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Summary

This on-demand teaching session invites medical professionals to learn from presentations from competing experts on adipocyte kinetics in Graves' Orbitopathy and the effect of high dose corticosteroids. It follows recommended guidelines from the European Group for Graves' Orbitopathy for high dose steroid treatment, and will discuss potential considerations for developing targeted non-steroidal treatment options. It will look at the levels of adipo cytokines from blood samples from controlled and active Graves' Orbitopathy patients, and their correlation with clinical activity scores, age, thyroid-stimulating hormone and smoking. Attendees may ask questions and learn more about the feasibility and efficacy of upper lid deterioration in this particular case.

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Learning objectives

  1. Recognize the signs and symptoms of Graves orbitopathy.
  2. Identify potential risk factors for Graves orbitopathy.
  3. Understand the most common medical treatments for Graves orbitopathy.
  4. Describe the role of adipocytes in Graves orbitopathy.
  5. Explain the potential of targeting macrophage activation as a treatment for Graves orbitopathy.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

listen to some or presentations. So, um, we've, uh We've heard firms and amazing species this morning. I'm including this Varian Doctor talk, or I'm very lucky to have them here too. The are judges four hour presentation, competition on day. So, um, we definitely very, very thankful. Toe Everyone who's been participating, attending and also it everyone who sent in, um, some abstract for consideration of presentation on. We have some really, really incredible abstracts admitted on, but we chose three of them. Um, which we wanted to hear a lot more about as a little presentations, which you'll hear from today s o um, got sucked the above it on. But what Yanis who were going to be speaking to you today got 15 minutes each so you can split that as 10 minutes of presentation driving it's questions. Or however you choose to do that, Um, on. But I think that a waiting here on which is lovely. And so I will, um, hand over to, um down who's going to introduce our first speaker? Welcome back. So it is my pleasure to invite off the speaker, which is Saturday, and Mary p. He was going to speak to us about adipose side kinds in graves orbitopathy and the effect of high dose cortico steroids. Let's just get so I think, uh, you gave me. Yeah, we can have you. Uh, okay, so I'm just gonna sex. Um, Okay, so good afternoon, everyone. Thank you for this opportunity. Today, I'm going to present our study that we did about adipocyte kinds in grape. So pretty and the effect of high dose corticosteroids on the left. So just a little bit about the background past s so graves open up. It is a progressive I ophthalmology that is associated with graves' disease, which is an order in the entire condition. So great over pretty is characterized by inflammation and swelling of the salt. Too soft orbital tissues around in the eye. This includes the ocular motor muscles, connective tissues on adipose tissues so you can give that gives the telltale signs off protruding eyes, which cases the retracted eyelids and one grove sign, which is the lagging off the up on the eyelid on down case and said that symptoms such as increased by pressure or pain on double vision. So Adam test issues is talk to play if you fall in our graves over Pretty by producing adequate kinds, which is an implementer mediator and influences the endocrine processes, it is currently treated with IV past corticosteroids. Open toed decompression surgical techniques on orbital radiotherapy so always aims with our clinical study is to identify the nation chips between the serum levels. Off selected Advair kinds on Also, says, report the levels of hydro systemic corticosteroids on the levels in patients with grapes. So we selected arm a little bored by with patients that had active grades are pretty, and we're also going to receive hydro systemic corticosteroids. The active groups over pretty status was determined by an ophthalmologist who use the clinical activity score, which is this fast tape of hair on the left. So assessment off three or more man that 60 patients were eligible for this clinical study. We then used a multi vary it analysis to determine the levels of selected adipo kinds arrived from blood samples. The samples off blood will then used to create hour before and after hydro systemic corticosteroid treatment Backwards, the taste DSC regimen followed the European group, or Grave's Hobart healthy recommendations. So there you go guidelines However, in between the study, the recommendations were actually altered, which meant that some patients in our cobalt received a total of 7.5 g off intravenous methylprednisolone, which were the initial recommendations on all the patients received total of six perms off um IV and methylprednisolone, which was the new recommendations after 2000 and 18. The actual current you go good recommendations as off to 2021 is actually a total of 4.5 g off I. We empty Okay, so the selected out of times were based on the relation to the tire disease tired woman's on the adipose tissues. We included added connected allograft inflammatory Factor, which is a a half one adipose fatty acid binding protein to a A ppd on fiberglass sport factor 21 FGF. Although we confirmed increased levels of are connected in crates over Pretty didn't find it to be an independent marker. Our data is their phone concordance. Without the studies, for example, came out who also reported similar findings. We did not find any statistical significant difference in the levels. All f a BP and FGF to anyone between controls on our patients with G o more Did the steroid treatment have any effect on their levels? However, we did find that there was a potential normal role in the involvement off allograft inflammatory factor one as an important permit associative the brakes since they I f one is considered to be a marker off macrophage activation increase opathy We think that they may be a potential, um in the future to produce targeted noble non steroid treatment options for these patients. For example, add a little map or attorney cept which block tumor necrosis factor alpha, which is a known microphage Kmart tractor. So here about you can see the table too is the, um Multivariate logistic repression analysis where the braves over producing the dependent variable on the highlighted highlighted rose are the ones that were significant who showed significant people. You However, the age and the TSH do something I'm going to mention in the next life in the limitations. Okay, so some of our limitations with the fact that we weren't always able to get consecutive patient samples, particularly sample tree which was obtained one month after the treatment in these cases, we did use theoretical sample to take it immediately off the steroid treatment instead of making a needs off the sample to example. Three. Ah, the