Prophylactic non-steroidal anti-inflammatory drugs for the prevention of macular oedema after cataract surgery.

BACKGROUND: Macular oedema (MO) is the accumulation of extracellular fluid in the central retina (the macula). It may occur after cataract surgery and may give rise to poor visual outcome, with reduced visual acuity and distortion of the central vision. MO is often self-limiting with spontaneous resolution, but a small proportion of people with chronic persistent MO may be difficult to treat. Chronic oedema may lead to the formation of cystic spaces in the retina termed 'cystoid macular oedema' (CMO). Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in cataract surgery and may reduce the chances of developing MO. OBJECTIVES: The aim of this review is to answer the question: is there evidence to support the prophylactic use of topical NSAIDs either in addition to, or instead of, topical steroids postoperatively to reduce the incidence of macular oedema (MO) and associated visual morbidity. SEARCH METHODS: We searched a number of electronic databases including CENTRAL, MEDLINE and Embase. Date last searched 2 September 2016. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which adult participants had undergone surgery for age-related cataract. We included participants irrespective of their baseline risk of MO, in particular we included people with diabetes and uveitis. We included trials of preoperative and/or postoperative topical NSAIDs in conjunction with postoperative topical steroids. The comparator was postoperative topical steroids alone. A secondary comparison was preoperative and/or postoperative topical NSAIDs alone versus postoperative topical steroids alone. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed risk of bias and extracted data using standard methods expected by Cochrane. We pooled data using a random-effects model. We graded the certainty of the evidence using GRADE and considered the following: risk of bias of included studies, precision of the effect estimate, consistency of effects between studies, directness of the outcome measure and publication bias. MAIN RESULTS: We identified 34 studies that were conducted in the Americas, Europe, the Eastern Mediterranean region and South-East Asia. Over 5000 people were randomised in these trials. The majority of studies enrolled one eye per participant; a small subset (4 trials) enrolled a proportion of people with bilateral surgery. Twenty-eight studies compared NSAIDs plus steroids with steroids alone. Six studies compared NSAIDs with steroids. A variety of NSAIDs were used, including ketorolac, diclofenac, nepafenac, indomethacin, bromfenac, flurbiprofen and pranopfen. Follow-up ranged from one to 12 months. In general, the studies were poorly reported. We did not judge any of the studies at low risk of bias in all domains. Six studies were funded by industry, seven studies were funded from non-industry sources, and the rest of the studies did not report the source of funding.There was low-certainty evidence that people receiving topical NSAIDs in combination with steroids may have a lower risk of poor vision due to MO at three months after cataract surgery compared with people receiving steroids alone (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.23 to 0.76; eyes = 1360; studies = 5; I2 = 5%). We judged this to be low-certainty evidence because of risk of bias in the included studies and indirectness, as the extent of visual loss was not always clear. Only one study reported poor vision due to MO at 12 months and we judged this to be very low-certainty evidence as there were only two events. Quality of life was only reported in one of the 34 studies comparing NSAIDs plus steroids versus steroids alone, and it was not fully reported, other than to comment on lack of differences between groups. There was evidence of a reduced risk of MO with NSAIDs at three months after surgery, but we judged this to be low-certainty due to risk of bias and publication bias (RR 0.40, 95% CI 0.32 to 0.49; eyes = 3638; studies = 21). There was inconsistent evidence on central retinal thickness at three months (I2 = 87%). Results ranged from -30.9 µm in favour of NSAIDs plus steroids to 7.44 µm in favour of steroids alone. Similarly, data on best corrected visual acuity (BCVA) were inconsistent, but nine out of 10 trials reporting this outcome found between-group differences in visual acuity of less than 0.1 logMAR.None of the six studies comparing NSAIDs alone with steroids reported on poor vision due to MO at three or 12 months. There was low-certainty evidence that central retinal thickness was lower in the NSAIDs group at three months (mean difference (MD) -22.64 µm, 95% CI -38.86 to -6.43; eyes = 121; studies = 2). Five studies reported on MO and showed a reduced risk with NSAIDs, but we judged this evidence to be of low-certainty (RR 0.27, 95% CI 0.18 to 0.41; eyes = 520). Three studies reported BCVA at three months and the results of these trials were inconsistent, but all three studies found differences of less than 0.1 logMAR between groups.We did not note any major adverse events - the main consistent observation was burning or stinging sensation with the use of NSAIDs. AUTHORS' CONCLUSIONS: Using topical NSAIDs may reduce the risk of developing macular oedema after cataract surgery, although it is possible that current estimates as to the size of this reduction are exaggerated. It is unclear the extent to which this reduction has an impact on the visual function and quality of life of patients. There is little evidence to suggest any important effect on vision after surgery. The value of adding topical NSAIDs to steroids, or using them as an alternative to topical steroids, with a view to reducing the risk of poor visual outcome after cataract surgery is therefore uncertain. Future trials should address the remaining clinical uncertainty of whether prophylactic topical NSAIDs are of benefit, particularly with respect to longer-term follow-up (at least to 12 months), and should be large enough to detect reduction in the risk of the outcome of most interest to patients, which is chronic macular oedema leading to visual loss

