41; 37%), the diagnosis was not immediately evident in all - two patients had 3 ptosis operations prior to obtaining a tissue biopsy that revealed amyloid deposition. Three-quarters (31/41; 76%) of patients had localised primary ocular adnexal and orbital amyloidosis, 4 (10%) had associated systemic disease, and 6 (15%) were found to have underlying haematological malignancy on further investigation. During a mean follow-up of 8 years (median 7 years; range 6 months - 36 years), 2 (5%) patients lost vision, 21 (51%) had surgical intervention other than biopsy, and 2 (5%) had local radiotherapy for amyloid deposition secondary to lymphoproliferative disease.: The varied presentations of ocular adnexal and orbital amyloidosis and the need for confirmatory biopsy often leads to a significant delay between first symptoms and diagnosis. While rarely sight-threatening, ocular adnexal and orbital amyloidosis carries significant morbidities and has a systemic association in a quarter of patients.
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http://dx.doi.org/10.1080/01676830.2019.1594988DOI Listing
February 2020

Tocilizumab for thyroid eye disease.

Cochrane Database Syst Rev 2018 11 27;11:CD012984. Epub 2018 Nov 27.

Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, UK, EC1V 2PD.

Background: Thyroid eye disease (TED) is an autoimmune disorder that constitutes a major clinical and therapeutic challenge. Current treatment options for moderate-to-severe TED include immunotherapy, orbital radiotherapy and decompression surgery. Limited drugs of proven efficacy are available for the treatment of people with TED. Given the role in the pathogenesis of TED of interleukin (IL)-6 expression in adipocytes, fibroblasts and macrophages, the proposed theory is that inhibition of IL-6 by tocilizumab may be an effective treatment in TED by directly reducing the inflammatory response. In addition, there is an unmet need for a new treatment that can modify the natural course of the disease and reduce the incidence of late complications that can occur as a result of fibrosis following inflammation.

Objectives: To investigate the efficacy and harms of tocilizumab for the treatment of people with TED.

Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase Ovid; LILACS BIREME; OpenGrey; the ISRCTN registry; ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the EU Clinical Trials Register. The date of the search was 31 July 2018.

Selection Criteria: We searched for trials of tocilizumab administered by intravenous infusion using any dosage regimen, compared with placebo or intravenous glucocorticoid therapy for people with TED.

Data Collection And Analysis: We planned to use standard methods recommended by Cochrane. The primary outcome was change in TED score (as defined by investigators). Secondary outcomes included measurement of the following parameters: change in proptosis, change in extraocular motility, change in palpebral aperture measurements, number of relapses, development of optic neuropathy and change in quality of life score. We planned to measure these outcomes at three months (range two to six months) and 12 months (range six to 18 months) post-treatment. Adverse outcomes included any adverse effects identified in the trials at any time point.

Main Results: No studies met the inclusion criteria of this review. We found one randomised, placebo-controlled, double masked study (NCT01297699). This study plans to evaluate the efficacy and harms of tocilizumab administration in people with moderate-to-severe or sight-threatening graves' ophthalmopathy (GO), that had not responded adequately to treatment with intravenous corticosteroid pulses. It was completed in December 2015 and will be assessed for inclusion in the review when data become available.

Authors' Conclusions: There is currently no evidence from randomised controlled trials evaluating the efficacy and harms of tocilizumab for the treatment of people with TED.
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http://dx.doi.org/10.1002/14651858.CD012984.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517231PMC
November 2018

Differentiated dysplasia of periocular epidermis: the first reported case in periocular region.

Can J Ophthalmol 2017 Aug 15;52(4):e134-e136. Epub 2017 Mar 15.

Moorfields Eye Hospital, London, United Kingdom.

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http://dx.doi.org/10.1016/j.jcjo.2017.01.014DOI Listing
August 2017

Patient Perception and Emotional Disturbance in Out-of-Hour Ophthalmic Emergency Care.

Semin Ophthalmol 2017 21;32(5):559-563. Epub 2016 Jun 21.

a Accident and Emergency Department , Western Eye Hospital, Imperial College Healthcare NHS Foundation Trust , London , UK.

Purpose: To investigate patient's perception of the severity of their symptoms, reasons for attending an ophthalmic emergency department (ED) out of hours, and to review the prevalence of anxiety and depression.