change in you go go recommendations when that the H. D S E regimen had dosage have changed. However, um, in the previous slide, I have mentioned that it didn't actually create a any significant statistical difference in patients at food, other condo levels. We also were not able to attain on aged Match Control group. But we did adjust with this in the different parameters. The Multivariate analysis, also found at the higher age on the low TSH, was significantly associated with the presence of GI. Yet, um, however, the former variable could be attributed to the fact that the age distribution of a control group on then the later variable is because that that there is increased incidence of hepatitis of patients with yet, so it's not. It's not something that's a significant finding. Okay, and then also finally, smoking is a well known risk factor. How we couldn't really confirmed that in this study because there was a low number or smokers within the patients and controlled so in some of the take away points that the added connected have been reported in the past in patients with years, but it's not really been shown to be an independent marker or ribs over over. Analysis revealed that there is a significant relationship in the presence of G O on the serum levels off al a Factive flammatory allograft inflammatory factor. One on this could highlight developing treatment strategies to limit macrophage activation, which plays a key volen endocrine processes. There's also a study of previously done by Leah Al that suggested elevated in drawer bittle pressure's encountered and graves opportunities could drive the adequate genesis and increase the fat levels in the eye in causing the um and then promoting the endocrine processes. And this could potentially explain the clinical results, suggesting that over to decompression can reduce orbital information. So finally, we conclude that the adipose tissue in the orbit affected by grades are pretty seems to be actively participating in the course of this disease, and targeting it's activation could actually help create new therapeutic options for these patients, which also is nonsteroidal so. This is the publication that we did last year in the out of beside journal. Um, free to read up on it a bit more on. Thank you for listening. I'll be happy to take any questions. Um, thanks. A tissue shy jump in with a question here is that Please do. Yeah. Okay. Thanks very much. Study. Very, very, very interesting. And so I Actually, I I am not from ologist, but I don't deal with orbits. Particularly is you'll be aware we all have our own areas of practice, and it'll the rest of the eyeball still fairly fairly foreign to me. In that respect, I'm just trying to insensitive a F one was increased in the patients with grave's or orbitopathy and then increased following treatment with IV methylprednisolone. Is that right? Um, no. So we found that the marker that it indicates I had some, uh, programs are pretty because it, uh I think yeah, that it did increase slightly after IV and two so especially to two questions. Really? So so that's a marker of macrophage activation. Is that what you're suggesting? So So giving the so giving the high dose steroid. I mean, why is that going up then? Sorry, Because because you think the steroid will be suppressing the inflammatory response, wouldn't you? Yes. And I I agree So we found that in the, um when we did, they would be did the regression Multivariate analysts. And we took in count for the age and the TSH levels. It actually sure that it was significant in terms of it, um, it lowered after the after the steroid treatment. But that's when we put in into the regression. Um, multi. Vary it. Logistic analysis. Okay, So the people is, um, who hit about here that you can see that the p value between the groups, we found that the control and then after the treatment that they was a military said before the treatment and after treatment of a P value, sure that it was quite significant in terms of the change in the AI okay, on dust fully on from from that Did you correlate this with clinical outcomes to that, the IV methylprednisolone. So have you got any data to say whether whether the patients actually improved in their clinical activity schools following the methylprednisolone? So we found out the, uh the actual grades are pretty improved. But to actually control the thyroid progression, they a lot of the patients have to have a car addicted me which we which we would recommend to patients after these after the steroid treatment in order to prevent further episodes or Brazel Pretty potential loss of sight if they didn't have it. Okay, thank thank you very much. Excellent. So thank you for that. We've had a question in the chat as well. So how did you choose which parameters to adjust for in your multi variable analysis? Looks from around here. Okay. Um, so the independent variables, we took it to count the stuff that that is a known factors for proves grave's disease to age sacks on smoking, and I am I That was the main focus off within the main purpose, but not independent variables as well as the add a concept are produced. Excellent. Thank you. Looks like we've got no questions in checks way we can really thank you very much. You talk 100. But you are really here to introduce our next person. Okay, thanks very much. So now we'll move on to our second or presentation, because by bother, daycare on the title of the feasibility lately. Efficacy of upper limit government integrated blood training yet? A little bit. 80. Good. Okay. Uh Hello through. Um um, thank you for, uh, taking part in this, like, wonderful conference today on I'm just, uh So my name's father Dokie. I'm a medical student. Bart's. I'm currently on my fourth year. Um and this is a project I undertook as part of my BFC last year. On it was around the feasibility, safety and efficacy of a pill in government integrated blood flow restriction training and healthy adults. Quite easy name that rolls off the tongue. But for a lot of you, I know a lot of your thinking. What is blood flow restriction training on? It's a technique that kind of originated in the 19 seventies around Japan. On what kind of involved is using a tourniquet or a kind of new originally involved using a 20 K and applying it quite approximately on your limb on you would then trained whilst having like partial occlusion of the limbus Electra on this would kind of the mechanism isn't really well understood at the moment. But it kind of encourages blood calling in the capillaries of the musculature. And, um, by doing this, you can combine it with a low resistance training. So, typically in order to again these kind of like benefits of like muscle strength, muscle endurance and muscle hypertrophy you'd want to be lifting kind of like heavy weights. But with the blood flow section training you conduct using relatively small weights of about 10 to 15% of the person's one repetition maximum. Um, so, uh, combined with, like, a low resistance training, we've seen, um, kind of like equal amounts of increases and muscle strength, endurance and hypertrophy. So