Adipokines and coronary artery calcification in incident dialysis participants.

PURPOSE: Adipokines have been associated with increased risk of cardiovascular disease. Our aim was to determine if adipokine levels are associated with coronary artery calcification (CAC) as well as all-cause mortality in incident dialysis patients. METHODS: In patients new to dialysis, we prospectively investigated the association of adiponectin, leptin and resistin with coronary artery calcification measured by ECG-gated computer tomography. Participants were recruited a median of two months after starting dialysis. RESULTS: The mean age was 50.0 (12.6) years and 31.1% were women. About 42% percent had BMI > 30. Higher adiponectin levels were inversely associated with CAC progression as change in Agatston score [-155.1 (-267.9, -42.2), p = 0.008] or change in CAC volumes between scans [-2.8 (-4.9, -0.6), p = 0.01]. Higher leptin levels were associated with CAC progression [110.4 (34.3-186.6), p = 0.005]. Decreased leptin [HR 0.5 (0.3-0.9), p = 0.05] was associated with all-cause mortality in adjusted models. There was no significant association between all-cause mortality and adiponectin [1.4 (0.6-3.4), p = 0.4] or resistin [HR 1.7 (0.5-5.0), p = 0.4]. CONCLUSION: High adiponectin protects against CAC progression, but is not associated with increased all-cause mortality. Higher leptin, as well as higher leptin to adiponectin ratio, is associated with CAC progression. Lower leptin levels were associated with all-cause mortality. The association of adipokines and cardiovascular disease in individuals on dialysis is complex and requires further study.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

The impact of distance cataract surgical wet laboratory training on cataract surgical competency of ophthalmology residents.

BACKGROUND: This study assessed the impact of distance cataract surgical wet laboratory training on surgical competency of ophthalmology residents at a tertiary-level ophthalmic training center in Trujillo, Peru. METHODS: Three five-week distance wet lab courses were administered through Cybersight, Orbis International's telemedicine platform. Weekly lectures and demonstrations addressed specific steps in phacoemulsification surgery. Each lecture had two accompanying wet lab assignments, which residents completed and recorded in their institution's wet lab and uploaded to Cybersight for grading. Competency was assessed through anonymous grading of pre- and post-training surgical simulation videos, masked as to which occurred before and after training, using a standardized competency rubric adapted from the Ophthalmology Surgical Competency Assessment Rubric (OSCAR, scale of 0-32). Day one best-corrected post-operative visual acuity (BVCA) was assessed in the operative eye on the initial consecutive 4-6 surgeries conducted by the residents as per the norms of their residency training. An anonymous post-training satisfaction survey was administered to trainees'. RESULTS: In total, 21 ophthalmic residents participated in the courses, submitting a total of 210 surgical videos. Trainees' average competency score increased 6.95 points (95%CI [4.28, 9.62], SD = 5.01, p < 0.0001, two sample t-test) from 19.3 (95%CI [17.2, 21.5], SD = 4.04) to 26.3 (95%CI [24.2, 28.3], SD = 3.93). Visual acuity for 92% of post-training resident surgeries (n = 100) was ≥20/60, meeting the World Health Organization's criterion for good quality. CONCLUSIONS: Structured distance wet lab courses in phacoemulsification resulted in significantly improved cataract surgical skills. This model could be applicable to locations where there are obstacles to traditional in-person training, such as the current COVID-19 pandemic.

Rapid assessment of avoidable blindness and cataract surgery coverage among forcibly displaced Myanmar Nationals (Rohingya refugees) in Cox's Bazar, Bangladesh.