Methods: We carried out a prospective analysis of the cases presenting out of hours (8:30 PM to 8:30 AM) over a four-month period. We also conducted two questionnaire studies. First, patient's perception of the severity of their symptoms (graded from 1-10). A score of 7 or above was defined as significant. A second questionnaire study used the Hospital Anxiety and Depression Scale (HADS), with a maximum score of 21. Patients who scored between 7-10 points on either anxiety or depression scales are defined as borderline; above 10 as pathological.

Results: A total of 1,531 patients attended the out-of-hours service. The most common diagnoses were trauma (22.8%), infective conjunctivitis (10.2%), and contact-lens-related problems (6.6%). Of 175 completed questionnaires, worry about sight impairment and pain were the most common concerns for attendance. A total of 91% of patients believed their conditions were emergencies that require medical review within 24 hours. 127 HADS questionnaires were completed, showing that 18.9% and 15.0% of patients were suffering from borderline and pathological anxiety, respectively, with a mean HADS-A score of 6.5, SD=3.9. The prevalence of possible and pathological depression was 14.2% and 6.3%, mean=4.9 (SD=3.6). There was no statistical significance difference of score with the time of patient presentation.

Conclusion: The prevalence of anxiety and depression is relatively high in patients who attended the ophthalmic ED and awareness of psychological impact should be raised amongst healthcare professionals.
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http://dx.doi.org/10.3109/08820538.2015.1131834DOI Listing
December 2017

Calculated plasma volume status and prognosis in chronic heart failure.

Eur J Heart Fail 2015 Jan 3;17(1):35-43. Epub 2014 Dec 3.

University College London Hospital NHS Trust, London, UK.

Aims: Plasma volume (PV) expansion hallmarks worsening chronic heart failure (CHF) but no non-invasive means of quantifying volume status exists. Because weight and haematocrit are related to PV, they can be used to calculate relative PV status (PVS). We tested the validity and prognostic utility of calculated PVS in CHF patients.

Methods And Results: First, we evaluated the agreement between calculated actual PV (aPV) and aPV levels measured using (125)Iodine-human serum albumin. Second, we derived PVS as: [(calculated aPV - ideal PV)/ideal PV] × 100%. Third, we assessed the prognostic implications of PVS in 5002 patients from the Valsartan in Heart Failure Trial (Val-HeFT), and validated this in another 246 routine CHF outpatients. On analysis, calculated and measured aPV values correlated significantly in 119 normal subjects and 30 CHF patients. In the Val-HeFT cohort, mean (+SD) PVS was -9 ± 8% and related to volume biomarkers such as brain natriuretic peptide (BNP). Over 2 years, 977 (20%) patients died. Plasma volume status was associated with death and first morbid events in a 'J-shaped' fashion with the highest risk seen with a PVS > -4%. Stratification into PVS quartiles confirmed that a PVS > -4% was associated with increased mortality (unadjusted hazard ratio 1.65, 95% confidence interval 1.44-1.88, χ(2)  = 54, P < 0.001) even after adjusting for 22 variables, including brain natriuretic peptide. These results were mirrored in the validation cohort.

Conclusions: Relative PVS calculated from simple clinical indices reflects the degree to which patients have deviated from their ideal PV and independently relates to outcomes. The utility of PVS-driven CHF management needs further evaluation.
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http://dx.doi.org/10.1002/ejhf.193DOI Listing
January 2015

Expansion of the red cell distribution width and evolving iron deficiency as predictors of poor outcome in chronic heart failure.

Int J Cardiol 2013 Oct 22;168(3):1997-2002. Epub 2013 Jan 22.

University College London Hospital, London, UK.

Background: An elevated red cell distribution width (RDW) and iron deficiency (ID) at baseline predict enhanced mortality in chronic heart failure (CHF), but little is known about the prognostic implications of their temporal trends. We sought to determine the survival implications of temporal changes in RDW and evolving ID in patients with CHF.

Methods: The relation between red cell indices on first consultation and over time with mortality in 274 stable patients with systolic CHF was analysed. The combination of a rising RDW with a falling mean cell volume (MCV) over time defined evolving ID.

Results: Over a median 12 month period, 51% and 23% of patients had a rise in RDW and evolving ID, respectively. After a median follow-up of 27 months, 60 (22%) patients died. A rising RDW predicted enhanced all-cause mortality (unadjusted HR for 1% per week rise 9.27, 95% CI 3.58 to 24.00, P<0.0001) independently and incrementally to baseline RDW, with an absolute increase >0.02% per week optimally predictive. Evolving ID also related to higher rates of mortality (HR 2.78, 95% CI 1.64 to 4.73, P<0.001) and was prognostically worse than a rising RDW alone (P<0.005). Patients with evolving ID who maintained their Hb levels over time had a 2-fold greater risk of death than those whose Hb levels declined without evolving ID.