we think blood for a trip in training convey used, like particularly individuals in early rehabilitation from injuries. Um, so, uh, because it just allows less stress to be put on the joint itself. But you can still maintain my muscle strength and muscle hypertrophy. So for athletes coming back from big injuries, it's between that early rehabilitation days they went to use is much muscle mass on. There's also been some studies and kind of like the possible benefits in the elderly population when they just passively yeah, applied the 20 cave with partial occlusion on. They've seen improvement and muscle hypertrophy and muscles strengthen, gaining some ability back in the elderly populations. Um, now there are, like particular challenges with traditional blood flow section technique. So pneumatic cuffs are the preferable technique on these involved, like using a BP cuff. And it would typically, uh, measure your BP and then apply a pressure that would be below your occlusion pressure. And these really great. But they're firstly quite expensive, with some busting up to 5 to 10,000 lbs on, um they also requires supervision by, like, a busy Oh, oh, oh, like a train healthcare professional on then, uh, on the other end of the spectrum, you have quite simple, like, 20 cases. Um, like a simple elastic bands that you can just like corn and you can buy a pound is, um, for about 10 15 lbs. Um, but the problem you have with these is you can Sometimes it could be in an unsafe position. So if you place it slightly too high up, you run the risk of, um, kind of including too much in in vasculature and also like, including some of your break your plexuses. Well, um, um, this is kind of where this New Year's time the technology is kind of come in. So we call it garment integrated. Glad for instruction training. So I worked with this company called High TRO on. They created this t shirt. Um, on it's got these are cuffs built in, um, it there's various, like, velcro points on the cough. So you can, uh, have, like, um, variable amounts of pressure. Um, and that very easily replicable because their number. So, you know, if you use on a number seven last time, you can do it again. This time they're relatively cheap compared to, um, the pneumatic kind of cuffs on the main benefits of these are they're really easy to set up, and they're really easy to use. Um, So traditionally, if, like, the whole sports team was going to be using the blood for the restriction training normally, by the time like some of the health care professionals upset up the first person by the time they get to the 20th person, the first person kind of ready had they're like, uh, blood flow a little bit. Cough for about 10 to 15 minutes on with these garments, the blood flow, uh, restriction calf is placed safely every time. Um, so it kind of takes away that whole safety element. So in terms of like, our aims and objectives, we were primarily aiming to explore the feasibility and safety of garment, integrated blood flow, restriction training and the upper limit healthy adults on. We kind of had a secondary aim of assessing the efficacy. Although our study isn't really powered. Teo, look at that in too much detail on, we're gonna make you measure the feasibility by looking into the endurance to an exercise program. The safety we were gonna measure by measuring any adverse events on, then efficacy. Looking at about noon time, the difference in arm girth on drops to failure on record, the total number of repetitions dictated. Um, so in terms of, like how we kind of carried out the study So each of the participants that were recruited would be us to do an exercise protocol on on this would be a kind of it was a five week, uh, exercise protocol where we would personally take some baseline measurements on that would give them to work out sessions per week for five weeks, and each workout consists of four exercises and lost abruptly about 20 minutes on the four exercises. We trade with push ups on these were either kneeling or standing banded rose, banded bicep curls and banded triceps extensions. And these were all home work outs, kind of do to pick a vin 19 and done it. I really would have liked the like to get them into the German, done a more tailored work out. But we settled for this on the way. These kind of exercises kind of work with blood prescription training is we have, like, one build up set of 30 reps, and that's just Oh, encourage the pooling of the blood within the muscles itself on, then would then have three working sets of 15 reps, and you would have a collision on for every single exercise, and you take it off at the end of each exercise. Um, like I said, we're measuring these few things, and we ask these participants to meet with us kind of weekly. Teo kind of, uh, fill out this questionnaire. Um, so in terms of like the timeline, we had an initial meeting with a participant where he took some basic demographic data. I'm kind of, ah, put them through what we kind of expected from them and how we wanted them to kind of do the exercises. We then I met up with them weekly during the exercise protocol to track it. There were any adverse events on answer any questions that they might have had during the preceding week. And then we've had one final meeting Where we, uh well, we took the baseline measurements again, just to see if we could see any difference. Then we finally did some data analysis, um, on then in terms of our results. So we had a total of 28 participants, 15 man and boating women. Um, Andi, I went, Boy, you're not to the basic demographic data. We had a mean age of 31. Um, Andi? Yeah, you can see those there. And in terms of like, the results that we're really interested in was the appearance. Eso the insurance is calculated is the number of sessions attempted? So we didn't necessarily penalize people attempting a exercise but not completing the whole amount of reputations. As long as they attempted this set, it was counted on. We had a recurrence of 99.3%. And we only had, like, one drop off towards the end because, uh, As I said, it was kind of in the middle of the pandemic, So people are hurting at the beginning. And then towards the end, people got busy again. So one person dropped off on. We had very minimal adverse events. So we had one incident of localized, bruising kind of narrative. The band struck that they've also been playing football that week is well, so they kind of may have had it from somewhere else on then. We had three incidences of excessive pain during your post exercise on. But this was mainly from one hardest kid who during the first a week, had a kind of misunderstanding about the instructions that we gave them and kind of kept the on thought they had to fulfill all the amount of repetitions on really push themselves. Teo, complete the repetitions on. Then finally, we had 82 incidences where the pulse oximeter reading was not recorded on. We used the pulse oximeter toe mainly. Make sure that all the participants were under arterial occlusion pressure to make sure they still had a pulse. But we think this is mainly down to the quality of the