Efficacy and timing of adjunctive therapy in the anti-VEGF treatment regimen for macular oedema in retinal vein occlusion:12-month real-world result

PurposeVarious combination treatment regimens have been tried to improve the short-term efficacy of intravitreal monotherapy for the treatment of macular oedema (MO) secondary to retinal vein occlusion (RVO). Our study introduces the RandOL protocol (Ranibizumab and Ozurdex with Laser photocoagulation) of initial anti-VEGF therapy, controlling recurrent non-ischaemic MO with an intravitreal steroid and applying laser therapy to non-perfused retina. We describe our 12-month follow-up experience on timing for adjunctive therapy and real-world effectiveness and safety data.MethodsA retrospective analysis was carried out on 66 consecutive treatment-naive RVO patients with MO who received our RandOL treatment regimen. Baseline visual acuity (VA) and central retinal thickness (CRT) were compared with 12-month result.ResultsAt 12 months, 77% had significant VA improvement, 52% had ≥3-line improvement, and 15% were worse. Significant improvements in CRT were observed in 97% (baseline median CRT=531 μm (IQR 435-622) reduced to 245 μm (IQR 221-351, P<0.001) at 12 months); 76% achieved a dry fovea at 1 year. Mean number of total injections required was 5.5 (range 2-11) and 6% required ≥9 injections in 1 year. Although 70% received additional Ozurdex, 82% received ≥1 sessions of laser therapy. The BRVO subgroup achieved better VA and CRT improvement at 1 year, but small numbers limit definitive statistical conclusions.ConclusionsOur real-world results using a combination treatment protocol for RVO-related MO achieved similar desirable anatomical and visual outcomes as with a single-agent therapy with less intravitreal re-treatment rates at first year. Randomised controlled studies are needed to evaluate the role of laser and the ideal timing of combination therapy

Left atrial and left atrial appendage functional recovery after cardioversion in patients with recent atrial fibrillation: Serial echocardiographic study

Background: The aim of this study is to point out timing of left atrium and its appendage functional recovery after cardioversion (CV) in recent onset atrial fibrillation (AF). Methods: Fifty patients; 27 within 48-h (group I) and 23 after 48-h (group II), of AF onset, who had successful CV underwent transthoracic echocardiography (TTE), before and im­mediately after CV, then 15, 30 and 90 days later. Transesophageal echocardiography (TEE) was performed for group II before and for all patients immediately after CV and 1 month later. Mitral peak A velocity and left atrial (LA) reversal (Ar) velocity, tissue Doppler imaging (TDI) of septal mitral annular velocity (A1) and LA free wall velocity (A3) were recorded. Absence or peak A velocity &lt; 50 cm/s was taken as a cut off value for atrial stunning. Intra-atrial conduction time (IACT) was measured. LA appendage late emptying (LAALE) velocity was measured by TEE-pulsed TDI of LA appendage. Results: Post CV, all group II and 34% of group I experienced stunning. In both groups, peak A, Ar, A1, A3 and LAALE velocities increased (p = 0.000), while IACT decreased (p = 0.000) progressively over time. Partial recovery occurred after 15 and 30 days, while full recovery occurred 30 and 90 days post CV in groups I and II, respectively. IACT1 and IACT2 correlated with LA diameter (r = 0.2778 and r = 0.227, respectively, p &lt; 0.01). Conclusions: Stunning and functional recovery of the LA and its appendage are strongly determined by the duration being in AF. Serial IACT by TDI was a good new parameter for detection of functional recovery of LA and LA appendage

Ebola and Health Partnerships, Action in a Time of Crisis

The chapter explores the role of health partnerships in delivering services throughout the West African Ebola Virus Disease epidemic, including the creation of the Ministry of Health and Sanitation, Sierra Leone, Ebola Holding Unit models, command and control structures, research into diagnostics and care pathways, and general medical care. It will highlight how this provided resilience during the Ebola response, and how this will aid health systems strengthening going forward

Assessing the Efficiency of Remote Sensing and Machine Learning Algorithms to Quantify Wheat Characteristics in the Nile Delta Region of Egypt

Monitoring strategic agricultural crops in terms of crop growth performance, by accurate cost-effective and quick tools is crucially important in site-specific management to avoid crop reductions. The availability of commercial high resolution satellite images with high resolution (spatial and spectral) as well as in situ spectra measurements can help decision takers to have deep insight on crop stress in a certain region. The research attempts to examine remote sensing dataset for forecasting wheat crop (Sakha 61) characteristics including the leaf area index (LAI), plant height (plant-h), above ground biomass (AGB) and Soil Plant Analysis Development (SPAD) value of wheat across non-stress, drought and salinity-induced stress in the Nile Delta region. In this context, the ability of in situ spectroradiometry measurements and QuickBird high resolution images was evaluated in our research. The efficiency of Random Forest (RF) and Artificial Neural Network (ANN), mathematical models was assessed to estimate the four measured wheat characteristics based on vegetation spectral reflectance indices (V-SRIs) extracted from both approaches and their interactions. Field surveys were carried out to collect in situ spectroradiometry measurements concomitant with the acquisition of QuickBird imagery. The results demonstrated that several V-SRIs extracted from in situ spectroradiometry data and the QuickBird image correlated with the LAI, plant-h, AGB, and SPAD value of wheat crop across the study site. The determination coefficient (R2) values of the association between V-SRIs of in situ spectroradiometry data and various determined wheat characteristics varied from 0.26 to 0.85. The ANN-GSIs-3 was found to be the optimum predictive model, demonstrating a greater relationship between the advanced features and LAI. The three features of V-SRIs comprised in this model were strongly significant for the prediction of LAI. The attained results indicated high R2 values of 0.94 and 0.86 for the training and validation phases. The ANN-GSIs-3 model constructed for the determination of chlorophyll in the plant which had higher performance expectations (R2 = 0.96 and 0.92 for training and validation datasets, respectively). In conclusion, the results of our study revealed that high resolution remote sensing images such as QuickBird or similar imagery, and in situ spectroradiometry measurements have the feasibility of providing necessary crop monitoring data across non-stressed and stressed (drought and salinity) conditions when integrating V-SRIs with ANN and RF algorithms

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112