Cystic lymphangioma of the lesser sac presenting as acute appendicitis: A case report

Intra-abdominal lymphangiomas usually present by 2 years of age and are uncommon in adults. Cystic lymphagiomas arising from the lesser sac are even more uncommon. We report an unusual case of a lesser sac cystic lymphangioma presenting as acute appendicitis. A 21 year old female was admitted with pyrexia, right iliac fossa tenderness and an elevated C-reactive protein (CRP). At laparotomy, a large fluid filled cystic lesion was observed occupying the right side of the abdominal cavity. The lesion was excised in its entirety and histological diagnosis confirmed lymphangioma. The patient remains well with no evidence of recurrence 1 year post resection

Moving from a Product-Based Economy to a Service-Based Economy for a More Sustainable Future

Traditionally, economic growth and prosperity have been linked with the availability, production and distribution of tangible goods as well as the ability of consumers to acquire such goods. Early evidence regarding this connection dates back to Adam Smith's Wealth of Nations (1776), in which any activity not resulting in the production of a tangible good is characterized as unproductive of any value." Since then, this coupling of economic value and material production has been prevalent in both developed and developing economies throughout the world. One unintended consequence of this coupling has been the exponential increase in the amount of solid waste being generated. The reason is that any production and consumption of material goods eventually generates the equivalent amount of (or even more) waste. Exacerbating this problem is the fact that, with today's manufacturing and supply chain management technologies, it has become cheaper to dispose and replace most products rather than to repair and reuse them. This has given rise to what some call a disposable society." To put things in perspective: In 2012 households in the U.K. generated approximately 22 thousand tons of waste, which amounted to 411 kg of waste generated per person (Department for Environment, Food & Rural Affairs, 2015). During the same time period, households in the U.S. generated 251 million tons of waste, which is equivalent to a person generating approximately 2 kg of waste every day (U.S. Environmental Protection Agency, 2012). Out of these 251 million tons of total waste generated, approximately 20% of the discarded items were categorized as durable goods. The disposal of durable goods is particularly worrisome because they are typically produced using material from non- renewable resources such as iron, minerals, and petroleum-based raw materials

A Herschel PACS and SPIRE study of the dust content of the Cassiopeia A supernova remnant

Using the 3.5-m Herschel Space Observatory, imaging photometry of Cas A has been obtained in six bands between 70 and 500 μm with the PACS and SPIRE instruments, with angular resolutions ranging from 6 to 37”. In the outer regions of the remnant the 70-μm PACS image resembles the 24-μm image Spitzer image, with the emission attributed to the same warm dust component, located in the reverse shock region. At longer wavelengths, the three SPIRE bands are increasingly dominated by emission from cold interstellar dust knots and filaments, particularly across the central, western and southern parts of the remnant. Nonthermal emission from the northern part of the remnant becomes prominent at 500 μm. We have estimated and subtracted the contributions from the nonthermal, warm dust and cold interstellar dust components. We confirm and resolve for the first time a cool (~35 K) dust component, emitting at 70-160 μm, that is located interior to the reverse shock region, with an estimated mass of 0.075