pulse ox Senators. Is we don't really have too many other adverse effects. Um and I think, uh, yeah, on in terms of, like, efficacy while So you weren't really powered. Teo really make draw conclusions about the efficacy. We looked at it anyway. A Z concede here. We had, like, an increase in the number of, like, push ups from baseline two, week five on. Quite a significant increase in size defect armed guard fitted. It really change at all on down. Total repetitions increased slightly. Um, on you can see here with our P value. Is that, uh, sorry. This is the normal itty test. So we then, based on the normality test picked, whether we do students T test or a wilcox in rank based on if it's normally distributed or or no normally distributed on, then Yeah, So, as you can see here, we had a good effect size of the push ups. Not so much on the arm girth on a little bit on the on the total repetitions. I don't get why we kind of saw those results in a little bit on these areas, like individual, kind of like graphs here for, like, three shots to volitional failure as you can imagine, asking people to do pushups every week, twice a week will naturally increase the number of push ups that they did. Um, so it's kind of Ah, yeah, it's a bit of a weird result, but it's kind of expected. And we can't really say it was due to the Garden integrated blood for a strict training robin from just the pushups itself on with the armed guard. Because we had to ask the participants to kind of measure that measure it themselves at home while we tried to guide them as much as they can. It was really, like, ineffective on not very accurate, asking the participants to do their own arm girth both before on after. So we saw quite a fall, and it's quite a variable, Um, factor in terms of like, lots of things influence it like muscle mass and, uh, total adipose tissue as well. On then, here we have repetitions completed. As you can see, most people kind of went up on. This is the kind of reason we wanted more individualized kind of, uh, program because, as you can see, a lot of people were kind of maxing out before we even started the protocol on most people went up and the one big person is down here. We kind of had a golf injury in between on, uh, in between the weeks so rapidly, kind of like well, in terms of the number of repetitions. So in terms of like the destruction, overall, we think gone and integrated blood flow restriction is feasible and safe to use. A difference was really high on that. The adverse events can be accounted for, and we're actually really rare on the study. Design doesn't really allow computers to be drawn on Africa. See, it would probably need a further further study being done around this. But it's promising. And we can probably draw on the conclusions of other studies finding blood restriction training quite efficacious. Uh, for this on. Like I said, with the limitations genetic code in 19, we had to shift the homework out, which was unsupervised, and we had a brother than been in a gym where we could give the person I program, Uh, rather than using um, resistance bands, which were standardized for everyone. Um, we're rather given them a personalized program where they could do something that was slightly more challenging for them, uh, or more doable for them. And again, Like I said, I'm got measurements were quite unreliable. So to kind of conclude garment, integrated blood restriction training is feasible and safe to use and healthy adults. And you kind of need further studies to determine the feasibility and safety and other population such as the elderly, all those in any rehabilitation from injury. And we really need further studies to determine the true efficacy of common integrated blood flow restriction training. Um, I'm I'm now open toe any questions on, but if there are any Yeah, on eye. Is there a list of references of people want to have a look? Okay, Um, but thank you very much. Your presentation. Hopefully you can hear me. Yeah. Um, so I guess my one of my questions was he said that it's a feasible option. Uh, yeah. You explained earlier that the tourniquet pneumatic to a pneumatic cuff brother was preferred option of return it because you could accurately measure the pressure. Yeah. Um, how can you be sure that the Darman, which looks like a tourniquet, go into the shirt? Yeah, just just to Okay, what's the difference other than you slip over your head and it's a you're on? Yeah. So in terms of like what we did with this particular study, we kind of made sure that when we spoke to the original participants, um, it's quite hard to achieve, like total arterial bleeding pressure, if you ever like. Not that I've ever tried to put on a tourniquet on someone, but it's normally quite hard to achieve that on these kind of coughs only got to a maximum of like 12. So it is. It's pretty hard to achieve in the first place. Um, Andi. There's been some studies to show that you can use pain is a relative, um, indicator of actually vision pressure. So the way we manage to do this with the participants, as we asked them to tighten it as much as they could on record that as a baseline of 10 out of 10 on, then reduced down to a seven out of turn in terms of like on their pain threshold so that we would roughly get around 70%. Obviously, that's not accurate in any by any sense of the means. And for the participants here. We also included a pulse oximeter on would ask after they tightened the garment that they would put the pulse oximeter on on if it recorded a pulse. We're pretty sure we're still under artery occlusion pressure Onda. We also ask them to measure it towards the end of the exercises while just to make sure. Okay, One plot question is you had This is most useful in people are coming from injury who are presumed kind of younger, which reflects your population in your study. But the other part of this was around elderly. Um, did you recruit any elderly people into your study to see if they could manage that by we didn't? Because it's kind of unproven, and this is like a feasibility and safety kind of study. So it wasn't really aimed that looking at the efficacy in any sort of target populations, we just want to make sure that the government was first safe and feasible to use on there. And I understand that is more from the feasibility point of view. Some elderly but might have arthritis in the hands and joint. That's making it more difficult for them to use Um, yeah. So there's definitely, like limitations as toe like who can use the like garment I know of not particularly of garment integrated, but there have been, like studies showing very strict and training in elderly adult in the elderly, population kind of helping with, like, mobility and getting them, like from maybe like bedbound to like sitting up slightly and that kind of, uh, energy. I'm not too sure if we would be able to directly apply this to that population. Um, but it would make sense is it's quite very easy to use. They could if they wanted Thio and had enough strength in and of themselves to act on that one. The cough themselves, then they could, uh, there's nothing