Global Retinoblastoma Presentation and Analysis by National Income Level

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4) were female. Most patients (n = 3685 84.7%) were from low-and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 62.8%), followed by strabismus (n = 429 10.2%) and proptosis (n = 309 7.4%). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 95% CI, 12.94-24.80, and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 95% CI, 4.30-7.68). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs. © 2020 American Medical Association. All rights reserved

Impact of transport infrastructure on international competitiveness of Europe

One of the main objectives of the European transport strategy in its 2011 White Paper is to help establish a transport system that enhances competitiveness of European countries. By performing a methodological study, analysing several European transport infrastructure investment cases and conducting a review on various assessment tools, we clarify the relationship between transport infrastructure investment and its wider economic impacts, namely competitiveness and economic growth, we make synthesis of some proposed improvement of the methodology used to assess these impact as well as some recommendations on assessing European Union (EU) policy in transport infrastructure investment in respect of competitiveness and economic growth

Association between carotid intima media thickness and acute ischemic stroke at an Indonesian tertiary referral hospital

الملخص: أهداف البحث: يساهم الانتشار المرتفع لتدخين التبغ في ارتفاع معدل الإصابة بالسكتة الدماغية الحادة في إندونيسيا. من المعروف أن تصلب الشرايين الكبير هو سبب مهم للسكتة الدماغية الحادة. هدفت الدراسة الحالية إلى تقييم العلاقة بين السكتة الدماغية الحادة وتصلب الشرايين بناءً على قياسات سماكة الطبقة الداخلية للشريان السباتي في مستشفى المستشفيات التخصصية الإندونيسية. طريقة البحث: إجمالا، تم تضمين 79 مريضا يعانون من السكتة الدماغية الحادة (مجموعة دراسة الحالة) و 79 فردا بدون سكتة إقفارية حادة (مجموعة التحكم). تم استخدام اختبار كاي تربيع ونسب الأرجحية لمقارنة المجموعات وتحديد ارتباطها. أخذنا في الاعتبار أيضا عوامل مثل العمر، ومؤشر كتلة الجسم، والجنس، وداء السكري من النوع 2، وارتفاع ضغط الدم، وعادات التدخين، وعسر شحميات الدم، والحالة الاجتماعية والاقتصادية، والمستوى التعليمي في التحليلات الإحصائية. النتائج: أظهر التقسيم الطبقي لتصلب الشرايين في دراسة الحالة ومجموعات الضبط فيما يتعلق بجميع متغيرات الدراسة علاقة معنوية بين تصلب الشرايين وجميع المتغيرات باستثناء الحالة الاجتماعية والاقتصادية المنخفضة والمستوى التعليمي المنخفض. أظهر تحليل الانحدار أن مؤشر كتلة الجسم 25 كجم / م 2 كان مرتبطا بخطر الإصابة بتصلب الشرايين بمقدار 2.139 ضعفا من مؤشر كتلة الجسم الطبيعي الاستنتاجات: ارتبطت السكتة الدماغية الحادة بتصلب الشرايين على أساس قياسات سماكة الطبقة الداخلية للشريان السباتي مع مراعاة العمر، ومؤشر كتلة الجسم، والجنس، وارتفاع ضغط الدم من النوع 2، وعادات التدخين، وخلل شحميات الدم، والحالة الاجتماعية والاقتصادية، ومستوى التعليم لدى السكان الإندونيسيين Abstract: Objectives: A high prevalence of tobacco smoking contributes to a high incidence of acute ischemic stroke (AIS) in Indonesia. Large-artery atherosclerosis is known to be a significant cause of AIS. The present study was aimed at evaluating the association between AIS and atherosclerosis on the basis of carotid intima-media thickness (CIMT) measurements in a tertiary care hospital in Indonesia. Methods: A total of 79 patients with AIS (case study group) and 79 individuals without AIS (control group) were included. Chi-squared tests and odds ratios were used to compare the groups and determine associations. We also considered factors such as age, body mass index (BMI), sex, type-2 diabetes mellitus (T2DM), hypertension, smoking status, dyslipidemia, socioeconomic status, and educational level in the statistical analyses. A p-value  0.05) between atherosclerosis and all variables except low socioeconomic status (p = 0.265) and low educational level (p = 0.180). Regression analysis demonstrated that a BMI ≥25 kg/m2, compared with a normal BMI, was associated with a 2.139-fold higher risk of atherosclerosis. Conclusions: AIS was associated with atherosclerosis, on the basis of CIMT measurements, according to age, BMI, sex, T2DM, hypertension, smoking status, dyslipidemia, socioeconomic status, and education level in the Indonesian population