The enigmatic nature of the circumstellar envelope and bow shock surrounding Betelgeuse as revealed by Herschel

Context. The interaction between stellar winds and the interstellar medium (ISM) can create complex bow shocks. The photometers on board the Herschel Space Observatory are ideally suited to studying the morphologies of these bow shocks. Aims. We aim to study the circumstellar environment and wind-ISM interaction of the nearest red supergiant, Betelgeuse. Methods.Herschel PACS images at 70, 100, and 160 μm and SPIRE images at 250, 350, and 500 μm were obtained by scanning the region around Betelgeuse. These data were complemented with ultraviolet GALEX data, near-infrared WISE data, and radio 21 cm GALFA-HI data. The observational properties of the bow shock structure were deduced from the data and compared with hydrodynamical simulations. Results. The infrared Herschel images of the environment around Betelgeuse are spectacular, showing the occurrence of multiple arcs at ~6–7′ from the central target and the presence of a linear bar at ~9′. Remarkably, no large-scale instabilities are seen in the outer arcs and linear bar. The dust temperature in the outer arcs varies between 40 and 140 K, with the linear bar having the same colour temperature as the arcs. The inner envelope shows clear evidence of a non-homogeneous clumpy structure (beyond 15′′), probably related to the giant convection cells of the outer atmosphere. The non-homogeneous distribution of the material even persists until the collision with the ISM. A strong variation in brightness of the inner clumps at a radius of ~2′ suggests a drastic change in mean gas and dust density ~32 000 yr ago. Using hydrodynamical simulations, we try to explain the observed morphology of the bow shock around Betelgeuse. Conclusions. Different hypotheses, based on observational and theoretical constraints, are formulated to explain the origin of the multiple arcs and the linear bar and the fact that no large-scale instabilities are visible in the bow shock region. We infer that the two main ingredients for explaining these phenomena are a non-homogeneous mass-loss process and the influence of the Galactic magnetic field. The hydrodynamical simulations show that a warm interstellar medium, reflecting a warm neutral or partially ionized medium, or a higher temperature in the shocked wind also prevent the growth of strong instabilities. The linear bar is probably an interstellar structure illuminated by Betelgeuse itself

A Herschel study of NGC 650

As part of the Herschel guaranteed time key project Mass loss of Evolved StarS (MESS) we have imaged a sample of planetary nebulae. In this paper we present the Photodetector Array Camera and Spectrometer (PACS) and Spectral and Photometric Imaging Receiver (SPIRE) images of the classical bipolar planetary nebula NGC 650. We used these images to derive a temperature map of the dust. We also constructed a photoionization and dust radiative transfer model using the spectral synthesis code Cloudy. To constrain this model, we used the PACS and SPIRE fluxes and combined them with hitherto unpublished International Ultraviolet Explorer (IUE) and Spitzer InfraRed Spectrograph (IRS) spectra as well as various other data from the literature. A temperature map combined with a photoionization model were used to study various aspects of the central star, the nebula, and in particular the dust grains in the nebula. The central star parameters are determined to be Teff = 208 kK and L = 261 L⊙ assuming a distance of 1200 pc. The stellar temperature is much higher than previously published values. We confirm that the nebula is carbon-rich with a C/O ratio of 2.1. The nebular abundances are typical for a type IIa planetary nebula. With the photoionization model we determined that the grains in the ionized nebula are large (assuming single-sized grains, they would have a radius of 0.15 μm). Most likely these large grains were inherited from the asymptotic giant branch phase. The PACS 70/160 μm temperature map shows evidence of two radiation components heating the grains. The first component is direct emission from the central star, while the second component is diffuse emission from the ionized gas (mainly Lyα). We show that previous suggestions of a photo-dissociation region surrounding the ionized region are incorrect. The neutral material resides in dense clumps inside the ionized region. These may also harbor stochastically heated very small grains in addition to the large grains