to say they didn. It's pretty safe from what we've like seeing, um, um if they need, like, supervision of maybe like a care or someone else to just tighten it on for them, then I don't see why not that we would need to obviously do a study to check. Thank you. Thank you. Thanks very much for an interesting presentation selling something I've never heard about before. So it's something very new for me. just just a quick question on the feasibility. You start off by saying that the the pneumatic tourniquets, or occlusion, was preferable, but is expensive, I think was one of your first comments. I just wondered, How much do these garments cost? Is there a price on these? Because? Well, but I just wondered in comparison. What What would be? What would the unit price be of one of these? These garments? Yes. So, in terms of the unit price of a single government, not too sure. The top of my head, I I think it's roughly around the 80 to 100 lb mark T shirt. Um, I've got one myself, um, from the company. Because one of the founders is the people that was helping with the study. They are really nice on in terms of in comparison, I guess it is quite expensive for a teacher. I'm not going to deny that. But in terms of in comparison to, like, a new magic cough, um, it's relatively on the cheap side and the further X and design it in the shops. They're a lot more expensive. Okay. Thank you. Okay. Okay. The question. We've got a couple of questions in the chat here. Uh huh. For me, and she thought that that woman, could she have. Could you just clarify with a technician standing? Yes. So, technically is, it's a scale that's used. It's a 10 point scale on it. It's basically did used to measure how active a person is. Normally, one is like not very active at all. 10 is quite active, and there's like various in between. That's if a person's been, like, run for, like, five plummeted on. It's the cells off kind of. And yeah, so there's just 10 points and you ask them to school themselves on that on those 10. Okay, thank you. On. Do you highlighted? Sort of kind of touched on this a little bit, but But if you go, uh, participant, the following the next type program, whether it's increasing the exercise of certain things anyway, then they will get stronger, the muscles will get bigger. Um, but it doesn't seem that you had sort of a control group in this study. By way of comparison. Just wanted to know a bit more about your thinking behind that. Yeah. So, initially, like the study was to kind of check it. It's feasible in safety years, and that was our primary sort of objective. We thought whilst we're getting them to do these exercises, let's just have a look and see if it improved the kind of like general muscle strength, um, on. We would need further studies to kind of, as you said, use a control group to see if it is more effective than just normal exercise on. We can kind of use the other existing data on this because there are other studies that have used blood flow restriction training in combination with the resistance training and compared it to a traditional your high mood resistance training. Um, and they found that it could be just a septic, a cious as highly resistant training. But obviously the advantages of doing it with a low load, uh, can kind of be beneficial for some bulk elation groups and even people looking for, like, a kind of if they've plateau did, in terms of their training a new stimulus, a zoo, well, convey, like, quite beneficial. Okay. Thank you. On the Got another question here from Dan. Thanks. You talk about it. You mentioned that this may have applications in rehabilitation. What do you think would be the potential challenges utilizing this in older or frail? A population, although suffering from admission associated muscle HPV as an adjunct to normal for the therapy intervention? Yeah, so there's definitely going to be like challenges in using this for the older population, but it is quite a he's eating to do. And we think it's probably safer to use the's things than it is to use the traditional, like 20 K, although they can be used with a trained health actual and there my name is like a bad way of doing things on. I see as exactly that as an adjunct to normal is your therapy. I don't imagine it kind of replacing normal busy over there on, I think the main kind of challenge that I can see is the actual like if the person themselves kind of doesn't have the like hand or grip strength toe actually call the 20 k in on themselves. Um, and also, uh, I guess like this might be something that will be changed with, like, future, kind of like governments that on these the arms are quite big and made quite mostly Jen people. So they would have to be made slightly smaller for the elderly population. That those are kind of like the, um, challenges that I see is when I used it myself, I'm quite a slim person. I'm not. Mostly by any means on it was a little bit bigger on May, but still made it work. But that's something that would definitely like that can be changed and be changed quite easily. Great. Thank you. So I think that's all our questions for your presentation there. Thank you very much. Um, on the hand over to Amy to introduce our third or presentation for today. Okay, so, um, but introduce be honest, Iowa know, um, who's coming in to talk about assessing connection? Sit here in, um, I'm seeing him, um, assessing clinicians, adherents, the recommended surveillance period of patients with Corinne only by and the But you will need this panic and not just the world I hospital. Okay. Thank you so much. Oh, just Can you hear me? Okay. Yeah, You'll just show my screen, so thanks so much. And really, really great speed here today. Um um I'm gonna listen. One of the one of the medical students in Manchester on, but I'm currently finishing my fourth year. This is a project I undertook attend of my third year almost exactly a year ago. Actually on it was part of my students selected clinical placement ophthalmologist, and at the time, I didn't really help much experience. Fact, I had no experience so far more that your particular knowledgeable from a while ago because I haven't done the irritation. Just get on. This was a recommendation or a suggestion, rather from my supervisor at the time. Who thought would be feasible project, given the timeframes be useful as well. And one thing that you we could learn where I could learn rather some some useful skills is to undertaking in order. So, as we said, assessing clinicians that here is the recommended surveillance period of patients with Korea leave us in the virtual needs clinic out Manchester, so we'll cover today is just a bit about ground about. The project will be looking at the studies that were set and the methodology that that came about two year olds. Some of the results We'll be looking at what we managed to yield out of this order in terms of results of the conclusion is inferred. And finally, we'll look at the action plan. It's well that we said so. Cory only work quite common in the general population, but they're usually incidental. You filed most likely when patients go for the annual eye screening to their optometrist store at a GP setting. But they were fairly Coleman, mostly under reports that I'd say, Um and that's with you know, very Pinter skin walls they usually don't of don't have any wearing features or anything of particular concern about, um uh, but it can be the case. That's what fortune cancer changes, which may resemble a melanoma. And in the patient's journey, that is quite an alarm. Me change to the clinical support so they need to mitigate such changes has Bean highly dependent on using risk factor stratification on multimodal imaging. Um, trying to assess and getting a better understanding of these lesions. So depending on the number of risk factors that are found in a patient, usually the follow up period in range from 4 to 6 months initially, and then either monitoring thumb annually or they may even just be discharged, know Ideally, I'd like to make. This session is interactive. It's possible. But that won't be. That wouldn't be the case today. One of these pictures is a core. It'll never So you have one. It's a melanoma. You can tell just roughly looking at them that they are quite, um, difficult to discern which ones which. But for the purposes off, being quite clear today, number one is the the neighbors. The picture will talk a number Two of the both of Ms middle number said that during that. So So we noticed that significant number of patients in Manchester specific you, uh, were kept under hospital review for these for these need. Funny on, it was deemed that there wasn't really a clinical need for for having these patients come in consistently. So the and we said it was to assess the efficiency of the nevus clinic and consider whether patients were being followed up or seen it appropriate time frames. And we felt that by achieving this, this would intern give us and understanding us whether they're script for improving, um, the implementation of the guidance, you know? Yeah. Sorry. Sorry to interrupt. We can see the pictures um, from around. Where have I left you? Out. We can see the rest of the slide. Just not the pictures. You can either. The bring it up if you just bring a pin. Parliament just for this moment rather than doing a full screen. Oh, try again. Um, in full screen. Was Is this okay? No. Yeah. Do you wanna? Perfect. So these were the images I was talking about? Um, this one's the actual corridor. Nevus on the bottom picture here is the melanoma, and they are quite difficult to discern to. Someone especially may not have a huge amount of experience in the family Gene. Say, Oh, so I really thing, this access burden that the never sleep clinic was facing, we'd hopefully be able to gain more capacity. And the neighbors clinic, but also relieve some of the access, burden or anxiety that, um, patients face during having a hospital appointments. So just simply, um, the patient journey. This is more supposed to be a non. It's a shin, but we can We can work through it as it is here. So the patient comes in assuming from a red arrow, so that would represent a um, let's try a full screen this thing. So this is the main rubric, or framework off the journey so the patient would come in with on a referral from the GPU per se or from the optometrist with other suspicious, for example, looking lesion at the back of their eyes, and it be referred to believe this clinic. Usually they have some information source they'd expect with scans toe expect under taking them now. When they come to the hospital, they're gonna help their vision check, and they're gonna have a set of Scott in stone. And those are going to be recorded and sent over. It's the consultants. Other consultants ago, the opportunity to review these guns on the days part with the patient and form depiction of essentially the current situation. So whether they have a lower risk, neighbors are high risk neighbors or it may be the case that may just be, um, it could be any of this and maybe something else. And there's two ways to go from here. Essentially, either the patient have enters this cycle off monitoring on attending. Leave this clinic every 46 months for what I'm using, or they may just be discharged. So the standard so except for this will do really do kind of revolver on the adult one college group guidance that was set. It's a patient with a flat Neighbors which didn't present with any of the Risperdal is that were listed. We're just a school should be discharged from their nevus. Okay, first patients who did have a flat nevus. But at least one risk factor there should be reviewed every six pills for the first year, and I nearly after that and fighting you for patients who had a race lesion. This is where it kind of get time. It gets more complicated. It was four months in the first year, six months in the second year, and I nearly after about So let's we'll help you stunned. It's really hot, too. Should we say, um, considered the boundaries of in terms of efficiency? So just roughly, I try to make this as into it's if it's possible green being like a good compliance. So if over 95% of the cases on a stick to the standards than I would indicate quite good compliance, Orange is moderate and right is quite poor compliance. So this is a retrospective review that we did of 100 consecutive patients with a confirmed cord on levers. There were a few dip in usion service in Manchester. Data collected was from mid January, up until April of last year, and it's just done through the electronic patient. Records on the data collected includes the size of collusion. What? See if there was any presence of orange pigment, any presence of subjects, no fluid, the overall thickness of allusion, the maximal thinking start over. And if there's any evidence of decline in visual acuity, and I suppose is support support, which is directly related to the Asian. So if a patient makes up from like, oh, more sensitive refractive, better up wouldn't really come a response. But looking into this a bit warm. If, um, usually we found a solution was fight over five millimeters that was considered to be a risk factor pulling to the Guardians. Certain picture. We'll just simply put a little arrow here. I don't know if you can see. I hope you can see these pictures. Um, I'm sorry on a surgeon. Interrupt you. We can't see them were still on the standard slide at the moment. Um, I wonder if it's something to do with the present of you. If you just make the you open, your there was in the same If you expand this, uh uh, when the power point of view, I just make it as big as you can. Um, And then if you click through on that way sorry your animation. But we can see your lovely pictures. Thank you. Thank you. So picture one of it here. This is quite a small, uh, the visits. It's temporal from like when this one really reconsidered. Um, you know, over five millimeters per same, but it's just a barren subsides. Wanted to know if there's any presence of fluid. So in pictures over here you can support nice don't shaped area of cooling off. You would, um, that's there's any orange pigment, and this is quite a difficult one to discern. Really. Picture