AIM: To determine the prevalence and causes of blindness, vision impairment and cataract surgery coverage among Rohingya refugees aged ≥ 50 years residing in camps in Cox's Bazar, Bangladesh. METHODS: We used the Rapid Assessment of Avoidable Blindness (RAAB) methodology to select 76 clusters of 50 participants aged ≥ 50 years with probability proportionate to size. Demographic and cataract surgery data were collected using questionnaires, visual acuity was assessed per World Health Organization criteria and examinations were conducted by torch, and with direct ophthalmoscopy in eyes with pinhole-corrected vision <6/12. RAAB software was used for data entry and analysis. RESULTS: We examined 3,629 of 3800 selected persons (95.5%). Age and sex adjusted prevalence of blindness (<3/60), severe visual impairment (SVI; >3/60 to ≤6/60), moderate visual impairment (MVI; >6/60 to ≤6/18), and early visual impairment (EVI; >6/18 to ≤6/12) were 2.14%, 2.35%, 9.68% and 14.7% respectively. Cataract was responsible for 75.0% of blindness and 75.8% of SVI, while refractive error caused 47.9% and 90.9% of MVI and EVI respectively. Most vision loss (95.9%) was avoidable. Cataract surgical coverage among the blind was 81.2%. Refractive error was detected in 17.1% (n = 622) of participants and 95.2% (n = 592) of these did not have spectacles. In the full Rohingya cohort of 76,692, approximately 10,000 surgeries are needed to correct all eyes impaired (<6/18) by cataract, 12,000 need distance glasses and 73,000 require presbyopic correction. CONCLUSION: The prevalence of blindness was lower than expected for a displaced population, in part due to few Rohingya being ≥60 years and the camp's good access to cataract surgery. We suggest the United Nations High Commissioner for Refugees include eye care among recommended health services for all refugees with long-term displacement.

Burden of eye disease and demand for care in the Bangladesh Rohingya displaced population and host community: A cohort study.

BACKGROUND: There is a growing awareness that addressing chronic as well as acute health conditions may contribute importantly to the well-being of displaced populations, but eye care service has generally not been prioritized in crisis situations. We describe a replicable model of eye care provision as delivered by Orbis International and local partners to the Rohingya and host population in Cox's Bazar, Bangladesh, and characterize the burden of vision impairment and demand for sight-restoring services in this setting. METHODS AND FINDINGS: Orbis International and local secondary facility Cox's Bazar Baitush Sharaf Hospital (CBBSH) provide eye care support to the Rohingya population and the host community of all ages in Cox's Bazar, Bangladesh, with fixed vision screening locations established in Camps 4 and 11 of the Kutupalong refugee settlement. Structured outreach targets these camps and four surrounding local subdistricts, with referrals made as needed for refraction (glasses measurement) and cataract surgery to CBBSH. Between February 2018 and March 2019, 48,105 displaced Rohingya (70.3%, among whom 71.6% were children and 46.5% women) and 20,357 local residents (29.7%, 88.5% children, 54.4% women) underwent vision screening. Displaced Rohingya sought services from a total of 12 surrounding camps, within which coverage was 17.3%, including 43.3% (27,027/62,424) of children aged 5-11 years and 60.0% (5,315/8,857) of adults ≥ 60 years old. The prevalence of blindness (presenting acuity < 3/60) among Rohingya patients exceeded that among local residents by 3- to 6-fold in each 10-year age group between 18 and 59 years (P < 0.001 comparing vision between the two groups in this age range), and the prevalence of cataract requiring surgery was also higher in Rohingya patients (18-29 years: 4.67% versus 1.80%, P = 0.0019; 30-39: 7.61% versus 2.39%, P < 0.001; and 40-49 years: 7.91% versus 3.77%, P = 0.0014). A limitation of the study is lack of data on population prevalence of eye disease. CONCLUSIONS: The burden of untreated eye disease is very high among the Rohingya, particularly those in their peak working years who could contribute most to the resiliency of their community. Demand for eye care service is also great among children and adults in this population with many competing healthcare priorities. Research is needed, building on strong evidence of benefit in settled populations, to explore the specific impact of vision care on the well-being of displaced populations.

New-onset hepatitis C virus-associated glomerulonephritis following sustained virologic response with direct-acting antiviral therapy
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Glomerulonephritis (GN) is an important extra-hepatic manifestation of infection with hepatitis C virus (HCV). HCV-associated GN occurs due to HCV-induced lymphoproliferation, leading to the generation of pathogenic immune complexes, including complexes containing cryoglobulins. The management of HCV-associated extra-hepatic disease is focused on viral eradication, with direct-acting antiviral agents leading to high rates of sustained virologic remission. There have been a few reports of relapsing cryoglobulinemic vasculitis after sustained virologic remission was achieved with interferon-based therapies. This report presents two cases of new-onset HCV-associated GN that occurred after sustained virologic response was achieved with direct-acting antiviral (DAA) therapy.
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Mass drug administration for trachoma: how long is not long enough?