The association between overall health, psychological distress, and occupational heat stress among a large national cohort of 40,913 Thai workers

Background: Occupational heat stress is a well-known problem, particularly in tropical countries, affecting workers, health and well-being. There are very few recent studies that have reported on the effect of heat stress on mental health, or overall health in workers, although socioeconomic development and rapid urbanization in tropical developing countries like Thailand create working conditions in which heat stress is likely. Objective: This study is aimed at identifying the relationship between self-reported heat stress and psychological distress, and overall health status in Thai workers. Results: 18% of our large national cohort (>40,000 subjects) often works under heat stress conditions and males are exposed to heat stress more often than females. Furthermore, working under heat stress conditions is associated with both worse overall health and psychological distress (adjusted odds ratios ranging from 1.49 to 1.84). Conclusions: This association between occupational heat stress and worse health needs more public health attention and further development on occupational health interventions as climate change increases Thailand's temperatures

Chronic hepatitis B: whom to treat and for how long? Propositions, challenges, and future directions

Recent guidelines of the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Asian Pacific Association for the Study of the Liver 2008 update of the “Asian-Pacific consensus statement on the management of chronic hepatitis B” offer comprehensive recommendations for the general management of chronic hepatitis B (CHB). These recommendations highlight preferred approaches to the prevention, diagnosis, and treatment of CHB. Nonetheless, the results of recent studies have led to an improved understanding of the disease and a belief that current recommendations on specific therapeutic considerations, including CHB treatment initiation and cessation criteria, particularly in patient populations with special circumstances, can be improved. Twelve experts from the Asia-Pacific region formed the Asia-Pacific Panel Recommendations for the Optimal Management of Chronic Hepatitis B (APPROACH) Working Group to review, challenge, and assess relevant new data and inform future updates of CHB treatment guidelines. The significance of and controversy about reported findings were discussed and debated in an expert meeting of the Working Group in Beijing, China, in November 2008. This review paper attempts to identify areas requiring improved CHB management and provide suggestions for future guideline updates, with special emphasis on treatment initiation and duration

Assisted evolution enables HIV-1 to overcome a high trim5α-imposed genetic barrier to rhesus macaque tropism

Diversification of antiretroviral factors during host evolution has erected formidable barriers to cross-species retrovirus transmission. This phenomenon likely protects humans from infection by many modern retroviruses, but it has also impaired the development of primate models of HIV-1 infection. Indeed, rhesus macaques are resistant to HIV-1, in part due to restriction imposed by the TRIM5α protein (rhTRIM5α). Initially, we attempted to derive rhTRIM5α-resistant HIV-1 strains using two strategies. First, HIV-1 was passaged in engineered human cells expressing rhTRIM5α. Second, a library of randomly mutagenized capsid protein (CA) sequences was screened for mutations that reduced rhTRIM5α sensitivity. Both approaches identified several individual mutations in CA that reduced rhTRIM5α sensitivity. However, neither approach yielded mutants that were fully resistant, perhaps because the locations of the mutations suggested that TRIM5α recognizes multiple determinants on the capsid surface. Moreover, even though additive effects of various CA mutations on HIV-1 resistance to rhTRIM5α were observed, combinations that gave full resistance were highly detrimental to fitness. Therefore, we employed an 'assisted evolution' approach in which individual CA mutations that reduced rhTRIM5α sensitivity without fitness penalties were randomly assorted in a library of viral clones containing synthetic CA sequences. Subsequent passage of the viral library in rhTRIM5α-expressing cells resulted in the selection of individual viral species that were fully fit and resistant to rhTRIM5α. These viruses encoded combinations of five mutations in CA that conferred complete or near complete resistance to the disruptive effects of rhTRIM5α on incoming viral cores, by abolishing recognition of the viral capsid. Importantly, HIV-1 variants encoding these CA substitutions and SIVmac239 Vif replicated efficiently in primary rhesus macaque lymphocytes. These findings demonstrate that rhTRIM5α is difficult to but not impossible to evade, and doing so should facilitate the development of primate models of HIV-1 infection