Conclusions: An expanding RDW and evolving iron deficiency over time predict an amplified risk of death in CHF and should be utilised for risk stratification and/or therapeutically targeted to potentially improve outcomes.
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http://dx.doi.org/10.1016/j.ijcard.2012.12.091DOI Listing
October 2013

Tuberculosis and anti-TNF treatment: experience of a central London hospital.

Clin Rheumatol 2011 Mar 23;30(3):399-401. Epub 2010 Oct 23.

Rheumatology Department, University College Hospital, 235 Euston Road, London, NW1 2BU, UK.

Reactivation of latent tuberculosis (TB) is an established risk of anti-tumour necrosis factor α (anti-TNF) therapy. We report five cases of active TB occurring in 703 patients treated with anti-TNF therapy over a 10-year period in a central London hospital and review our screening practices for identifying latent TB prior to anti-TNF treatment. Four patients were receiving adalimumab and one patient etanercept at the time of TB diagnosis. Four of the five patients were born in countries with a high TB prevalence. Two of the five patients were healthcare workers. All patients had normal chest radiographs prior to anti-TNF treatment. Our data emphasise that country of origin is important in the determining risk of latent TB and that a normal chest radiograph does not exclude latent TB.
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http://dx.doi.org/10.1007/s10067-010-1605-1DOI Listing
March 2011

Structural rearrangements in RNA on the binding of an antisense oligonucleotide: implications for the study of intra-molecular RNA interactions and the design of cooperatively acting antisense reagents with enhanced efficacy.

J Drug Target 2005 Jan;13(1):61-70

Department of Biochemistry, South Parks Road, University of Oxford, Oxford OX1 3Q, UK.

We show that binding of an antisense oligonucleotide can lead to considerable changes in the target mRNA structure. The approaches described here are not only useful in the study of intra-molecular interactions in RNAs but can also be used to design oligonucleotides that facilitate binding of other antisense reagents. Such "cooperatively acting" antisense reagents have the potential to overcome several problems faced in their use, for example, low efficacy and non-specificity. To provide proof-of-principle, radiolabelled cyclin B5 transcript, a model mRNA, was hybridised with an antisense oligonucleotide array. An oligonucleotide sequence was selected from the array hybridisation data and was used in an RNase H/oligonucleotide library (dN12) assay to assess its ability to enhance cleavage of target RNA. This oligonucleotide ("facilitator") greatly enhanced cleavage of B5 RNA at a neighbouring site. The precise position and sequence of this "new" site was determined by further hybridisation of RNA-facilitator mixture to the B5 antisense array. Antisense oligonucleotides designed from the new region were used in combination with the facilitator in a cell-free system. The presence of the facilitator considerably enhanced cleavage of B5 RNA with these oligonucleotides. These approaches may be useful in designing antisense reagents against sequences of specific interest, such as, gene fusion sites, splice variants, mutant alleles and tightly structured RNA sites.
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http://dx.doi.org/10.1080/10611860400003825DOI Listing
January 2005

Reinterpretation of curved Hammett plots in reaction of nucleophiles with aryl benzoates: change in rate-determining step or mechanism versus ground-state stabilization.

J Org Chem 2002 Nov;67(24):8475-80

Department of Chemistry, Ewha Womans University, Seoul 120-750, Korea.

A kinetic study is reported for the reaction of the anionic nucleophiles OH-, CN-, and N 3 - with aryl benzoates containing substituents on the benzoyl as well as the aryloxy moiety, in 80 mol % H2O - 20 mol % dimethyl sulfoxide at 25.0 degrees C. Hammett log k vs sigma plots for these systems are consistently nonlinear. However, a possible traditional explanation in terms of a mechanism involving a tetrahedral intermediate with curvature resulting from a change in rate-determining step is considered but rejected. The proposed explanation involves ground-state stabilization through resonance interaction between the benzoyl substituent and the electrophilic carbonyl center in the two-stage mechanism. Accordingly, the data are nicely accommodated on the basis of the Yukawa-Tsuno equation, which gives linear plots for all three nuceophiles. Literature reports of the mechanism of acyl transfer processes are reconsidered in this light.
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http://dx.doi.org/10.1021/jo026339gDOI Listing
November 2002
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