BACKGROUND: Blinding trachoma is targeted for elimination by 2020 using the SAFE strategy (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements). Annual mass drug administration (MDA) with azithromycin is a cornerstone of this strategy. If baseline prevalence of clinical signs of trachomatous inflammation - follicular among 1-9 year-olds (TF1-9) is ≥ 10% but <30%, the World Health Organization guidelines are for at least 3 annual MDAs; if ≥ 30%, 5. We assessed the likelihood of achieving the global elimination target of TF1-9 <5% at 3 and 5 year evaluations using program reports. METHODOLOGY/PRINCIPAL FINDINGS: We used the International Trachoma Initiative's prevalence and treatment database. Of 283 cross-sectional survey pairs with baseline and follow-up data, MDA was conducted in 170 districts. Linear and logistic regression modeling was applied to these to investigate the effect of MDA on baseline prevalence. Reduction to <5% was less likely, though not impossible, at higher baseline TF1-9 prevalences. Increased number of annual MDAs, as well as no skipped MDAs, were significant predictors of reduced TF1-9 at follow-up. The probability of achieving the <5% target was <50% for areas with ≥ 30% TF1-9 prevalence at baseline, even with 7 or more continuous annual MDAs. CONCLUSIONS: Number of annual MDAs alone appears insufficient to predict program progress; more information on the effects of baseline prevalence, coverage, and underlying environmental and hygienic conditions is needed. Programs should not skip MDAs, and at prevalences >30%, 7 or more annual MDAs may be required to achieve the target. There are five years left before the 2020 deadline to eliminate blinding trachoma. Low endemic settings are poised to succeed in their elimination goals. However, newly-identified high prevalence districts warrant immediate inclusion in the global program. Intensified application of the SAFE strategy is needed in order to guarantee blinding trachoma elimination by 2020.

Elimination of blinding trachoma by 2020: a call for rapid scale-up and strengthening programmes.

Elimination of blinding trachoma is targeted for the year 2020, making scale-up extremely urgent. Preferred practices have been developed for mass drug administration and trichiasis surgery to assist new countries and districts. However, these need to be utilised on a broader scale to ensure quality output of programmes and the highest coverage possible of their implementation. Although in recent years there has been a significant increase in programmatic funding, there are still gaps. In addition, continued insecurity in several regions and outbreaks that require refocusing of staff threaten the goal. Close partnerships and collaboration enable the trachoma community to be well on track to reaching the goal, but it cannot be business as usual to achieve this.

Trachoma.

Trachoma is the most common infectious cause of blindness. Repeated episodes of infection with Chlamydia trachomatis in childhood lead to severe conjunctival inflammation, scarring, and potentially blinding inturned eyelashes (trichiasis or entropion) in later life. Trachoma occurs in resource-poor areas with inadequate hygiene, where children with unclean faces share infected ocular secretions. Much has been learnt about the epidemiology and pathophysiology of trachoma. Integrated control programmes are implementing the SAFE Strategy: surgery for trichiasis, mass distribution of antibiotics, promotion of facial cleanliness, and environmental improvement. This strategy has successfully eliminated trachoma in several countries and global efforts are underway to eliminate blinding trachoma worldwide by 2020.

Effect of water, sanitation, and hygiene on the prevention of trachoma: a systematic review and meta-analysis.

