Surgical checklist for cataract surgery:progress with the initiative by the Royal College of Ophthalmologists to improve patient safety

PurposeThe World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012.Patients and methodsA survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate).ResultsRespondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college's bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist.ConclusionNinety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.Eye advance online publication, 24 May 2013; doi:10.1038/eye.2013.101.

Exodus? The training paths and plans of postgraduate medical trainees, under the Royal College of Physicians of Ireland

Background: In 2006, the Buttimer report highlighted the paucity of demographic data on those applying for and entering postgraduate medical education and training (PGMET) in Ireland. Today, concerns that there is an "exodus" of graduates of Irish medical schools are at the forefront of national discussion, however, published data on PGMET remains inadequate.

Aims: The objectives of this study were to collate existing data relating to trainees and training programmes at three stages of training and to examine the career plans of junior trainees.

Methods: Data from application forms for training programmes, commencing July 2012, under the Royal College of Physicians of Ireland (n = 870), were integrated with data from other existing sources. Candidates entering basic specialist training were surveyed with regard to career plans. Descriptive and comparative analysis was performed in SPSS version 18.

Results: Graduates of Irish medical schools made up over 70 % of appointees. Over 80 % of BST trainees aspired to work as consultants in Ireland, but 92.5 % planned to spend time working abroad (response rate 77 %). Decisions to leave the Irish system were linked to lifestyle, but also to failure to be appointed to higher specialist training. Significant numbers of trainees return to Ireland after a period abroad.

Conclusions: The trainee "exodus" is more complex than is often portrayed. The desire to spend time working outside Ireland must be accounted for in workforce planning and configuration of training programmes. Expansion of HST is a potential solution to reduce the numbers of graduates leaving Ireland post-BST.

Modern management of head injuries

Management of the head-injured patient is designed to prevent secondary injury and to provide the neurosurgeon with a live patient who has some hope of recovery. This review sets out the background essentials for the non-neurosurgeon dealing with the initial care of a head-injured patient.

Functional expression of thermo-sensitive TRP channels in human odontoblasts

Introduction: Accumulating evidence supports a role for odontoblasts in initiating tooth pain, however direct ionic mechanisms underlying dentine nociceptive function remain unclear. The transient receptor potential (TRP) ion channels are directly related to cellular mechanisms of nociception and thermo-sensitive function but their expression by human odontoblasts remains to be determined. Objectives: To investigate the expression and functionality of the thermo-sensitive TRP channels TRPV1, TRPV4, TRPM8 and TRPA1 in human odontoblasts. Methods: Human odontoblasts were derived from dental pulp of immature permanent third molars by explant method. Cell lysates of odontoblasts were subject to SDS- polyacrylamide gel electrophoresis and proteins were blotted onto nitrocellulose membranes. Blots were probed with primary antibodies to TRPA1, TRPM8, TRPV4 and TRPV1. Detection of bound primary antibodies was achieved using appropriate anti-species antibody conjugates and chemiluminescent substrates. Functionality of the channels was determined with Ca2+ microfluorimetry, where cells grown in cover slips and incubated with Fura 2AM prior to stimulation with capsaicin (TRPV1 agonist), 4 alpha-phorbol 12,13-didecanoate (4áPDD) (TRPV4 agonist), icilin (TRPA1 agonist) and menthol (TRPM8 agonist). Emitted fluorescence was measured and the fluorescence ratio (R) was calculated as F340/F380 to determine the level of [Ca2+]i. Results: Western blotting confirmed the molecular localisation of thermo-sensitive TRP channels in human odontoblasts. Functionality assays revealed increase in [Ca2+]i in response to capsacin, icillin, methanol and 4áPDD indicating functional expression of TRPV1, TRPA1, TRPM8 and TRPV4 respectively. Conclusions: Functional expression of thermo-sensitive TRP channels in human odontoblasts may indicate a crucial role for odontoblasts in thermally induced dental pain. (Supported by a Research Grant from the Royal College of Surgeons of Edinburgh)

Targeting Trypsin-Like Proteases: A Mechanism to Restore Mucociliary Function in Cystic Fibrosis Airways