three. She's allusion with orange pigment, and it's It's quite difficult to really appreciate this because the background colors of the fun disorder orangey right. So it does. It does make it quite difficult to discern Valium. If a lesion is ever two millimeters take that was considered to be a risk factor. So infection before year this's on CT optical coherence tomography, and you can see how far but the lesion extensive in here and find, as I said, visual acuity is only loss and envision. I feel secure did be scan, which is a type of ultrasound scan, and right, because this isn't actually routine, you don't lunch is the, um, unless you have other centers do this routinely. But this is still a very ad hoc basis because it's not deemed to be as useful some of these other investigations. So because we have such a huge and consistency with with which patients how to be scan which didn't know, you know, this part of the every factors we were looking for. So after that, we'll want to used to toe defines an inclusion exclusion criteria. Um, inclusion was fairly straightforward. It was purely just patients who are in her forward in the virtual need. This clinic within the dates that was specified and lot of confirmed core don't need this. The exclusion was a little bit more complicated. Patients who were did not an appointments consistently and weird discharge is a result of that, uh, we're know included, because that did skew the results in the way off compliance and no patients who had other kind of a record of lesions who are falling in the virtual clinic worlds and included. So there was quite a few patients who have things like a therapy or bear tracks or something that wasn't exactly a nevus. And finding patients who developed the melanoma were excluded because these patients were followed up, at least in lunch. They're All these cases are sent over to the liver, poor urologist service so and they're carriers kind of taken over by the by the neighboring team. So once we had all these results and we had collected all this data, we ended up with something along the lines of this where you had the patient number, which was another most. We have the number of risks factors that were present. This's very rough table, quite, or you're making from back in the day that the number of respect Ear's whether the solution was raised on know because patients essentially fell into a raised or flood usually cuts it going, and whether the guidance was for liver. So once we had all the states and we correlated it to the standards that we set, we also, um, calculates the global it here in the clinic, and the results are a little bit discouraging. But I wouldn't I wouldn't dwell too much on on this, essentially patients with a raised lesion within consecrate that was able to achieve the motor adherence, um, to to burst. And it's always set, whereas everything will flatten in this category was poor compliance and the compliance, which was quite. But it's interesting to see why this may be the case. So from the conclusions that we were able to infirmed and all the White case, I think this is probably most fascinating patients. Were you sheet saying too often or we're not discharge? And this kind of ties into the hypothesis we hardware the clinic was a little bit such rated. Um, one case was seen later than the recommended surveillance period that I should mention. That wasn't a high risk canes. It was just a lower risk ace that was delayed for whatever reason. And the other thing was, the data was beautiful. Isolation plus changes to clinical history. So therefore, any changes. The patient may hard to the wrist five years, we're know, considered in the scope of the data analysis in the way that a clinician may have considered it at that moment in time when arrange follow up. So we felt up by having a stripper stricture story. Implementation of the guidance would be able to achieve a great plus, a new clinic to be able to see more patients are newer patients. And, you know, in terms of the patient experience, we'd be able to reduce the number of visits that patients would have and hopefully use any any inside of the many things. So, as I said before, there may be perceived risk of miscarriage. High risk neighbor. Still, there was never a case where high risk grievous was missed. Some more importantly, me ox and plan, what were you able to set? So the order, that's what it was submitted to the order team at the hospital on it was disseminated to the medical Retin a team and presented at our ordering. In fact, in this departmental meetings, I'll just come to now point, I'll come back, sit up with you in a year and, um, But we're also able to share the current guidelines. That of the team was using, um, kind of incorporated into the regular departmental training that's usually done. That was actually my supervisor who was able to do that. And this is the final on this stage crying out. So we did this about a year ago, and now we're looking at closing the order loop and recollecting the states and seeing what changes have been made after or what in fact, that changes. We've kind of being the changes we've made hard. So revoting. The first point Manchester has quite a strange isn't lot stranger require strict template as to how they want the order, and it's not the most intuitive. So we thought we'd, um, make a little book stone getting in a four sites posted. But it's one side, and it's very succinct. On Essentially is quite good snatcher, a stamp short story of all the data that we hard and main findings on bunch. So has this clinical effect that this week, where it encourages the lots of, um for the participation and undertaking water, it's It's like a good a good thing to do find a house and references here, the first ones of the guidance out at lunch. So uses and then just some interesting articles about Coreg. Only if I'm I know Mom on for any other students were or anyone really who's considering undertaking a little bit, um, used to re sources of the bottom or really, really good to try and get my head rolled. Helps of structure and what's include and things to keep in line through the process. So I think that's me. Let me finish. Uh, said like to just think everyone for listen to me and bearing with all the technical difficulties. Um, but I'd like to invite any questions. You often well, thank very much. Um, uh, yeah, I feel like I've been spoiled. Takes. I think we started the day thinking about embryo pia were talking about, um, the opiate. And we've now had to ophthalmology presentations in the afternoon. So good to see lots of people interested in iced today. Yeah. I mean, in interesting order on down. Um I think in the in the broadest sense, this is this is quite common area of concern across all. Our unit's on D. I suppose I'm going to start with a slightly, I guess. Abstract question really did. Did you provide kind of working out how to ask this in a way, you can answer it, or at least give the answer I'm looking for. But in my experience is not the patients that are known to the screening clinic that the issue. It's the patients not known to the