Sustainable Agroforestry Landscape Management: Changing the Game

Location-specific forms of agroforestry management can reduce problems in the forest–water–people nexus, by balancing upstream and downstream interests, but social and ecological finetuning is needed. New ways of achieving shared understanding of the underlying ecological and social-ecological relations is needed to adapt and contextualize generic solutions. Addressing these challenges between thirteen cases of tropical agroforestry scenario development across three continents requires exploration of generic aspects of issues, knowledge and participative approaches. Participative projects with local stakeholders increasingly use ‘serious gaming’. Although helpful, serious games so far (1) appear to be ad hoc, case dependent, with poorly defined extrapolation domains, (2) require heavy research investment, (3) have untested cultural limitations and (4) lack clarity on where and how they can be used in policy making. We classify the main forest–water–people nexus issues and the types of land-use solutions that shape local discourses and that are to be brought to life in the games. Four ‘prototype’ games will be further used to test hypotheses about the four problems identified constraining game use. The resulting generic forest–water–people games will be the outcome of the project “Scenario evaluation for sustainable agroforestry management through forest-water-people games” (SESAM), for which this article provides a preview

Chemotherapy-Related Side Effects in Childhood Acute Lymphoblastic Leukemia in Indonesia: Parental Perceptions

Noncompliance with prescribed medication has been associated with increased chance of relapse and poor outcome. Side effects may be an important cause of noncompliance. Fifty-one parents of children with acute lymphoblastic leukemia in a tertiary care hospital in Indonesia were interviewed about their perception of side effects and their impact on treatment noncompliance and daily activities. A symptom checklist assessing 13 common symptoms was used to examine side effects. During chemotherapy, childhood acute lymphoblastic leukemia patients suffered from psychological as well as physical side effects. The most frequent side effect reported by parents was behavior alteration (92%). Second and third in frequency were increased appetite and infections, reported by 88% and 83% of parents, respectively. The most severe side effects were leg weakness, increased appetite, and behavior alteration. The overall frequency of side effects was weakly correlated to noncompliance. Reducing the impact of side effects may increase compliance with the treatmen

Global Retinoblastoma Presentation and Analysis by National Income Level

This cross-sectional analysis reports the retinoblastoma stage at diagnosis across the world during a single year, investigates associations between clinical variables and national income level, and investigates risk factors for advanced disease at diagnosis. Key PointsQuestionIs the income level of a country of residence associated with the clinical stage of presentation of patients with retinoblastoma? FindingsIn this cross-sectional analysis that included 4351 patients with newly diagnosed retinoblastoma, approximately half of all new retinoblastoma cases worldwide in 2017, 49.1\% of patients from low-income countries had extraocular tumor at time of diagnosis compared with 1.5\% of patients from high-income countries. MeaningThe clinical stage of presentation of retinoblastoma, which has a major influence on survival, significantly differs among patients from low-income and high-income countries, which may warrant intervention on national and international levels. ImportanceEarly diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. ObjectivesTo report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and ParticipantsA total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and MeasuresAge at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. ResultsThe cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4\%) were female. Most patients (n=3685 {[}84.7\%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n=2638 {[}62.8\%]), followed by strabismus (n=429 {[}10.2\%]) and proptosis (n=309 {[}7.4\%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5\%) patients having intraocular retinoblastoma and 2 (0.3\%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1\%) having extraocular retinoblastoma and 94 of 498 (18.9\%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 {[}95\% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 {[}95\% CI, 4.30-7.68]). Conclusions and RelevanceThis study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs