Ophthalmoscopy is a required clinical skill which is difficult to learn. This paper describes the development of a VR ophthalmoscopy app to support learning of this skill. It was developed using the Unity game engine, Google CardboardTM and smart phone. Forty-eight clinicians agreed to evaluate it for system usability (SUS), technology acceptance and knowledge acquisition (pre and post quizzes). Twenty-seven volunteers undertook the quiz. Mean scores improved by all (6.3 +/- 1.5 to 8.4 +/- 0.8 p <0.001); medical students (6.2 +/- 1.5 to 8.5 +/- 0.9 p <0.001 n:20); doctors (6.4 +/- 1.5 to 8.3 +/- 0.8 p <0.05 n:7). Overall, SUS was 74 +/- 11 (n:33), medical students rating 72 +/- 12 (n:20) and doctors 77 +/- 9 (n:13). Forty-eight volunteers provided feedback on technology acceptance. All highly rated its ease of use and how it improved their confidence in being able to perform this diagnostic procedure. Regression analyses emphasized the importance of usability, ability to perform the task and ease of use as predictors of success. Ninety percent of users felt that this type of technology would benefit their clinical training but should not replace other forms of teaching. Owing to the lack of technical -focused development frameworks this study also defines an appropriate framework that ensures clinicians are central to the process.

Sepsis is a main cause of death, by infection in the world. Despite modern treatments, mortality and morbidity could be reduced by improved training of the clinical teams. SEPSIS COLLAB (developed using Unity game engine and C# programming language for Meta Quest 2) is a unique virtual reality simulation for training both doctors and nurses to treat sepsis. It was evaluated with the help of 110 volunteers, in terms of usability (System Usability Scale) and knowledge acquisition. The latter used pre/post-tests based on clinical treatment guidelines. Participants were divided into a control group (doctors n:35 and nurses n:20) who did not use SEPSIS COLLAB and a test group (doctors n:35 and nurses n:20) who did. The consensus regarding the usability of SEPSIS COLLAB was rated as excellent. Analysis showed significant improvement in the post-test results of the test group compared to their pre-test. There was no significant difference in the pre- or post-test scores of the control group. The test group performed significantly better in the post-test than the control group. These findings show SEPSIS COLLAB has potential to provide positive educational benefits to medical teams in their treatment of sepsis and act as a complement to traditional in -person training.

Abstract Introduction Behçet’s Disease (BD) is a complex, multisystem auto-inflammatory disorder. The most frequent manifestations are oral aphthous ulcers, genital ulcers and uveitis. Vascular involvement is less common but one of the major causes of mortality and morbidity. This case highlights the need to consider BD, especially in young, male, patients with arterial abnormalities and the challenges of treatment. Case description A 20-year-old man with a Moroccan father, presented to A&E with abdominal pain, constipation and night sweats, following recurrent admissions with lower abdominal and back pain. On this occasion he was noted to have a CRP of 160 mg/L and a subsequent CT scan of the abdomen showed a 4 cm pseudo-aneurysm arising from the right lateral infrarenal abdominal aorta which was initially repaired with open surgery and a vein graft. This subsequently leaked and so he had further surgery and an EVAR procedure. On further questioning it was noted that he had had frequent mouth ulcers for seven years and also episodes of epididymo-orchitis and folliculitis and the possibility of BD was considered. He was seen in the Birmingham Behçet’s Centre of Excellence and started azathioprine together with oral prednisolone. Six months later he required embolization of a left renal artery pseudoaneurysm and stent-grafting of the same artery. Given these new changes he was commenced on IV cyclophosphamide. Despite six pulses of cyclophosphamide and high doses of prednisolone he continued to have a raised CRP and so was switched to tocilizumab infusions. His inflammatory markers initially improved, but after about two years he attended for an infusion and complained of worsening abdominal pain. At that point it was noted that his inflammatory markers had been intermittently raised over the preceding few months. There had been a few breaks in treatment due to possible infections and non-attendance. A further CT scan was performed that showed disease progression at the distal site of the graft with small new aneurysms. After an MDT discussion it was decided to switch him to infliximab. He has now been on infliximab for over six months and his inflammatory markers have, reassuringly, remained low. Discussion Arterial involvement in BD is relatively uncommon, presenting variably with stenosis, thrombotic occlusions and aneurysms, as the vasculitic process can affect perivascular and endovascular tissues. Aneurysms are typically seen a number of years after the initial diagnosis and are believed to be due to an obliterative endarteritis with inflammation causing destruction of elastic and muscle cells in the media. The aneurysms tend to be more saccular, and the abdominal aorta is more frequently involved than the thoracic aorta or pulmonary artery. In this case the initial surgical procedure was performed prior to the diagnosis of BD, so it was not possible to give something such as cyclophosphamide prior to surgical intervention which would be advised. The EULAR guidelines recommend cyclophosphamide and corticosteroids as first line in treatment in arterial involvement. However, no further guidance is given regarding subsequent immunosuppression if needed. In this case the decision to start tocilizumab was made based on successful use in other patients with vascular Behçet’s disease. Subsequently infliximab was chosen as it has been used more widely in BD including in patients with vascular BD. Biochemically and symptomatically the patient has been well since infliximab was started, but we are currently awaiting a repeat CT scan. This case has also proved challenging as the patient has struggled with the diagnosis and need for frequent hospital appointments. He has had some help from the psychologist available through the Behçet’s service but has continued to DNA appointments and turn up for infusions at times that suit him. We are hopeful that a longer period of stability will also be beneficial from that point of view. Key learning points Vascular is less common than other features of BD but can sometimes be a presenting feature and is a major cause of mortality and morbidity. Unlike the international study group (ISG) criteria for Behçet’s disease the international criteria for Behçet’s disease (ICBD) do include vascular lesions. The possibility of BD needs to be considered, especially in patients presenting with potential vascular involvement. For both aortic and peripheral artery aneurysms the 2018 update of the EULAR guidelines recommend medical treatment with cyclophosphamide and corticosteroids before surgical intervention. If there is ongoing arterial disease activity despite cyclophosphamide anti-TNF and IL6 inhibition can be considered and have shown some success. Endovascular surgery is increasingly being preferred to open surgery, although there is a risk of further aneurysm formation, particularly at graft peripheries. Conflicts of interest The authors have declared no conflicts of interest.

A prototype virtual reality (VR) game for use in rehabilitation programmes for complex regional pain syndrome (CRPS) has been developed. The game uses a ‘catch and throw’ mechanic with a transposed ‘handiness’ control system. The game activities reflect ‘mirror therapy’ which is used to help patients learn to re-use their affected limbs. The game was developed with the Unity game engine and is played with the HTC Vive VR system. It was evaluated by thirty members of staff and students (age range 18-40+) form Birmingham City University (UK) using the System Usability Scale (SUS). The volunteer testers were differentiated into two groups, regular gamers (n=11) who played several times of day, daily or several times a week and less frequent gamers (n=16) who only played a few times a month or once a month. One person did not provide this information and two could not be classified clearly into either group and were therefore exclude from the analysis. Each group was standardized with results presented based upon the percentage of respondents within each group who answered either ‘agree/strongly agree’ or ‘disagree / strongly disagree’ to the SUS statements. Less frequent gamers (63%) said they would play the game frequently whereas 45% of the regular gamers said they would. Less frequent games (63%) thought the game was easy to use where as only 36% of regular gamers thought so. Ninety one percent of regular gamers and 75% of less frequent gamers said they thought people would find the game easy to learn. Seventy-five percent of less frequent gamers and 64% of regular gamers did not think the game was unnecessarily complex. Fifty-six percent of less frequent gamers and 36% of regular gamers said they did not find the game very cumbersome to use however the current control system should be refined as some found collecting the virtual balls difficult. This study records the systematic development of a prototype for a virtual reality based rehabilitation game. Despite some initial minor usability issues the game is playable and can be used to facilitate usability evaluations with CRPS patients.

Background: Rituximab (RTX), a monoclonal anti-CD20 B-cell depleting antibody, is a treatment option in severe active rheumatoid arthritis (RA).Maintenance regimes for RTX in RA are debated with trials of ultra-low RTX protocols while the European license is of two 1000 mg infusions two weeks apart.Dosing schedules from 1 x 50mg up to 1 x 1000mg show evidence of B-cell depletion and have benefits of convenience for the patient as well as cost effectiveness.We conducted a baseline audit in 2013 in our trust to assess usage of RTX in RA with 72 RTX (2 x 1000 mg) cycles administered in 67 patients.In 2014, after internal approval, we implemented a single 1 x 1000mg dose maintenance RTX regimen in RA.After 18 months, we initiated a review of the outcome data presented here.Methods: Data logs from the medical infusion suite were accessed to create a working list of patients receiving RTX in the audit period (year to April 2017) and cross-referenced with pharmacy prescription data as well as review of patient letters to confirm diagnosis and review patient outcomes.Data collection continued for a further six months after the audit period for data on ongoing drug efficacy.Factors considered predictive of a better clinical response of RTX in RA such as rheumatoid factor seropositivity and number of previous biological agents were recorded.Results: Data from 116 patients with RA scheduled to receive RTX in the year up to April 2017 are reported with 156 RTX cycles (one or two infusions) administered.101 (87%) were female and 15 (13%) male.Median age was 59.5 years (range 27-85 years).15 patients (13%) had a diagnosis of RA for <5 years, 27 patients (24%) for 5-10 years and the majority, 74 patients (64%) more than 10 years.Rheumatoid Factor was negative in 18 patients (15%), not known in 18 patients (16%) and was positive in the remaining 81 patients (69%).Anti-cyclic citrullinated peptide (anti-CCP) status not known in 45 patients (39%), negative in 11 patients (9%) and positive in 60 patients (53%).108 out of 116 patients (93%) remained on RTX with a median number of RTX cycles of 4 (range 1-12).88 patients switched to single infusions remain on this regimen while 28 patients who had at least one cycle of single RTX infusion have continued with cycles of two infusions.Conclusion: These data suggest that after an initial two RTX infusions, maintenance single infusions of rituximab can be effective in RA.Further analysis to understand the reasons affecting success of single infusion cycles are underway.

Arterial manifestation of Behçet disease represents a challenging clinical scenario with a potential for fatal complications. This case depicts the surgical management of a 4.5-cm infrarenal aortic aneurysm and a 6-cm left renal artery aneurysm in a patient with known Behçet disease. The presence of a contralateral living donor kidney transplant added to the complexity of the case. Open surgical repair was performed on both aneurysms with the use of axillofemoral bypass to protect the transplanted kidney. This case highlights the challenges of treating an aortic aneurysm in a patient with Behçet disease and a kidney transplant.

In collaboration with doctors and medical students a novel ophthalmology training solution based upon virtual reality (VR) and gamification was developed. Fifteen fourth year medical students at Birmingham City Hospital (UK) helped evaluate it. Evaluations were based upon the Technology Acceptance Model and related to how well users learnt to use the app, their satisfaction with it; if it helped them learn ophthalmology and their view on the teaching approach used within it. Responses were rated on a five point Likert scale (completely agreed to completely disagree). Results represent those that agreed or completely agreed with the questions. Students agreed they could easily learn how to use the app (n:14) and it was clear how to use (n:15). The feedback systems supported both this (n:11) as well as learning how to perform eye examinations (n:13). Users felt the app improved their understanding of the processes involved in ophthalmology (n: 14); their ability to recognize main landmarks of the eye (n:14) and abnormalities (n:15). They felt the app would give them confidence to perform eye examinations on patients in future (n:12) and it would increase other students’ confidence too (n: 15). Users found the app enjoyable to use (n:15); would use it in future (n:13) and would like to learn other clinical skills in this way (n:15). A rigorous User-Centred approach has been used to successfully develop a novel ophthalmology training tool. The approach used will help inform others interested in developing VR educational tools.

to help ensure aplanned and safe pregnancy.

Background: Performing eye examinations is an important clinical skill that medical students often find difficult to become proficient in. This paper describes the development and evaluation of an innovative 3D virtual reality (VR) training application to support learning these skills. Methods: The VR ophthalmoscope was developed by a clinical team and technologist using the unity game engine, smartphone and virtual reality headset. It has a series of tasks that include performing systematic eye examinations, identifying common eye pathologies and a knowledge quiz. As part of their clinical training, 15 fourth-year medical students were surveyed for their views on this teaching approach. The Technology Acceptance Model was used to evaluate perceived usefulness and ease of use. Data were also collected on the usability of the app, together with the students' written comments about it. Results: Users agreed that the teaching approach improved their understanding of ophthalmoscopy (n = 14), their ability to identify landmarks in the eye (n = 14) and their ability to recognise abnormalities (n = 15). They found the app easy to use (n = 15), the teaching approach informative (n = 13) and that it would increase students' confidence when performing these tasks in future (n = 15). Discussion: The evaluation showed that a VR app can successfully simulate the processes involved in performing eye examinations. The app was highly rated for all elements of perceived usefulness, ease of use and usability. Medical students stated that they would like to be taught other medical skills in this way in future.

This study reports on the analysis of the application and diagnostic predictability of the revised 2014 ICBD criteria in an unselected cohort of UK patients, and the ensuing organ associations and patterns of disease.

Giant cell arteritis (GCA) and Takayasu's arteritis (TA) are the two primary large vessel vasculitides. They are idiopathic systemic inflammatory conditions characterized by granulomatous inflammation of large and medium-sized arteries. TA affects a younger age group, predominantly involves the aorta and its main branches, and tends to be a two-phase disease with inflammatory and occlusive stages. In contrast, GCA affects an older age group and classically involves the temporal and other cranial arteries, although extracranial GCA can affect the aorta and its primary branches. Constitutional symptoms are a feature of both diseases and vascular symptoms are dependent on the pattern of arterial involvement. Temporal artery biopsy and angiography remain the gold standard for diagnosis of GCA and TA, respectively. New imaging modalities are challenging this practice and have the potential to allow early diagnosis and monitoring of disease activity. Over the last decade treatment has seen major advances and, with the advent of vigorous immunosuppressive therapy, new means for intervention with percutaneous transluminal angioplasty supported by stenting and biological therapies on the horizon, the prognosis of patients with large vessel vasculitis seems likely to improve.

AIMS:Severe ocular inflammation is a blinding ophthalmological emergency. This study evaluates the efficacy and patient tolerance of a validated regime of pulsed intravenous cyclophosphamide and methylprednisolone ('PICM protocol') for these patients. METHODS:26 patients with severe inflammatory eye disease (43 eyes: 22 uveitis, 21 scleritis/sclerokeratitis; median age 52 years (IQR 40.25-62.25)) presenting to a regional tertiary referral centre were recruited over a 10-year period (January 2002-December 2011) into the PICM protocol, comprising intravenous cyclophosphamide 15 mg/kg, intravenous methylprednisolone 10 mg/kg, maximum nine pulses over 20 weeks supplemented with low-dose continuous oral prednisolone. Data were captured pretreatment and at 6 and 12 months follow-up. Primary outcome measures were control of inflammation according to standard criteria and reduction in systemic glucocorticoid to ≤10 mg prednisolone/day. RESULTS:A median of six pulses (IQR 5-6) were administered over a median of 3 months (IQR 2.25-4). In the scleritis/sclerokeratitis group, 15/21(71%) achieved success or partial success at 6 and 12 months versus 9/22 (41%) for the same time points in the uveitis group (χ(2)=4.058, p=0.044). Two patients had adverse events requiring treatment withdrawal. CONCLUSIONS:This PICM protocol is a well-tolerated regimen for managing severe ocular inflammation and appears particularly useful in patients with scleritis/sclerokeratitis.