screening clinic hands. I've been caught out by this relatively recently, where at where you've seen lesions that have suddenly sort of been picked up or diagnosed and could potentially have been acted on a bit sooner. And I'm just thinking about it again, coming back to in hospitals, we tend to will be very obsessed with our own part of the eye. So you go to a corneal clinic, and the chance of a corneal consultant looking at a retina is vanishingly small. I just wondered if you've got any advice or screening suggestions for some of the General hospital population s so that so that you can be sure that you've got all the patients that you need in this sample to begin with. If that makes sense, yeah, absolutely. I I think it's really important to consider, though, as you said, the patients who have no parts of the Nevus clinic and help or no monitored and essentially half of Nevis, which isn't being followed up by anyone, is very difficult to to kind of reach out of these populations because you know, core it'll move are quite instance, he found, and usually they don't present with any kind of visual loss or anything of that sort. So most patients who have one don't even know they have one. In this case, we weren't I I think this case was more so for the smuggling operation running of the nevus Kleenex to try and get know streamline. But, um, try and get the patients that need to be there to actually be there rather than following a patients on this area. Um, I didn't think it was over the case that believes clinic was saturated enough that new referrals couldn't come in. But it was just the case. Thought there was a little bit too much going on for the team. Yeah, I mean, what can you suggest? A simple initial screening test of it that could be done on patients I think I'm something that would be quite useful for for everyone where you is just being able to follow a keep up to date with your annual eye checks. Um, I know I understand that a little patient information specially occasion with diabetes, for example tends to have a regular eye checks both for lots of us, including myself. Function at night, like in a while on. But I think just encouraging that engagement with either the GP or optometrist in the community is a really useful first step to atleast see if there's anything worrying going on in terms of stratifying something like that in the community. I suppose we could look at making something that would be something like the poster for itself, which would be a simple reswab stuff to be used in in the primary care of community settings to try and guide. The decision making proves is quite regular. Okay, Yeah, I suppose I was sort of getting out on an annual wide field retinal photograph for any patient under the eye clinic. Might Would Would would sort of document and pick up any any lesions, but yeah, Okay. I'm my second question. Actually, mentioned it there again. So one of your risk factors is patients that have got reduced vision because of the nevus under what circumstances would've cried. Leave us cause the vision to drop. Um, to be honest, I don't think there would be to my understanding of loose. I don't think any of us would cause a visual acuity to drop. I think that would be the case where you probably be thinking of something a bit more suspicious or sinister, or alternatively, looking at something that may be completely unrelated to the Memphis itself. Um, so some other co morbidity or something else? I mean, interesting. There is one of your other risk factors that might drop the vision that's related to the nevus, but that's that. So if there is subretinal fluid, that's them sort of affecting the central retina. That that might that essentially, Yeah. The only time I can really think apart from some very rare circumstances with, um that's that's great. Now that Thank you very much. Thank you. Uh, like it coming, then, um, I have no problem. Allergic background, really difficult. That's all questions for me. It's just gonna be a ah couple of questions. What? Firstly, what you said is, essentially, you're overusing the service. But this too many appointments given you have a feel for over the course of a year, if you're snapshot was Joe over the course of a year, how many appointments are overly over subscribed? That's a good question. To be honest, I'm not too sure of the course of the year. I mean, for us, it was over the span of a few months, both kind of thinking about, um, you know, I have had this. We have the resources. No, that no being on shared around with the team on should the situation of being progressing as it waas I suppose we probably see similar of trends over the course of a year just because it did seem like there was this repetitive trend of just seeing patients a bit too, too soon more than you need to. Um, it probably would be quite beneficial to try and get a much larger time frame on by extension of much larger and patient population. Um, but given the kind of constrictions of the time when we weren't taking this timing and, um, just two people doing it. Basically, we tried to get a much as possible, um, during that, but that time we have, I guess, then my other question is what the form sounds. I can order it. Um, Andi, you're proposing to really? It's having having had some ideas for changed, uh, improve things. Kind of question, then, is how well you know what impact any of your changes individually of made to the problem. When you come to reorder, it is difficult to to see which specific. Um, I may have played the largest role in making a change, whether being positive or negative. Um, I suppose when reorganising, we'll be able to see an overview of whether things have stayed the same, whether they've improved or, you know, hopefully not guilty words, but it could be the case on. But I think in terms of seeing what specific factor was able to achieve the best intervention, that probably would be looking a bit more on a qualitative side of things and trying to see individually with each clinician war really aided there kind of a day A. Did the usefulness in undertaking, uh, this was running of the clinic. Um, so it's been difficult, but I think we'd be able to get on overall feel as as to what changes have been made. Okay. Strikes me that you have the beginning of this quality improvement project. You know, uh, to a hammer, everything to mail and all of that. So it is. It is something that you've noticed. An issue. You got change ideas and actually actually, a bit of a Q I project. And you collected dynamic data regularly, and you annotated when you made the change of it, but they just almost like you're on. Well, then better understand what the impact of each change Waas. So just a suggestion, then I guess which would be to find somebody ripped some Q I expertise. You could maybe give you some advice around that. Sure. Thank you very much. Amazing. Thank you so much. I don't in there any other questions in the chapter. Judges happy? Um, well, and our presentations that Thank you. So sorry for all the issues of bearing with us. Glad we got to see the pictures of man. They're very pretty