Royal Victoria Hospital

Assessment and management of dry eye disease (DED) in the UK is increasingly taking place outside of specialist ophthalmology settings. While comprehensive, evidence-based international guidance exists, much of it does not reflect the realities of practice in the UK. A panel of experts was brought together to identify areas of consensus on assessment, management, and appropriate referral of DED in the UK National Health Service (NHS). A questionnaire was circulated to a panel consisting of 15 optometrists, ophthalmologists, and corneal specialists with experience and expertise in DED. Based on their responses, consensus statements were developed and underwent two rounds of voting, in which respondents indicated to what extent they agreed with each statement. A core steering panel of seven experts discussed the results and provided further context for the statements. Strong or very strong consensus was reached for 57/62 statements. Statements with very strong consensus included guidance on the minimum symptoms and signs to be assessed on initial presentation and simple guidance for grading the severity of the disease. Statements regarding initial treatment were divided by setting (primary and secondary care), and a strong or very strong consensus was reached on 17/20 statements relating to treatment options in these settings. Statements specific to referral included approximate target timelines, where possible, as well as guidance on key supporting information to help improve the efficiency of patient care. This consensus provides a UK-focused resource to support consistent and effective care for patients with DED within the NHS.

Airway-related complications are common in ICUs and cause serious patient harm. We determined the prevalence of known and predicted difficult airways in ICU patients in the UK, assessed whether these patients are identifiable as at risk, and evaluated the presence of airway management plans through local investigator-led bedside assessment. We conducted a prospective, multicentre, observational study in 106 UK ICUs. Adult patients without treatment escalation plans precluding artificial airway insertion were included. Patients with known difficult airways (defined as difficulty in face-mask ventilation, laryngoscopy, or intubation) or predicted difficult airways (defined as BMI ≥30 kg m-2, tracheostomy in situ, pathology or recent surgery affecting airway management, or modified MACOCHA score ≥3) were evaluated. Presence of clear identification and airway management planning for at-risk patients was assessed by local investigators. Amongst 1965 patients, 872 (44.4%) had an artificial airway in situ (tracheal tube n=639 [73.3%], tracheostomy tube n=233 [26.7%]). Among 1519 patients with intubation details, 244 (16.1%) had a known difficult airway (difficult face-mask ventilation n=32 [2.1%], laryngoscopy n=37 [2.4%], intubation n=182 [12.0%]). In this population, 70 (28.7%) were clearly identifiable to investigators, and 75 (30.7%) had airway management plans. Excluding patients with a known difficult airway, 922 patients had predicted difficult airway management, of whom 125 (13.6%) were clearly identifiable and 181 (19.6%) had airway management plans. Known and predicted difficult airways are common in UK ICU patients, but these at-risk patients are often not clearly identifiable to healthcare professionals.

Background/Objectives: Poiseuille’s law describes the influence of radius, length, viscosity, and pressure on the flow of Newtonian fluids. Although bone cement is a non-Newtonian, shear-thinning, and polymerizing material that does not comply with this law in any predictive or quantitative sense, its qualitative principles may offer a didactic framework for understanding factors that affect injectability during cementoplasty. The objective of this Technical Note is to provide an educational and conceptual interpretation of Poiseuille’s law as it relates to trocar selection, cement behavior, and procedural planning. Methods: This work presents theoretical calculations based on the r4/L component of Poiseuille’s equation, using manufacturer-specified internal radii for commonly used trocars. Relative flow rates were computed as r4/L ratios normalized to a 13-gauge, 15 cm trocar. Conceptual viscosity profiles illustrate qualitative differences among cements over time. A representative, fully anonymized clinical example is provided to illustrate the integration of these conceptual principles into practice. No experimental measurements were performed. Results: Theoretical calculations show that trocar radius has the strongest influence on theoretical flow, with an exponential effect (r4), whereas increasing trocar length proportionally reduces flow. Conceptual viscosity curves demonstrate the rapid rise in viscosity during polymerization and highlight the importance of timing and cement selection. The clinical example illustrates how trocar choice, access planning, and cement viscosity are adapted to lesion morphology and cortical integrity. Conclusions: Poiseuille’s law cannot model or predict bone cement behavior and has no procedural or clinical validity in cementoplasty. Its use in this Technical Note is strictly educational, providing a qualitative framework to illustrate general relationships between equipment characteristics, viscosity evolution, and resistance during injection, without offering clinical guidance or implying any impact on procedural planning, safety, or outcomes.