BACKGROUND: Trachoma is the world's leading cause of infectious blindness. The World Health Organization (WHO) has endorsed the SAFE strategy in order to eliminate blindness due to trachoma by 2020 through "surgery," "antibiotics," "facial cleanliness," and "environmental improvement." While the S and A components have been widely implemented, evidence and specific targets are lacking for the F and E components, of which water, sanitation, and hygiene (WASH) are critical elements. Data on the impact of WASH on trachoma are needed to support policy and program recommendations. Our objective was to systematically review the literature and conduct meta-analyses where possible to report the effects of WASH conditions on trachoma and identify research gaps. METHODS AND FINDINGS: We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through October 27, 2013 with no restrictions on language or year of publication. Studies were eligible for inclusion if they reported a measure of the effect of WASH on trachoma, either active disease indicated by observed signs of trachomatous inflammation or Chlamydia trachomatis infection diagnosed using PCR. We identified 86 studies that reported a measure of the effect of WASH on trachoma. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. If three or more studies reported measures of effect for a comparable WASH exposure and trachoma outcome, we conducted a random-effects meta-analysis. We conducted 15 meta-analyses for specific exposure-outcome pairs. Access to sanitation was associated with lower trachoma as measured by the presence of trachomatous inflammation-follicular or trachomatous inflammation-intense (TF/TI) (odds ratio [OR] 0.85, 95% CI 0.75-0.95) and C. trachomatis infection (OR 0.67, 95% CI 0.55-0.78). Having a clean face was significantly associated with reduced odds of TF/TI (OR 0.42, 95% CI 0.32-0.52), as were facial cleanliness indicators lack of ocular discharge (OR 0.42, 95% CI 0.23-0.61) and lack of nasal discharge (OR 0.62, 95% CI 0.52-0.72). Facial cleanliness indicators were also associated with reduced odds of C. trachomatis infection: lack of ocular discharge (OR 0.40, 95% CI 0.31-0.49) and lack of nasal discharge (OR 0.56, 95% CI 0.37-0.76). Other hygiene factors found to be significantly associated with reduced TF/TI included face washing at least once daily (OR 0.76, 95% CI 0.57-0.96), face washing at least twice daily (OR 0.85, 95% CI 0.80-0.90), soap use (OR 0.76, 95% CI 0.59-0.93), towel use (OR 0.65, 95% CI 0.53-0.78), and daily bathing practices (OR 0.76, 95% CI 0.53-0.99). Living within 1 km of a water source was not found to be significantly associated with TF/TI or C. trachomatis infection, and the use of sanitation facilities was not found to be significantly associated with TF/TI. CONCLUSIONS: We found strong evidence to support F and E components of the SAFE strategy. Though limitations included moderate to high heterogenity, low study quality, and the lack of standard definitions, these findings support the importance of WASH in trachoma elimination strategies and the need for the development of standardized approaches to measuring WASH in trachoma control programs.

Prevalence of trachoma in unity state, South Sudan: results from a large-scale population-based survey and potential implications for further surveys.

BACKGROUND: Large parts of South Sudan are thought to be trachoma-endemic but baseline data are limited. This study aimed to estimate prevalence for planning trachoma interventions in Unity State, to identify risk factors and to investigate the effect of different sampling approaches on study conclusions. METHODS AND FINDINGS: The survey area was defined as one domain of eight counties in Unity State. Across the area, 40 clusters (villages) were randomly selected proportional to the county population size in a population-based prevalence survey. The simplified grading scheme was used to classify clinical signs of trachoma. The unadjusted prevalence of trachoma inflammation-follicular (TF) in children aged 1-9 years was 70.5% (95% CI: 68.6-72.3). After adjusting for age, sex, county and clustering of cases at household and village level the prevalence was 71.0% (95% CI: 69.9-72.1). The prevalence of trachomatous trichiasis (TT) in adults was 15.1% (95% CI: 13.4-17.0) and 13.5% (95% CI: 12.0-15.1) before and after adjustment, respectively. We estimate that 700,000 people (the entire population of Unity State) require antibiotic treatment and approximately 54,178 people require TT surgery. Risk factor analyses confirmed child-level associations with TF and highlighted that older adults living in poverty are at higher risk of TT. Conditional simulations, testing the alternatives of sampling 20 or 60 villages over the same area, indicated that sampling of only 20 villages would have provided an acceptable level of precision for state-level prevalence estimation to inform intervention decisions in this hyperendemic setting. CONCLUSION: Trachoma poses an enormous burden on the population of Unity State. Comprehensive control is urgently required to avoid preventable blindness and should be initiated across the state now. In other parts of South Sudan suspected to be highly trachoma endemic, counties should be combined into larger survey areas to generate the baseline data required to initiate interventions.