Dehydration of the airway surface liquid (ASL) and the resultant decline in function of the mucociliary escalator in cystic fibrosis airways is largely underpinned by the excessive flux of Na+ and water though ENaC. Proteolysis of the endogenous  and  subunits of epithelial sodium channels (ENaC) by channel activating proteases (CAPS) is the key regulatory mechanism for channel activation. Recent reports highlight that (1) CFTR (cystic fibrosis transmembrane conductance regulator) normally protects ENaC from the action of proteases and (2) a stark imbalance in proteases/protease inhibitor levels in CF airway cultures favour activation of normally inactive ENaC. The current study examines the potential therapeutic benefit of CAPS/ENaC inhibition in CF airways.
Our group has developed a panel of active-site directed affinity-based probes which target and inhibit trypsin-like proteases (potential CAPS); including the broad-spectrum inhibitor QUB-TL1. We have utilised this compound to interrogate the impact of trypsin-like protease inhibition on ENaC activity in differentiated primary airway epithelial cell cultures.
Electrophysiological data demonstrate QUB-TL1 selectively and irreversibly binds to extracellularly located trypsin-like proteases resulting in impaired ENaC-mediated Na+ transport. Visualisation of ENaC at the apical surface compartment of primary airway epithelial cells shows a large reduction in a low molecular weight (processed and active) form of ENaC, which was found to be abundant in untreated CF cultures. Consistent with the reduction in ENaC activity observed, QUB-TL1 treatment was subsequently shown to increase ASL height (performed in collaboration with Royal College of Surgeons in Ireland).
Our results are consistent with the hypothesis that targeting the CAPS-ENaC signalling axis may restore the depleted ASL seen in CF airways.

'Heat-sensing' TRP channel expression in human odontoblasts

Background: Thermal changes in the oral cavity are a common trigger of dental pain. Several members of the transient receptor potential (TRP) super family of ion channels are believed to play a critical role in sensory physiology, where they act as transducers for thermal, mechanical and chemical stimuli. Objectives: The present study was designed to determine the expression and functionality of the TRPV1 channel in human odontoblasts. Methods: Cultured human odontoblasts were derived from dental pulp cells induced with 2 mM beta-glycerophosphate. Molecular and protein expression of TRPV1 was confirmed by PCR, western blotting and immunohistochemistry. Functional expression of the ‘heat-sensing' TRPV1 channel was investigated using a Ca2+ microfluorimetry assay in the presence of agonists/antagonists or with appropriate adjustment of the recording chamber temperature. Results: The odontoblastic phenotype of the cells was confirmed by the expression of the odontoblast markers dentin sialophosphoprotein (DSPP) and nestin. Expression of TRPV1 in human odontoblastic cells was confirmed by PCR, western blotting and immunohistochemistry. Odontoblasts were shown to respond to pharmacological agonists and to increasing temperature by an increase in intracellular Ca2+. Both the pharmacological and temperature responses could be blocked by specific antagonists. These results indicate that odontoblasts may sense heat via TRPV1. Conclusion: This study reports that TRPV1 is expressed by human odontoblasts and is activated by specific pharmacological agonists and by heat.
This work was supported by Research Grants from the Royal College of Surgeons of Edinburgh and the British Endodontic Society

Transient receptor potential (TRP) channel expression in pulpal fibroblasts

Introduction: Transient receptor potential (TRP) channels are widely, but not uniformly, distributed in tissues. To date the dominant focus of attention has been on TRP expression and functionality in neurons. However, their expression and activation in selected non-neuronal cells suggest TRPs have a potential role in coordinating cross-talk during the inflammatory process. Fibroblasts comprise the major cell type in the dental pulp and play an important role in pulpal inflammation. Objectives: The aim of this study was to investigate the expression and functionality of the TRP channels TRPA1, TRPM8, TRPV4 and TRPV1 in human dental pulp fibroblasts. Methods: Dental pulp fibroblasts were derived by explant culture of pulps removed from extracted healthy teeth. Fibroblasts were cultured in DMEM supplemented with 10% FCS, 100U/ml penicillin and 100µg/ml streptomycin. Protein expression of TRP channels was investigated by SDS- polyacrylamide gel electrophoresis and Western blotting of cell lysates from fibroblast cells in culture. TRPA1, TRPM8, TRPV4 and TRPV1 expression was determined by specific antibodies, detected using appropriate anti-species antibodies and chemiluminescence. Functionality of TRP channels was determined by Ca2+ microfluorimetry. Cells were grown on cover slips and incubated with Fura 2AM prior to stimulation with icilin (TRPA1 agonist), menthol (TRPM8 agonist), 4 alpha-phorbol 12,13-didecanoate (4alphaPDD) (TRPV4 agonist) or capsaicin (TRPV1 agonist). Emitted fluorescence (F340/F380) was used to determine intracellular [Ca2+] levels. Results: Fibroblast expression of TRPA1, TRPM8, TRPV4 and TRPV1 was confirmed at the protein level by Western blotting. Increased intracellular [Ca2+] levels in response to icillin, methanol, 4alphaPDD and capsacin, indicated functional expression of TRPA1, TRPM8, TRPV4 and TRPV respectively. Conclusions: The presence and functionality of TRP channels on dental pulp fibroblasts suggests a potential role for these cells in the pulpal neurogenic inflammatory response. (Supported by a research grant from the Royal College of Surgeons of Edinburgh).

A New Method of Demonstrating Spider Nevi

This paper describes a new clinical sign not previously reported. It is a method of demonstrating that a vascular lesion of the skin is a 'Spider Nevus' as opposed to any other type of vascular lesion.