Despite low pain scores after minimally invasive gynecologic surgery (MIGS), opioids remain overprescribed in patients undergoing these procedures. In a single-blind randomized trial conducted at a tertiary-care academic center, we assessed whether a multimodal opioid-free exit prescription (OFP) for analgesia would result in noninferior postoperative pain control compared to an opioid-containing prescription in patients undergoing MIGS. Female patients without prior pain conditions undergoing outpatient laparoscopic MIGS were randomized to receive either an OFP or a restrictive opioid prescription (ROP; five tablets hydromorphone 1 mg) alongside multimodal analgesia. The primary outcome was patient-reported pain on postoperative day (POD) 1. Secondary outcomes included patient-reported pain and measures of recovery such as total opioid consumption, participant mobility, opioid-related side effects, return to emergency room or clinic, need for rescue analgesia prescription, overall satisfaction with pain control and overall satisfaction with postoperative care, which were assessed on POD1 and POD7 by a blinded outcome assessor. Of n = 110 patients randomized, n = 103 completed the study (OFP = 49, ROP = 54). No significant difference in mean pain scores on POD1 (3.1 versus 3.5, P = 0.31) or POD7 (1.0 versus 1.5, P = 0.14) were found. Mobility and satisfaction were comparable. ROP patients experienced more nausea and vomiting (14.3% versus 35.2%, P = 0.01). No OFP patients required rescue opioids. Only 27.8% and 11.1% of ROP patients consumed opioids by POD1 and POD7 respectively. Thus, in patients undergoing outpatient MIGS, an OFP resulted in noninferior postoperative pain compared to an ROP, suggesting that opioids may be safely omitted in this clinical context. ClinicalTrials.gov identifier: NCT04837014 .

ImportanceBRAF V600E mutations are frequently associated with aggressive papillary thyroid carcinomas (PTCs), yet tumors with low allele frequency (AF) are often considered to be indolent. However, exceptions exist, suggesting additional factors may influence tumor behavior. Gene expression alterations (GEA) may help identify tumors with more aggressive molecular phenotypes.ObjectiveTo evaluate whether aggressive clinicopathologic features are associated with GEA positivity in low AF BRAF V600E-mutated PTCs.DesignRetrospective cohort study.SettingTwo McGill University Academic Hospitals, 2019 to 2024.ParticipantsPatients with PTC harboring BRAF V600E (AF ≤ 25%) who underwent preoperative testing.Intervention or ExposureLow AF BRAF V600E mutation (≤25%) characterized using ThyroSeq v3 genomic classifier.Main Outcome MeasuresThe primary outcome was GEA status. Tumor aggressiveness (defined by extrathyroidal extension, lymph node metastasis, lymphovascular invasion, high-risk histology, or aggressive variants), Bethesda classification, and AF were evaluated as predictors of GEA using logistic regression. Stratified analysis was performed based on AF (≤10% vs. >10%).ResultsAmong 49 patients identified (mean age 49 ± 14 years; 86% female; mean AF 11% ± 8%), 73% (36/49) had aggressive features and 61% (30/49) had GEA-positive tumors. Among GEA-positive tumors, 80% (24/30) were classified as aggressive and had a significantly-higher median AF (16.5%) than GEA-negative tumors (P = .0003). Stratified analysis showed that Bethesda VI nodules significantly predicted GEA positivity in tumors with AF > 10% (P = .03).ConclusionIn low AF BRAF V600E-mutated PTCs, GEA positivity is associated with high-risk cytology, higher AF, and aggressive tumor features.RelevanceGEA may be a useful molecular marker of aggressive tumor biology in low AF PTCs and holds potential as a complementary tool for preoperative risk stratification.

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spinal fractures despite minute trauma. As there is a lack of consensus on which surgical approach is the most efficacious in treating cervical spinal fractures in AS patients, we sought to compare the posterior-only and combined (anterior-posterior) approach regarding intraoperative and postoperative complications. This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (ID: CRD42024284877). Studies published up to May 20, 2025, were searched in PubMed, MEDLINE, and CENTRAL (Cochrane Central Register of Controlled Trials) with predetermined terms. Studies reporting outcomes, including intraoperative and postoperative complications and mortality rate, were evaluated. Included studies underwent a risk of bias assessment. Seventeen studies (one prospective, 16 retrospective) involving 858 patients (with AS and cervical spine fractures) with an average age of 59.9 years were included. The most common mechanism of injury was minor trauma (173, 66%), and C6-7 was the most common level injured (185, 50.6%). Although the posterior-only approach yielded fewer intraoperative complications (4 (4.8%) vs. 2 (15%); p>0.05), postoperative complications (17 (7.5%) vs. 16 (22.6%); p>0.05), and instrument-related complications (1 (2.8%) vs. 3 (12.5%); p>0.05) compared to the combined approach, the difference was not statistically significant. However, the combined approach recorded a significantly lower mortality rate (3 (9.2%) vs. 13 (24.5%); p>0.05) when compared with the posterior-only approach. The results of this systematic review suggest that both the combined and posterior-only approaches have advantages and disadvantages and approach selection should be done on a case-by-case basis. Future randomized controlled trials directly evaluating the efficacy of surgical approaches in such patients are needed to form a consensus.

Objective:To confirm the long-term safety and performance of the Bonebridge BCI 602 in patients suffering from conductive or mixed hearing loss (CMHL) or single-sided deafness (SSD) over a 12-month period post-implantation.Study design:Multicentric, multinational, ambidirectional, observational Post-Market Clinical Follow-Up (PMCF) study.Setting:Eight tertiary referral hospitals.Participants:Fifty-two participants in 3 categories: adults CMHL (N=24), children CMHL (N=17), and SSD (N=11; 9 adults and 2 children).Intervention:Participants were implanted with the Bonebridge BCI 602 device.Main outcome measure(s):Outcome measures focused on sound field thresholds (SF), word recognition scores (WRS), speech reception thresholds (SRT) in both quiet and noise, adverse events, and subjective satisfaction (SSQ and AQoL questionnaires) at initial activation and at 3-month and 12-month post-implantation.Results:Safety was established by stable bone conduction (BC) thresholds and a low adverse event rate with no unanticipated events. Safety was underlined by clinically relevant improvements in the health-related assessment of Quality of Life (AQoL) questionnaire of mean+0.1 (adults and children CMHL) and +0.07 (SSD). Hearing significantly improved in sound field thresholds with mean functional gains of 24.05±8.68 dB (adults CMHL), 21.34±25.43 dB (children CMHL), and 32.89±25.87 dB (SSD). Mean word recognition scores improved by 65.83±28.62 percent points (PP) for adult CMHL and 65.77±27.53 PP for children CMHL and speech reception thresholds (SRT) in quiet by 15.4±9.34 dB and 19.96±14.66 dB, respectively. SRT in noise improved by −5.57±4.23 dB (adults; S0°N0°), −5.12±5.08 dB (children, S0°N0°), and −3.05±3.06 dB (SSD, SSSDNNH). Subjective hearing ability tested with the Speech, Spatial, and Qualities (SSQ) of Hearing questionnaire improved and was clinically relevant for the adult (+2.23) and children (+1.51) CMHL groups.Conclusions:The Bonebridge BCI 602 demonstrates significant enhancements in hearing and speech understanding 12 months postoperatively, showing high user satisfaction and safety.